Probiotic intake unmasking a gastro-pleural fistula.

OBJECTIVE: Gastropleural fistula represents a rare clinical event often resulting in an iatrogenic complication of gastrointestinal surgery. Clinical presentation is insidious, patients complain of chronic and non-specific respiratory symptoms and may be conservatively treated for lung infections for several months until detailed tests finally reveal the correct diagnosis. PATIENTS AND METHODS: We describe a case of a healthy patient with an unexpected diagnosis of empyema due to a gastropleural fistula. RESULTS: A 51-year-old man with a past history of splenectomy for cyst was admitted because of high fever and cough. A chest radiography and CT-scan revealed a left-side pneumonia complicated with pleural empyema. Broad spectrum empirical antibiotics and pleural drainage did not significantly improve the clinical picture. While the need for a surgical complex thoracic approach becomes a collective awareness, questions about causes of empyema and its unfavorable evolution in our patient did not initially find a common satisfactory answer. It was only by the identification of probiotics bacteria in the pleural fluid that a gastropleural fistula was suspected, and then, it was confirmed by CT-scan and by digestive endoscopy. A combined thoraco-abdominal surgical treatment was therefore scheduled, leading to progressive improvement till total healing. CONCLUSIONS: Although gastropleural fistula is rare, it is necessary to include this pathological condition in the differential diagnosis of a persistent complicated pneumonia, because early diagnosis and, consequently, surgical management, may significantly impact on the prognosis of these patients. In our case, the detection of probiotics bacteria in the pleural fluid helped us to suspect and to look for the fistula.

Small Intestinal Bacterial Overgrowth Affects the Responsiveness to Colchicine in Familial Mediterranean Fever.

OBJECTIVE: Familial Mediterranean fever (FMF) is an autosomal recessive disease due to a MEFV gene mutation. Since Helicobacter pylori infection has been described to increase the severity and frequency of FMF attacks, we evaluate if overgrowth of small intestinal bacterial (SIBO), associated with a release of bacterial products, can affect the response to colchicine in FMF patients poorly responsive to colchicine. METHODS: We revised our Periodic Fever Centre database to detect FMF patients who were poorly responsive to colchicine, without a well-defined cause of drug resistance. They were evaluated for SIBO presence, then treated with decontamination therapy. RESULTS: Among 223 FMF patients, 49 subjects show colchicine resistance, and no other known causes of colchicine unresponsiveness has been found in 25 patients. All 25 patients underwent glucose breath test; 20 (80%) of them were positive, thus affected by SIBO. After a successful decontamination treatment, 11 patients (55%) did not show FMF attacks during the following three months (p < 0.01), while 9 of them revealed a significant reduction of the number of attacks compared to three months before (p < 0.01). CONCLUSION: The SIBO eradication improves laboratory and clinical features of FMF patients. Thus, patients with unresponsiveness to colchicine treatment should be investigated for SIBO.

Systematic review: Sprue-like enteropathy associated with olmesartan.

BACKGROUND: The onset of a sprue-like enteropathy in association with olmesartan therapy has been recently reported. AIMS: To perform a systematic review of the literature and describe three additional cases of olmesartan-associated enteropathy. METHODS: Electronic and manual bibliographic searches were performed to identify original reports in which subjects who were undertaking olmesartan developed a sprue-like enteropathy. Because of the scarcity of studies with adequate sample size, case series with less than 10 patients and case reports were also considered. Data extraction was performed independently by two reviewers. RESULTS: A total of 11 publications met our pre-defined inclusion criteria, for an overall number of 54 patients (including our series). Almost all patients presented with diarrhoea and weight loss. Normocytic normochromic anaemia and hypoalbuminaemia were the commonest laboratory defects at presentation. Antibody testing for coeliac disease was always negative. Variable degrees of duodenal villous atrophy were present in 98% of patients, while increased intra-epithelial lymphocytes were documented in only 65% of cases. After discontinuation of olmesartan, all reported patients achieved resolution of signs and symptoms. CONCLUSIONS: Although the available evidence is limited, the olmesartan-associated sprue-like enteropathy may be considered as a distinct clinical entity, and should be included in the differential diagnosis when serological testing for coeliac disease is negative.

Role of fecal calprotectin in gastrointestinal disorders.

BACKGROUND: Fecal calprotectin (FC) has been proposed as a useful and non-invasive marker of acute intestinal inflammation. AIM: We summarize recent evidences on FC, providing practical perspectives on its diagnostic and prognostic role in different gastrointestinal conditions. MATERIALS AND METHODS: We performed a MEDLINE search for all articles published on FC in human gastroenterology field up to December 2011. We chose evidences from well-designed and controlled studies when available. A meta-analysis was not performed because of the heterogeneity of these studies. RESULTS: Most of relevant data derived from studies on inflammatory bowel disease (IBD). FC concentrations (FCCs) showed a good diagnostic precision for separating organic and functional intestinal diseases and well correlated with IBD activity. FCCs were higher in subjects with NSAID enteropathy, but the actual correlation between FC and endoscopy is under investigation. FCCs can not be recommended for colorectal neoplasia population screening purpose. Few and heterogeneous studies have been performed in order to evaluate role of FC in other gastrointestinal conditions. CONCLUSIONS: FC has been widely proposed as a filter to avoid unnecessary endoscopies. Nevertheless, it should not be considered as a marker of organic intestinal disease at all; rather it represents a marker of "neutrophilic intestinal inflammation". In IBD, more and larger studies are needed to confirm FC's capacity to correlate with IBD extent, to predict response to therapy and relapse, and the presence of a subclinical intestinal inflammation in asymptomatic first-degree relatives of patients. For NSAID enteropathy, the actual correlation between FC and endoscopic results needs further confirmation. Finally, as regarding other gastrointestinal conditions, available data are still insufficient to draw any final conclusion and further studies should be encouraged.

Lactose intolerance: from diagnosis to correct management.

This review discusses one of the most relevant problems in gastrointestinal clinical practice: lactose intolerance. The role of lactase-persistence alleles the diagnosis of lactose malabsorption the development of lactose intolerance symptoms and its management. Most people are born with the ability to digest lactose, the major carbohydrate in milk and the main source of nutrition until weaning. Approximately, 75% of the world's population loses this ability at some point, while others can digest lactose into adulthood. Symptoms of lactose intolerance include abdominal pain, bloating, flatulence and diarrhea with a considerable intraindividual and interindividual variability in the severity. Diagnosis is most commonly performed by the non invasive lactose hydrogen breath test. Management of lactose intolerance consists of two possible clinical choice not mutually exclusive: alimentary restriction and drug therapy.

Fructose, trehalose and sorbitol malabsorption.

Carbohydrate malabsorption is a frequent clinical condition, often associated with abdominal symptoms. Although lactose represents the most commonly malabsorbed sugar, also other carbohydrates, such as fructose, trehalose and sorbitol may be incorrectly absorbed in the small intestine. Fructose malabsorption seems more common in patients with functional bowel disease, even if randomized and controlled studies on these topic were few and on small samples. Interpretation of breath hydrogen testing is difficult. In particular, neither studies comparing this test with a gold standard, nor validated doses and concentrations to be used, are available. Trehalose malabsorption due to trehalase deficiency represents a very rare condition and available studies do not support its relevance in clinical practice. Sorbitol absorption is dose and concentration related, and depends on the entity of intestinal absorption surface. Nevertheless, the finding of its malabsorption is not expression of a specific cause of intestinal bowel damage. From available data, it is not possible to draw definite conclusions about clinical relevance of fructose, trehalose and sorbitol malabsorption, as well as, about diagnostic accuracy of commonly used tests to detect all these conditions. On the other hand, in patients who refer abdominal discomfort after ingestion of different carbohydrate-containing foods, a small intestinal bacterial overgrowth, should be promptly considered. This is because the large amount of intestinal bacteria may unspecifically ferment sugars, causing an abnormal H2 production and consequently a misleading diagnosis of sugar malabsorption.

Reduced performance of Troponin T for acute coronary syndromes diagnosis in the elderly and very elderly patients: a retrospective study of 2688 patients.

STUDY OBJECTIVE: We evaluated the performance of Troponin T (cTnT) for acute coronary syndrome (ACS) diagnosis in elder compared to younger patients. MATERIALS AND METHODS: We retrospectively evaluated 2688 patients admitted to our Emergency Department for suspected ACS. All patients received ECG, serum creatinine determination, and serial cTnT samplings. Patients were considered positive for cTnT if they had a cTnT above our reference standard (>0.03 microg/L) in any determination obtained within 6 hours from admission. ACS diagnosis, either acute myocardial infarction or unstable angina, was based on reviewed data and discharge diagnosis hospital. Patients were divided in three groups according to age: <65-years-old, elders > or =65 and <80 years, and very elders > or =80 years. CTnT diagnostic accuracy for ACS was compared in these three groups in patients <65 years. RESULTS: Two thousands six and hundred eighty-eight patients (35.3% female) were enrolled in this study. 1087 patients (40.4%) were <65 years old, while 1205 patients (44.8%) were >or =65 and <80 years, and 396 patients (14.8%) were > or =80 years. The overall sensitivity of cTnT for ACS diagnosis was 0.57 (CI 95% 0.54-0.60) with a specificity of 0.71 (CI 95% 0.69-0.73). In older cohorts cTnT showed a reduced performance for ACS diagnosis. Area under the receiver operating characteristic curve of abnormal cTnT for ACS was 0.70 (0.66-0.73) in <65 years, 0.61 (95% CI 0.60-0.66) in > or =65 and <80 years, and 0.59 (0.53-0.65) in > or =80 years. CONCLUSION: Compared to younger patients cTnT showed a reduced performance for ACS diagnosis in elders > or =65 and <80 years; cTnT performance was further reduced in patients > or =80 years.

[Stability study of paediatric extemporaneous parenteral nutrition with lipids]. / Estudio de estabilidad de mezclas de nutrición parenteral extemporáneas neonatológicas con lípidos.

UNLABELLED: Stability of extemporaneous parenteral nutrition is a critical aspect of these formulations, with impact in patient safety and quality of service. In lipid emulsions physical stability can be assessed by the increase in the number of lipid globules of size superior than 500 nm, generated by coalescence of small globules during time. OBJECTIVES: To determine medium size of the lipid globules that compose the internal phase of TNA, in order to evaluate its stability and establish beyond-use date of the parenteral nutrition. To evaluate distribution profile of the lipid globules in the parenteral nutrition and compare it with this of the lipid emulsion used as raw material. METHOD: Globule size assessment by dynamic light scattering in a paediatric extemporaneous parenteral nutrition formula of frequent use, stored in different periods of time and temperatures. RESULTS: Medium globule size of the parenteral nutrition analyzed samples did not exceed the limit recommended by literature. Medium size and distribution of the lipid globules in the original lipid emulsion did not have significative changes after the compounding of the parenteral nutrition. DISCUSSION: Obtained data allow to consider that the extemporaneous parenteral nutrition evaluated would have a beyond-use date superior than the one now in use. This research must be deepened by the study of other formulas of parenteral nutrition in order to optimize the setting of beyond-use date.

[Comparison of a new medical device with domperidone in functional dyspepsia: a randomized, cross-over, controlled study]. / Confronto tra un nuovo dispositivo medico e domperidone in pazienti con dispepsia funzionale: studio randomizzato, cross-over, controllato.

AIM: Management of functional dyspepsia is still controversial. Different controlled trials reported a superiority of prokinetics, H2-receptor antagonists and proton-pump inhibitors over placebo; nevertheless, symptomatic improvement after therapy is often incomplete and some of these drugs possess serious side effects. The aim of the study was to evaluate the efficacy of a new medical device in respect to domperidone in patients with functional dyspepsia. METHODS: In a cross-over, randomized trial, 36 patients with functional dyspepsia ingested two daily doses of a medical device (Digerfast) or domperidone (Peridon) for 21 days. Clinical evaluation was performed at baseline (T0) and after 21 days (T1) for each treatment. A Visual Analogue Scale (VAS) and the generic scale 36-item Short Form (SF-36) were used to assess symptom intensity and changes in health-related quality of life, respectively. RESULTS: At T0 no statistical difference was found for each symptom between medical device and domperidone. At T1 both treatments significantly improved in respect to baseline values all the evaluated gastrointestinal symptoms (P<0.5 for all comparisons) except for vomiting. No difference in gastrointestinal symptoms between the two treatments was found at T1. Regarding SF-36 evaluation, at T0 no statistical differences were found for each SF-36 parameter between the two regimens. At T1 both treatments significantly improved most of the evaluated SF-36 parameters in respect to baseline values. No difference in SF-36 parameters between the two treatments was found at T1. CONCLUSION: Both the medical device and domperidone significantly improved gastrointestinal symptoms and quality of life in subjects with functional dyspepsia, not showing significant difference in efficacy.

Clinical trial: the effects of a probiotic mixture on non-steroidal anti-inflammatory drug enteropathy - a randomized, double-blind, cross-over, placebo-controlled study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) can cause serious gastrointestinal side effects. Faecal calprotectin assay represents a simple and practical method for diagnosis of NSAID enteropathy. Intestinal micro-organisms are necessary for the development of NSAID-induced small bowel lesions and hence it has been suggested that probiotics could protect against NSAID enteropathy. AIM: To evaluate the effect of a probiotic mixture in comparison with placebo on faecal calprotectin concentrations (FCCs) in healthy volunteers receiving indomethacin. METHODS: In a double-blind, cross-over trial, 20 healthy volunteers ingested a daily dose of probiotic mixture (VSL#3) or placebo for 21 days. From day 16 to day 19, all subjects were also administered 50 mg/day of indomethacin. FCCs were measured the day before starting probiotic/placebo ingestion (T0), and every day from day 15 to day 21. RESULTS: During dosing with probiotic, median FCCs were significantly increased only at day 17 with respect to T0 values, whereas during dosing with placebo, they were significantly increased at every day from day 17 to day 21 with respect to T0 values. CONCLUSIONS: Treatment with VSL#3 before and during indomethacin therapy significantly reduces FCCs in healthy subjects with respect to placebo, suggesting that this approach could be useful in decreasing indomethacin-induced intestinal inflammation.

Severe giant cell arteritis associated with essential thrombocythaemia.

Giant-cell arteritis (GCA) is a chronic vasculitis of the elderly usually involving the ophthalmic arteries, which can result in visual loss. High platelet counts may have some pathogenic significance in the obstruction of the ophthalmic circulation and a few cases of associated essential thrombocythaemia and GCA have been described. Here we report a case of severe temporal arteritis associated with essential thrombocythaemia.

Evaluation of symptoms and palatability in healthy volunteers after ingestion of an iced dessert by using different flavours.

It is well-known that digestion has a pivotal role in maintaining a state of wellbeing. The influence of certain foods and some herbal drugs has been ascertained. Epidemiological data show that the Mediterranean diet, with a high consumption of fresh vegetables and fruit, mainly citrus, has a beneficial effect and plays a protective gastrointestinal role. Previously, we assessed the influence on the eventual occurrence of symptoms during digestion of an iced dessert containing a mixture of digestive plant extracts, citrus juices and liquors, showing that its ingestion does not cause significant gastrointestinal symptoms in healthy volunteers. Taking into consideration that sensory properties of food may also influence digestion, we also evaluated the palatability of the product. In order to evaluate the effect of different tastes on the digestive processes, we performed a further similar evaluation with two new flavours. The ingestion of these iced desserts at the end of the meal does not cause significant gastrointestinal symptoms. Moreover, palatability median score shows a good appreciation of the products. Therefore, the combination of digestive herbs, citrus juice and liquors in different flavours gives rise to a product with a positive mix of good palatability, favourable acceptance and herbal constituents, able to maintain a good digestive condition.

Clinical features of familial Mediterranean fever: an Italian overview.

Familial Mediterranean Fever (FMF) is the most frequent periodic febrile syndrome among the autoinflammatory syndromes (AS), nowadays considered as innate immunity disorders, characterized by absence of autoantibodies and autoreactive T lymphocytes. FMF is a hereditary autosomal recessive disorder, characterized by recurrent, self-limiting episodes of short duration (mean 24e72 h) of fever and serositis. In FMF, periodic attacks show inter- and intra-individual variability in terms of frequency and severity. Usually, they are triggered by apparently innocuous stimuli and may be preceded by a prodromal period. The Mediterranean FeVer gene (MEFV) responsible gene maps on chromosome 16 (16p13) encoding the Pyrine/Marenostrin protein. The precise pathologic mechanism is still to be definitively elucidated; however a new macromolecular complex, called inflammasome, seems to play a major role in the control of inflammation and it might be involved in the pathogenesis of FMF. The most severe long-term complication is type AA amyloidosis, causing chronic renal failure. Two types of risk factors, genetic and non-genetic, have been identified for this complication. Currently, the only effective treatment of FMF is the colchicine. New drugs in a few colchicine resistant patients are under evaluation

Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference.

BACKGROUND: Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular. AIM: The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H2-breath testing in gastrointestinal diseases. METHODS: Experts were selected on the basis of a proven knowledge/expertise in H2-breath testing and divided into Working Groups (methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group. RESULTS AND CONCLUSIONS: The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H2-breath testing in the clinical practice and methods to be used for performing the tests.

Evaluation of effects (symptoms and palatability) after ingestion of "Gran Soleil" in healthy volunteers.

A good digestion is essential to maintain a healthy status. It is known that physiological digestive processes could be improved by the ingestion of some medicinal plants, while specific foods can facilitate the occurrence of gastrointestinal symptoms. Moreover, sensory properties of food seem to also influence digestion. We assessed the influence on physiological digestive processes of two Gran Soleil (GS) products containing a mixture of digestive plant extracts, citrus juices and liquors. We evaluated, in 10 healthy volunteers, the eventual occurrence of gastrointestinal symptoms after their ingestion and measured their palatability. Ingestion of GS did not cause significant gastrointestinal symptoms. Moreover, the palatability median score shows a good appreciation of the products. In conclusion, it is possible to suppose that a product with a good palatability, able to support and maintain a good digestive condition, derives from the mixture of digestive herbs, citrus juices, liquor and other ingredients.

Low-dose lactose in drugs neither increases breath hydrogen excretion nor causes gastrointestinal symptoms.

BACKGROUND: Despite the reported tolerance to a low dose of lactose, many lactose malabsorbers follow a rigorous lactose-free diet also avoiding lactose-containing drugs. Up to now, only a few case reports have described the onset of gastrointestinal symptoms in lactose malabsorbers following the ingestion of these drugs. It has been suggested that capsules/tablets contain no more than 400 mg of lactose. AIM: To evaluate breath H(2) excretion and intolerance symptoms after ingestion of a capsule containing 400 mg of lactose or placebo through a randomized, cross-over, double-blind, controlled study. METHODS: Seventy-seven lactose maldigesters with intolerance underwent two H2 breath tests with both 400 mg of lactose and 400 mg of placebo. Gastrointestinal symptoms occurring in the 8 h following the ingestion of different substrates were evaluated by a visual-analogue scale. RESULTS: Ingestion of 400 mg of lactose did not cause a significant difference in breath H2 excretion or in the severity of gastrointestinal symptoms compared to placebo. CONCLUSION: In patients with lactase deficiency, drugs containing 400 mg of lactose or less can be used safely.

A highly accurate method for monitoring histological recovery in patients with celiac disease on a gluten-free diet using an endoscopic approach that avoids the need for biopsy: a double-center study.

BACKGROUND AND STUDY AIM: Endoscopy with duodenal biopsy is often performed in order to assess histological recovery in patients with celiac disease who are on a gluten-free diet. Use of the "immersion" technique during upper endoscopy allows visualization of duodenal villi or detection of total villous atrophy. In this two-center study, we investigated the accuracy of the immersion technique in predicting histological recovery in patients on a gluten-free diet whose initial diagnosis of celiac disease had been made on the basis of total villous atrophy. PATIENTS AND METHODS: The immersion technique was performed in 62 patients with celiac disease who were being treated and who had been referred for follow-up (26 patients at the Rome center and 36 patients at the Vicenza center). All these patients had an initial diagnosis based on positive antibodies and biopsy-proved duodenal total villous atrophy. At the follow-up examination, the duodenal villi were re-evaluated as present or absent by one endoscopist at each center, and the results were compared with the histology. RESULTS: At the follow-up endoscopy, the duodenal villi were found to be present in 51 patients and absent in 11. The sensitivity, specificity, positive predictive value, and negative predictive value of the immersion technique for detecting the presence or absence of villi were all 100 %. CONCLUSIONS: This study demonstrated the feasibility and the high level of accuracy of the immersion technique in predicting the histological recovery of duodenal villi in patients with celiac disease who are following a gluten-free diet. An endoscopy-based approach that avoids the need for biopsy could be useful for monitoring the dietary adherence and/or response of patients with an initial diagnosis of celiac disease based on total villous atrophy.

Hypokalemic nephropathy in an adult patient with partial empty sella: a classic Bartter's syndrome, a Gitelman's syndrome or both?

Bartter's syndrome belongs to a group of hypokalemic renal channel diseases. These channels are located in the lipid layer of cell membranes where they exist as water channels through which ion transport is performed. Based on the type of genetic disorder and clinical presentation, Bartter's syndrome is classified as neonatal, classical and Gitelman's syndrome. Most of the cases have been noted in pediatric age groups and adult-onset cases are very rare. Moreover, an association between Bartter's syndrome and empty sella has recently been reported in 3 children. We report here the second case of an adult patient affected by Bartter's syndrome with partial empty sella. The patient showed some clinical and histological characteristics of both classic Bartter's syndrome and Gitelman's syndrome, suggesting that genotype and phenotype of Bartter's syndrome are not so clear-cut and that phenotypic overlap may occur, according to a recent hypothesis. Magnetic resonance imaging disclosed a partial empty sella. A thorough endocrinological investigation showed normal hypophyseal, thyroidal, adrenal and gonadal function. Good therapeutic effects were achieved using spironolactone, ACE-inhibitor and potassium supplementation, with normalization of the kalemia. At present, the value of the association of Bartter's syndrome and empty sella remains unclear and future studies are needed to clarify the importance of this association, both in children and in adult patients affected by Bartter's syndrome.