Fish intake interacts with TM6SF2 gene variant to affect NAFLD risk: results of a case-control study.

PURPOSE: Non-alcoholic fatty liver disease (NAFLD) is a complex disease, resulting from a variety of genetic and environmental factors. The aim of this case-control study was to evaluate the effect of selected genetic polymorphisms, nutrition aspects and their interaction on the risk of NAFLD. METHODS: The sample consisted of 134 patients with NAFLD and 217 controls. Disease was diagnosed by liver ultrasound and volunteers were clinically and nutritionally assessed. Food groups were extracted from a 172 food-item FFQ questionnaire. Three genetic polymorphisms were assessed: PNPLA3 rs738409, TM6SF2 rs58542926 and GCKR rs780094. RESULTS: We replicated the effect of previously reported risk factors for NAFLD, such as elevated liver enzymes, obesity and metabolic syndrome. Food groups rich in simple sugars, fat and especially saturated fat were positively associated with NAFLD risk, whereas food groups rich in polyunsaturated fatty acids were reversely associated with the possibility of developing the disease (p < 0.05). Only the PNPLA3 genetic variant was statistically significantly associated with the disease (padditive = 0.015). However, it was found that a one-portion increase in fish intake increased the risk of NAFLD in carriers of the risk allele of TM6SF2 rs58542926 polymorphism compared to non-carriers, after adjusting for age, gender, energy intake, pack-years, PAL, TM6SF2 genotype and fish consumption (ORdominant = 1.503, 95% CI 1.094-2.064). CONCLUSIONS: Fish intake exerts an additive effect on NAFLD risk for carriers of the TM6SF2 polymorphism. This novel finding provides further rationale on the need for personalized nutritional advice, based on the genetic background of NAFLD patients.

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.

Serotonin transporter and G protein beta 3 subunit gene polymorphisms in Greeks with irritable bowel syndrome.

BACKGROUND: Polymorphisms in the serotonin transporter (SERT) and G protein ß3 subunit (GNB3) genes might contribute to the pathophysiology of irritable bowel syndrome (IBS). Association studies of SERT and GNB3 polymorphisms and IBS have shown diverse results among different populations, which might be due to subject composition differences. AIMS: The aim of the study was to assess the potential association between SERT and GNB3 polymorphisms and IBS in Greeks. METHODS: A total of 124 patients with IBS diagnosed according to the Rome III criteria and 238 healthy individuals were included in the study. SERT and GNB3 gene polymorphisms were genotyped using polymerase chain reaction-based methods. RESULTS: It was shown that the frequencies of the SS genotype and S allele of the serotonin transporter polymorphism were significantly associated with IBS (P = 0.0314 and P = 0.019, respectively). TT genotype and T allele frequencies of G protein ß3 subunit showed also significant difference between the IBS patients and healthy controls IBS (P = 0.0163 and P = 0.0001, respectively). None of the clinical symptoms analyzed was significantly associated with the polymorphisms tested. CONCLUSIONS: The results suggest that SERT and GNB3 gene polymorphisms might be associated with irritable bowel syndrome predisposition in Greeks.

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.

Dramatic decline of acute appendicitis in Greece over 30 years: index of improvement of socioeconomic conditions or diagnostic aids?

BACKGROUND AND AIMS: There are several reports showing a continuing fall in the incidence of acute appendicitis in the western countries. Our aim was to study the trend of the incidence of acute appendicitis in the Greek population over 30 years. METHODS: We analyzed the data referring to the years 1970-1999 on the incidence and mortality of acute appendicitis for the entire Greek population. Data were retrieved from the Annual Bulletin for the Social Welfare and Health Statistics of the National Statistics Service of Greece. In this database, acute appendicitis was a hospital discharge diagnosis. RESULTS: Over the study period, there was a 75% decrease of the age-standardized incidence of acute appendicitis from 652/100,000 to 164/100,000. The median female-to-male ratio of hospitalized patients for appendicitis of the study period (1970-1999) fell progressively from 1.27 in the year 1970 to 0.93 in the year 1999. The case fatality rates remained constant, ranging below 0.09 deaths per 100 appendicitis cases. CONCLUSION: There is a significant decline of the incidence of acute appendicitis in the Greek population over the years 1970-1999. This time trend is probably related to the improvement of the socioeconomic conditions over the same period and not to the introduction of new diagnostic aids.

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.

Comparison of T- and Z-score in identifying risk factors of osteoporosis in inflammatory bowel disease patients.

OBJECTIVE: Most studies have shown contradictory results regarding predictive factors of osteoporosis in inflammatory bowel disease (IBD). Since in these studies either T- or Z-scores has been used, our aim was to compare T- and Z-score in identifying risk factors of osteoporosis in IBD patients. MATERIALS AND METHODS: Bone density was measured by dual X-ray absorptiometry (DXA) at L2-L4 of the spine and femoral neck in 122 patients. Twenty-two clinical parameters were recorded prior to DXA and evaluated by univariate and multivariate analysis. RESULTS: On multivariate analysis, cumulative steroid dose was a predictive factor of femoral neck T-score (p<0.001) and Z-score (p=0.001). Age was a predictive factor of femoral neck T-score (p<0.001). BMI was a predictive factor of femoral neck Z-score (p=0.03). None of the other 19 variables tested had any predictive value for bone density. Age >or=55 years was a risk factor of low femoral neck T-score (OR 5.08, 95% CI 1.90-13.57, p=0.001), as was cumulative dose of prednisolone >or=5 g (OR 3.41, 95% CI 1.50-7.73, p=0.004). CONCLUSIONS: There is a discordance of results depending on whether T- or Z-scores are used in analysis. Among 22 parameters, cumulative steroid dose and age proved to be the most important factors.

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.

The Bcl-2/Bax system and apoptosis in ulcerative colitis.

BACKGROUND/AIMS: Ulcerative colitis (UC) constitutes a chronic inflammatory process of the colon of unknown etiology. Current data support a pivotal role of apoptosis in the evolution of pathogenesis of UC. We performed a prospective study in order to determine the role of Bcl-2, Bax and Bcl-x in the apoptotic pathway in UC. METHODOLOGY: We included 23 patients with UC and 11 controls. Histological severity of the disease was assessed according to the Sidney classification system. Patients in the UC group were divided in 2 groups according to histological severity of the disease. The TUNEL method was used for the in situ evaluation of apoptosis. Immunohistochemical staining was used for the detection of Bax, Bcl-2, Bcl-x. For the assessment of cellular proliferation we used the monoclonal antibody Ki67. Appropriate statistical methods were applied. RESULTS: Overall 77 specimens were assessed; 57 from UC patients and 20 from controls. Bcl-2, Bax and Bcl-x were upregulated in the group of patients with UC compared to controls. Nevertheless, Bax in epithelial cells and Bcl-x in lymphocytes were downregulated in patients with moderate/severe disease (p = 0.029 and 0.04 respectively). A weak correlation between epithelial apoptosis and Bcl-x expression in lymphocytes (r = 0.31, p = 0.02) was found. An even weaker correlation was also noticed between the epithelial component apoptosis and Bax in lymphocytes (r = 0.02, p = 0.07). CONCLUSIONS: Bcl-2/Bax system does not appear to be involved in the induction of apoptosis in UC. Activation of intraepithelial lymphocytes may be associated with epithelial apoptosis or simply represent epiphenomena related to the inflammatory process.

Honey may have a laxative effect on normal subjects because of incomplete fructose absorption.

Honey contains fructose in excess of glucose, which may lead to incomplete fructose absorption associated with abdominal symptoms and/or diarrhea. This hypothesis was investigated in 20 healthy volunteers (13 males, 7 females) with a mean (+/- SD) age of 35.9 +/- 12.1 y. Each subject drank the following aqueous solutions in random order: 20 g lactulose, 100 g honey, 50 g honey, and 35 g each of a glucose and fructose mixture. The breath-hydrogen concentration was measured every 15 min for 6 h. Semiquantitative estimates of carbohydrate malabsorption were assessed with lactose as a nonabsorbable standard. Breath-hydrogen concentrations increased by 52 +/- 6, 30 +/- 4, 20 +/- 3, and 4 +/- 1 ppm (mean +/- SEM) after each of the four test solutions, respectively. The estimated carbohydrate malabsorption was 10.3 +/- 1.8, 5.9 +/- 1.2, and 0.5 +/- 0.2 g after 100 g honey, 50 g honey, and the glucose-fructose mixture, respectively (F[2,57] = 16.05, P < 0.001). Within 10 h after the ingestion of 100 g honey, 50 g honey, and the glucose-fructose mixture, six, three and none of the volunteers, respectively, reported loose stools (chi 2 = 7.1, df = 2, P < 0.03). The results of this study suggest that carbohydrate malabsorption after ordinary doses of honey is frequent in healthy adults and may be associated with abdominal complaints. Honey may have a laxative effect in certain otherwise healthy individuals, probably because of incomplete fructose absorption.

Lactose maldigestion and milk intolerance in healthy Greek schoolchildren.

The prevalence of lactose maldigestion in Greek adults is 75% but the age at which the lactase activity starts declining is not known. The prevalences of lactose maldigestion and intolerance were investigated in 150 randomly selected Greek children 5-12 y old by using breath-hydrogen analysis after ingestion of lactose (2 g/kg body wt, maximum 50 g) or 0.240 L of milk. Prevalence of lactose maldigestion increased with age (y = -7.30 + 6.49x, r = 0.88, P = 0.004), being 29.4% and 80.0% at ages 5 and 12 y, respectively. Before testing, the reported prevalences of milk-related symptoms by children with high and low lactose-digestion capacity were 21.1% and 39.7% (chi 2 = 5.96, P = 0.015), respectively. However, the corresponding prevalences of lactose intolerance after ingestion of milk were 7.3% and 8.6% (chi 2 = 0.1, P = 0.72) and only three children had a delta H2 greater than or equal to 20 ppm postprandially. Although intestinal lactase activity declines before age 5 y and many Greek children report milk-related symptoms, true malabsorption and intolerance of lactose after a glass of milk is rarely seen at this age.

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.

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.

Pancreatic tuberculosis in non-immunocompromised patients: reports of two cases, and a literature review.

We present two cases of biopsy proven tuberculosis of the pancreas in non-immunocompromised patients diagnosed and treated in our unit within the last 14 years. The first case presented with abdominal pain and fever, and the second with iron deficiency anaemia and severe weight loss. In both cases abdominal ultrasound and computed tomography suggested a pancreatic carcinoma. There was no pulmonary or intestinal tuberculosis. The tuberculin skin test was positive. Upon exploratory laparotomy the macroscopic appearance of the pancreas was that of an inoperable pancreatic carcinoma. Following the histological diagnosis of pancreatic tuberculosis, both patients were successfully treated with triple antituberculous therapy for 6 months. Isolated pancreatic tuberculosis is an extremely rare disease with only 41 cases in non-immunocompromised patients reported worldwide (1966-1997). It is a curable disease and should be considered in the differential diagnosis of a pancreatic mass or abscess shown on ultrasound or computed tomography, especially in developing countries, where tuberculosis is common.