Increased expression of VEGF and CD31 in postradiation rectal tissue: implications for radiation proctitis.

Background. Inflammation mediators related to radiation proctitis are partially elucidated, and neovascularization is thought to play a key role. Objectives. To investigate the expression of vascular endothelial growth factor (VEGF) and CD31 as angiogenetic markers in postradiation rectal tissue. Methods. Rectal mucosa biopsies from 11 patients who underwent irradiation for prostate cancer were examined immunohistochemically for the expression of VEGF and CD31 at three time settings-before, at the completion of, and 6 months after radiotherapy. VEGF expressing vascular endothelial cells and CD31 expressing microvessels were counted separately in 10 high-power fields (HPFs). VEGF vascular index (VEGF-VI) and microvascular density (MVD) were calculated as the mean number of VEGF positive cells per vessel or the mean number of vessels per HPF, respectively. Histological features were also evaluated. Results. VEGF-VI was significantly higher at the completion of radiotherapy (0.17 ± 0.15 versus 0.41 ± 0.24, P = 0.001) declining 6 months after. MVD increased significantly only 6 months after radiotherapy (7.3 ± 3.2 versus 10.5 ± 3.1, P < 0.005). The histopathological examination revealed inflammatory changes at the completion of radiotherapy regressing in the majority of cases 6 months after. Conclusions. Our results showed that in postradiation rectal biopsy specimens neoangiogenesis seems to be inflammation-related and constitutes a significant postradiation component of the tissue injury.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Covid-19: exploring the "new normal" in gastroenterology training.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented.

European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases.

These recommendations on video capsule endoscopy, an emerging technology with an impact on the practice of endoscopy, were developed by the European Society of Gastrointestinal Endoscopy (ESGE) Guidelines Committee. The first draft of each section was prepared by one or two members of the writing team, who were selected as experts on the content of that section on the basis of their published work. They used evidence-based methodology, performing MEDLINE and PubMed literature searches to identify relevant clinical studies. Abstracts from scientific meetings were included only if there was no published full paper on a particular topic. If there was disagreement, the first author of the Guideline made the final decision. Recommendations were graded according to the strength of the supporting evidence. The draft guideline was critically reviewed by all authors and submitted to the ESGE councillors for their critical review before approval of the final document. The ESGE Guidelines Committee acknowledges that this document is based on a critical review of the data available at the time of preparation and that further studies may be needed to clarify some aspects. Moreover, this Guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This document should be regarded as supplying recommendations only to gastroenterologists in providing care to their patients. It is not a set of rules and should not be construed as establishing a legal standard of care, or as encouraging, advocating, requiring, or discouraging any particular treatment. These recommendations must be interpreted according to the clinician's knowledge, expertise, and clinical judgment in the management of individual patients and, if necessary, a course of action that varies from recommendations must be undertaken.

Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy?: A meta-analysis.

OBJECTIVES: Video capsule endoscopy (VCE) is a useful tool in investigating small bowel pathology. However, the role of bowel preparation is controversial. Therefore, the aim of this study was to explore the role of bowel preparation and in particular its consequences on diagnostic yield in a meta-analysis of all relevant studies. METHODS: Extensive English-language medical literature searches were performed up to February 2008, using suitable keywords, looking for human studies that compared different modes of small bowel preparation (purgative vs. clear liquids diet). We examined the effects of this preparation on the following three primary end points, diagnostic yield (DY), small bowel visualization quality (SBVQ), and VCE completion rate (CR) by meta-analysis of relevant studies. RESULTS: A total of 12 eligible studies (6 prospective, 6 retrospective) were identified, including 16 sets of data relevant to our primary end points. There were significant differences between patients prepared with purgative vs. those prepared with clear liquids diet in DY (263 vs. 213 patients, respectively; OR (95% CI)=1.813 (1.251-2.628), P=0.002) and SBVQ (404 vs. 249 patients, respectively; OR (95% CI)=2.113 (1.252-3.566), P=0.005). There was no statistically significant difference regarding CR rate. Purgatives did not affect VCE gastric transit time (GTT) or VCE small bowel transit time (SBTT). CONCLUSIONS: Pooled data showed that in comparison to clear liquids diet, purgative bowel cleansing, before VCE, improves the SBVQ and increases the DY of the examination, but does not affect the VCE completion rate.

Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis.

BACKGROUND AND STUDY AIMS: The optimal treatment of bleeding due to radiation proctitis is still controversial. Although argon plasma coagulation (APC) has been recently reported as an effective treatment, its efficacy in relation to disease severity is unknown. The study aims were to prospectively evaluate (i) the efficacy of APC in endoscopically mild and severe radiation proctitis, and (ii) the recurrence rate following successful treatment. PATIENTS AND METHODS: 56 patients (mean age 68.4 years) with radiation proctitis after radiotherapy for prostate cancer were studied. All presented with rectal bleeding, occurring a median 21.5 months after radiotherapy. Using an established scoring system, patients were classified into two groups, with mild or severe disease. We also examined the correlation between endoscopic severity and hemoglobin level as a more objective measure of bleeding activity. Success was defined either as cessation of bleeding or a significant reduction so that further treatment was not required. RESULTS: Proctitis was classified as mild in 27 patients (48%) and severe in 29 (52%). Endoscopically judged severity and hemoglobin level showed good correlation (R = 0.58). All patients with mild proctitis and 23/29 (79%) with severe disease were successfully treated (P < 0.05). During a follow-up of a mean of 17.9 months (range 6-33), 34/38 patients (89.5%) remained in clinical remission. Recurrence was higher in those using anticoagulant or aspirin (P = 0.02). CONCLUSIONS: APC is highly effective in all patients with mild radiation proctitis and in the majority of those with severe disease, providing long-lasting clinical remission.

Keratinocyte growth factor is effective in the prevention of intestinal mucositis in patients with hematological malignancies treated with high-dose chemotherapy and autologous hematopoietic SCT: a video-capsule endoscopy study.

Oral and/or intestinal mucositis is a severe complication of hematopoietic SCT. Keratinocyte growth factor (KGF) has proven activity in the prevention of oral mucositis. We examined the efficacy of KGF in the prevention of intestinal mucositis. From January 2006 until December 2007, 35 consecutive patients underwent autologous SCT (auto-SCT) in our institution. A total of 15 consecutive patients who underwent auto-SCT from March 2007 to December 2007 received KGF for the prevention of mucositis and were included in the study group A, whereas 20 consecutive patients treated from January 2006 to March 2007, were included in the historical control group B. Oral and intestinal mucositis were significantly less severe in group A (P=0.002 and P<0.001, respectively). These results were confirmed with the use of video-capsule endoscopy. Patients in group A had a significantly lower incidence of neutropenic fever (P=0.026). Severe intestinal mucositis was significantly associated with a higher incidence of documented infections too (P=0.019). KGF is effective in the prevention of intestinal mucositis in patients undergoing auto-SCT. Patients with severe intestinal mucositis run a higher risk to develop infections.

Do we present abstracts on ethical, legal, cost-effectiveness and patient care issues at major gastroenterology congresses?

INTRODUCTION: In the era of the new millennium, a lot of preclinical and clinical research is published. However, ethico-legal, cost-effectiveness and patient care issues are not addressed equally. AIM: To investigate whether abstracts presented at major international gastroenterology congresses refer to issues relevant to doctor-patient relationship, cost-effectiveness and care. METHODS: We reviewed the abstracts on disk CD-ROMs of the United European Gastroenterology Week (UEGW) and the Digestive Disease Week (DDW), for the years 1998-2006. We used the following keywords: ethical/ethically, legal, consent, cost-effective/effectiveness, care, quality and tolerable/tolerability. RESULTS: Over the study period, 1,612/20,018 (8.05%) and 764/45,628 (1.67%) abstracts including the above keywords were presented at UEGW and DDW congresses (p = 0.013), respectively. Statistically significant more abstracts containing separately any of the key words (apart from 'legal') were presented at the UEGW than at the DDW congress. There was a significant trend of increased referring to these key words over the study period for UEGW (p < 0.041) but not for DDW congresses (p = 0.70). CONCLUSION: The abstracts presented at the UEGW refer to ethico-legal, cost-effectiveness and patient care issues more frequently than those presented at the DDW. There is a trend of increased referring to these subjects at the UEGW but not at the DDW.

Epithelial cell turnover, p53 and bcl-2 protein expression during oncogenesis of early and advanced gastric cancer in a Western population.

OBJECTIVES: To investigate epithelial cell turnover alterations, and p53, bcl-2 protein expression during development of early and advanced gastric cancer in a Western population. METHODS: We investigated cell apoptosis and proliferation rates, p53 and bcl-2 protein expression in 17 early and 34 advanced gastric carcinomas and in the adjacent non-dysplastic mucosa. Cell proliferation, p53 and bcl-2 expression were detected immunohistochemically using MIB-1, anti-p53 and anti-bcl-2 monoclonal antibodies. Apoptosis was measured by TUNEL. The rate of the positive stained cells (labelling index) was count using image analysis technique. RESULTS: No difference was observed of either apoptotic (10 vs. 11) or proliferation (35 vs. 25) index between early and advanced cancers. However, the apoptotic index was significantly higher in intestinal type advanced tumors. While both apoptotic and proliferation indices were significantly higher in tumors than in the adjacent mucosa, no difference was observed of either apoptotic (2 vs. 2) or proliferation (8 vs. 13) index between the tissues adjacent to early and advanced tumors. p53 protein expression was significantly higher in advanced cancers (7 vs. 5, p=0.001) and in the non-dysplastic tissue adjacent to advanced tumors (3.5 vs. 2, p=0.001). bcl-2 labelling index was significantly higher in the mucosa adjacent to advanced carcinomas (15 vs. 5, p=0.016) but this difference did not reach significance in the tumors (20 vs. 15, p=0.37). CONCLUSIONS: Our data indicate similar cell turnover during tumorigenesis of early and advanced cancer. p53 and bcl-2 protein accumulation is more intense in gastric mucosa adjacent to advanced tumors and p53 immunoreactivity peaks in advanced carcinomas.

Mental health and psychosocial factors in young refugees, immigrants and Greeks: A retrospective study.

Since 1989, Greece has accepted thousands of economic immigrants and more recently, since 2010, has been transformed to a host country for refugees mainly from countries at war. Refugees experience a number of serious traumas, i.e. death of family member or a close friend, physical, emotional or sexual abuse, and at the same time have to confront poverty, hostility and racism during and after the settlement in the host country. On the other hand, economic immigrants have mainly to face adaption difficulties in a host country including racism, poverty, different culture, bureaucracy. The aim of the current retrospective study was to examine the differences in psychopathology between immigrants, refugees and natives. We examined differences in psychiatric diagnoses and factors influencing their health status between four groups: (i) 90 files of children whose families referred to the Department of Child and Adolescent Psychiatry (DeCAP), University of Athens, during 2005-2009, (ii) 216 files of children whose families seek for help during 2010-2014. Immigrants who referred to the DeCAP during the first period were mainly economic immigrants, whereas immigrants of the second period were mainly refugees from countries in conflict. These data were matched with age and sex with 151 files of natives who referred to the DeCAP during the aforementioned decade: (iii) 72 Greek families who seek for help during 2005-2009, and (iv) 79 Greek families who seek for help during 2010-2014. The Greek comparison group consisted of children and adolescents whose parents were both Greek. Investigating the differences in psychiatric diagnoses (F) and factors influencing health status (Z) between the groups, young refugees received a greater number of Z compared to Greeks (2010-2014). The proportion of refugees who had at least two Z was greater than that of immigrants and Greeks 2010-20014. Regarding the psychiatric diagnoses, Greek sample after 2010 received a greater proportion of psychiatric diagnoses than refugees. These results highlight that refugee families seek for help mainly not for psychiatric reasons. This could reflect their different needs or their difficulty to have access in public health services comparing to immigrants and natives.

Accuracy of measurements of the length of esophageal lesions: an experimental study.

BACKGROUND AND STUDY AIMS: Hiatal hernia, Barrett's esophagus and erosive esophagitis are defined and classified by measuring their length during endoscopy. The primary aim of our study was to evaluate the accuracy of length measurement of esophageal lesions with the conventional gastroscope marked at 5-cm intervals, and the secondary aim was to test the performance of a modified gastroscope marked at 1-cm intervals. METHODS: 24 senior endoscopists carried out endoscopy on a plastic mannequin. The esophagus was randomly replaced by one of a set of seven plastic tubes, each tube having two colored rings which were 1, 1.5, 2, 2.5, 3, 3.5 or 4 cm apart. The endoscopists were asked to measure the distance between the mouth-guard and each of the two "esophageal" rings during endoscope withdrawal, with a precision of 0.5 cm. All participants endoscoped all seven tubes blindly, first using the conventional scope and then the modified scope. RESULTS: Using the conventional gastroscope, measurements were overall incorrect in 67.9 % (95 % CI 61 - 75.1) of cases and incorrect by at least 1 cm in 21 % (95 % CI 14.8 - 27.2) of cases. These percentages were significantly reduced by using the modified gastroscope (47.6 %, 95 % CI 40.1 - 55.2 and 7.1 %, 95 % CI 3.2 - 11.0, respectively) ( P < 0.001). Overall accuracies in measuring lengths of >or= 2 cm and >or= 3 cm, corresponding to hiatal hernia and Barrett's esophagus definitions, were 83 % and 94 % - 95 % with the conventional and modified gastroscopes, respectively ( P < 0.05). CONCLUSIONS: Our data suggest that estimation of the length of esophageal lesions using conventional endoscopes is inaccurate. The accuracy of measurements is significantly improved with the use of an endoscope marked at intervals of 1 cm.

Video-capsule endoscopy gastric and small bowel transit time and completeness of the examination in patients with diabetes mellitus.

BACKGROUND: Small intestine video-capsule endoscopy examination in patients with diabetes mellitus may be incomplete due to delayed gastric emptying. AIM: To measure video-capsule endoscopy gastric and small bowel transit time and to assess the completeness of the examination in diabetes mellitus patients. METHODS: In this retrospective, case-control study, we examined capsule endoscopy videos from 29 consecutive diabetes mellitus patients. Fifty-eight matched for sex, type of preparation, age and reason for referral non-diabetic controls were selected from our video-capsule endoscopy database. Two independent experienced investigators measured transit times and assessed examinations' completeness. RESULTS: Video-capsule endoscopy gastric transit time was significantly longer in diabetes mellitus (87, 1-478 min) compared to non-diabetic patients (24, 4-108 min, p<0.001). The caecum was visualized in 20/29 (69%) diabetes mellitus and 52/58 (89.6%) non-diabetic controls (p=0.02). In 16 diabetes mellitus patients that video-capsule endoscopy reached the caecum, small bowel transit time was significantly shorter (261.2+/-55.5 min) compared to their 32 non-diabetic matched controls (302+/-62.7 min, p=0.03). CONCLUSIONS: Patients with type 2 diabetes mellitus have prolonged video-capsule endoscopy gastric transit time compared to non-diabetic patients. Prospective studies are required to complete our understanding of video-capsule endoscopy transit times in the setting of diabetes mellitus.

Functional dyspepsia susceptibility is related to CD14, GNB3, MIF, and TRPV1 gene polymorphisms in the Greek population.

BACKGROUND: Functional dyspepsia (FD) susceptibility might be influenced by polymorphisms of genes related to inflammation (CD14, macrophage migration inhibitory factor [MIF]), motor (GNB3), and sensory dysfunction (GNB3, TRPV1). We examined the association between CD14 rs2569190, GNB3 rs5443, MIF rs222747, and TRPV1 rs755622 gene polymorphisms with FD (Rome III criteria) in the Greek population. METHODS: We genotyped 174 dyspeptics (115 with epigastric pain syndrome; 41% Helicobacter pylori positive) and 181 controls using polymerase chain reaction-based methods and we measured disease symptoms' burden with a modified Gastrointestinal Symptoms Related Scale. KEY RESULTS: Homozygous for the TT genotype and the T allele of the CD14 gene were significantly associated (OR [95% CI]) with FD (2.65 [1.42-4.94] and 1.67 [1.23-2.26], respectively). The CT, TT genotypes, and T allele frequencies of GNB3 showed also significant association with FD (2.18 [1.35-3.54], 3.46 [1.30-9.23], and 2.18 [1.48-3.19]). While heterozygous GC MIF genotype was more common in dyspeptics (1.67 [1.07-2.60]), homozygous CC genotype and the C allele of TRPV1 gene were more prevalent in controls (0.47 [0.25-0.87] and 0.69 [0.51-0.92], respectively). None of the gene polymorphism was related either to dyspepsia clinical syndrome type or to the H. pylori infection. Among dyspeptics, CD14 TT genotype was related to lower epigastric pain burden score (p<.011); CD14 CT genotype was related to higher epigastric burning and nausea burden scores (p<.04) while belching score was lower (p=.027) in MIF CG dyspeptics. CONCLUSION & INFERENCES: Functional dyspepsia susceptibility is related to CD14, GNB3, MIF, and TRPV1 gene polymorphisms, while CD14 and MIF gene variants are also associated with dyspepsia symptoms burden.

The association between CagA status and the development of esophagitis after the eradication of Helicobacter pylori.

BACKGROUND: Strains of Helicobacter pylori with the cytotoxine-associated gene A (cagA) are linked to severe forms of gastroduodenal disease. Although eradication of H. pylori may predispose to the development of reflux esophagitis, the effects of CagA status on risk of esophagitis after successful H. pylori treatment are not known. METHODS: We studied 50 consecutive patients without esophagitis in whom H. pylori was eradicated successfully. CagA status was determined by immunoblotting sera from patients against H. pylori antigens. Patients underwent upper gastrointestinal endoscopy before eradication and 6, 12, 18, and 24 months after eradication or when reflux symptoms occurred. Biopsy specimens of the antrum and corpus were evaluated for gastritis before H. pylori eradication and at the end of the study. The sum of the scores for acute and chronic inflammation (both measured on a 0 [absent] to 3 [severe] scale) comprised the total gastritis severity score. RESULTS: In a multivariate proportional hazards regression analysis, positive CagA serology (hazard ratio [HR] = 10, 95% confidence interval [CI]: 1.3 to 81) and moderate-to-severe corpus gastritis (total severity score > or =4) before eradication (HR = 2.3, 95% CI: 1.2 to 6.1) were independent risk factors for the development of esophagitis after H. pylori eradication. CONCLUSION: Patients infected with strains of H. pylori that are cagA-positive are at increased risk of developing esophagitis after eradication of H. pylori.

Effectiveness of two quadruple, tetracycline- or clarithromycin-containing, second-line, Helicobacter pylori eradication therapies.

BACKGROUND: There are no guidelines on second-line therapies for Helicobacter pylori eradication failures of omeprazole-clarithromycin-amoxicillin triple therapy. AIM: To compare the efficacy of two second-line therapies for persistent H. pylori infection. METHODS: Over a 6-year period, patients with persistent H. pylori infection following omeprazole-clarithromycin-amoxicillin eradication therapy were randomized to receive omeprazole, 20 mg twice daily, bismuth, 120 mg four times daily, metronidazole, 500 mg twice daily, and either tetracycline, 500 mg four times daily, or clarithromycin, 500 mg twice daily, given for 7 days. Before therapy, patients underwent endoscopy with biopsies for histology, culture and antibiotic susceptibility tests. H. pylori infection was confirmed by histology. RESULTS: Of the 95 randomized patients, 88 (93%) completed the study. Age, sex, smoking, ulcer/non-ulcer dyspepsia ratio and antibiotic resistance were not significantly different between the treatment groups. On intention-to-treat analysis, eradication was achieved in 41 of the 49 patients (84%; 95% confidence interval, 70.4-92.7%) and 27 of the 46 patients (59%; 95% confidence interval, 43.3-73.0%) of the tetracycline- and clarithromycin-containing groups, respectively (P=0.007). On multivariate regression analysis, the sensitivity of H. pylori to metronidazole had a likelihood ratio of 5.2 (P=0.022), followed by the type of quadruple therapy (likelihood ratio, 4.4; P=0.036). CONCLUSIONS: Tetracycline-containing quadruple rescue therapy is highly effective in treating H. pylori eradication failures of the omeprazole-amoxicillin-clarithromycin regimen.

p53 protein accumulation and colonic adenoma recurrence.

OBJECTIVES: The prognostic value of p53 protein accumulation in colonic adenomas is still controversial. The aim of the present study was to determine whether the evaluation of p53 protein accumulation in newly diagnosed colonic adenomas could predict the development of metachronous adenomas. DESIGN/METHODS: Fifty-five patients who underwent prior endoscopic polypectomy for colonic adenomas were colonoscopically re-evaluated at 24-38 months after index colonoscopy. In cases with more than one adenoma, the one with the greatest diameter and the most serious histology was taken into account. p53 protein expression was immunohistochemically examined using specific monoclonal antibody. RESULTS: p53 protein was detected in 41.8% of the 55 index adenomas. Recurrent adenomas were present in 21 patients (38.2%). Metachronous adenomas were present in 56.5% of patients with p53-positive index adenomas and in 25% of those with p53-negative index adenomas (odds ratio 3.90, P = 0.018). Among patients with 1 or 2 index adenomas, metachronous adenomas were found in 50% of those with p53-positive index adenomas and in 22.6% of those with p53-negative index adenomas (odds ratio 3.43, P= 0.042). Multivariate stepwise logistic regression analysis revealed that number of index adenomas per patient (1 or 2 versus > 2) and p53 expression (positive versus negative) in index adenomas contain independent prognostic information for adenoma recurrence (chi2 = 8.2, P= 0.004 and chi2 = 4.08, P = 0.04 respectively). Patients aged < 60 years developed recurrent adenomas relatively more frequently if they had a p53-positive index adenoma (P= 0.068). In the subgroup of patients aged < 60 years with 1 or 2 index adenomas, the recurrence of adenomas was more frequent in those with a p53-positive index adenoma but the difference did not reach statistical significance (P= 0.13). CONCLUSIONS: Our data suggest that p53 expression in index adenomas is associated with recurrent colonic adenomas.