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.

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.

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.

Functional symptoms in inflammatory bowel disease and their potential influence in misclassification of clinical status.

BACKGROUND: Functional symptoms occur in inflammatory bowel disease probably more than in the general population. Existing disease indices rely heavily on symptoms that may be organic or functional. This may explain inconsistencies between recent therapeutic trials in inflammatory bowel disease. Clinically, misinterpretation can lead to over-treatment of functional symptoms with potent agents, and to under-treatment of inflammatory bowel disease when inflammatory features are more subtle. AIM: To assess functional symptoms in inflammatory bowel disease and to devise simple means of their evaluation. METHODS: Patients with Crohn's disease, ulcerative colitis, and irritable bowel syndrome completed questionnaires, generating inflammatory bowel disease and irritable bowel syndrome indices. Data from outliers selected as exemplars were employed to create a new index. RESULTS: One hundred and ninety patients completed questionnaires. Overall, Crohn's and irritable bowel syndrome patients had similar functional features. The new scoring system was based on the eight apparently discriminant symptoms. Prospective evaluation in a separate cohort of 180 inflammatory bowel disease patients yielded scores that are independent of established indices, inflammatory markers and psychometric scores. CONCLUSIONS: Patients with Crohn's report comparable rates of apparently functional symptoms to those with irritable bowel syndrome. A new score has been developed to help in their identification. This has the potential to guide therapeutic decisions and optimize future trial recruitment.

Comparison of 1-week vs. 2- or 4-week therapy regimens with ranitidine bismuth citrate plus two antibiotics for Helicobacter pylori eradication.

BACKGROUND: Helicobacter pylori eradication therapies based on ranitidine bismuth citrate have recently been introduced in clinical practice. AIM: To compare the efficacy of three regimens containing ranitidine bismuth citrate given for 1, 2 and 4 weeks, combined with two antibiotics for the first week, in the eradication of H. pylori. METHODS: Eighty-six consecutive patients (50 duodenal ulcer disease, 36 non-ulcer dyspepsia) with H. pylori infection were offered three eradication regimens: (a) 1-week group (n=28), ranitidine bismuth citrate 400 mg b.d. for 7 days; (b) 2-week group (n=29), ranitidine bismuth citrate 400 mg b.d. for 14 days; and (c) 4-week group (n=29), ranitidine bismuth citrate 400 mg b.d. for 28 days. In all patients, clarithromycin 500 mg b.d. and metronidazole 500 mg b.d. were given for the first week. Endoscopy was repeated 1 month after the end of treatment and eradication was considered to be successful if both rapid urease test and histology were negative. RESULTS: Overall, H. pylori was eradicated in 84% (72/86) patients on intention-to-treat analysis, whereas the per protocol cure rate was 89% (72/81). Eradication rates were 23/27 (85%) (95% confidence interval (CI): 66-96%), 25/27 (92%) (95% CI: 76-99%) and 24/27 (89%) (95% CI: 71-98%) in the 1-, 2- and 4-week groups, respectively, on per protocol analysis, and 25/28 (82%) (95% CI: 63-94%), 25/29 (86%) (95% CI: 68-96%) and 24/29 (83%) (95% CI: 64-94%), respectively, on intention-to-treat analysis (P > 0.05, N.S.). No significant differences were observed between groups concerning duodenal ulcer healing, resolution of symptoms and adverse effects. CONCLUSIONS: The 1-week regimen with ranitidine bismuth citrate, clarithromycin and metronidazole is effective in H. pylori eradication. Prolongation of treatment with ranitidine bismuth citrate for 2 or 4 weeks does not achieve a statistically significant more favourable outcome.

Leukocytoclastic vasculitis as an onset symptom of Crohn's disease.

We report the case of an octagenerian who presented with leukocytoclastic vasculitis as the first symptom of Crohn's disease. The patient was admitted with skin rash on the lower extremities and ankles and episodes of bloody diarrhea. Skin and colon biopsies revealed acute leukocytoclastic vasculitis and moderate Crohn's disease, respectively. The patient was treated with intravenous corticosteroids in conjunction with antibiotics and per os mesalazine. Symptoms resolved rapidly within 5 days, and the patient was still asymptomatic on follow-up 3 months later.

Extensive homology between the major immunodominant mitochondrial antigen in primary biliary cirrhosis and Helicobacter pylori does not lead to immunological cross-reactivity.

BACKGROUND: Primary biliary cirrhosis (PBC) is an immune-mediated chronic cholestatic disease characterized by the presence of antibodies directed predominantly against the E2 subunit of the pyruvate dehydrogenase complex (PDC-E2). What provokes tolerance breakdown in PBC remains to be established, though there is evidence to indicate that microbes may induce anti-mitochondrial antibodies (AMA) through a mechanism of molecular mimicry. METHODS: Having found that urease beta (UREB)(22-36) antigen of Helicobacter pylori (HELPY) shares extensive (87%) similarity with PDC-E2(212-226), the major mitochondrial autoepitope, it was hypothesized that this would also lead to cross-reactivity. The UREB/PDC-E2 mimics were thus constructed and tested by ELISA in 112 PBC patients and 114 controls. RESULTS: Reactivity to PDC-E2(212-226) was found in 104 patients but to UREB(22-36) in only 2. In these two patients, the double reactivity was not cross-reactive. The lack of surface antibody accessibility to UREB(22-36), as demonstrated through three-dimensional model prediction analysis, may explain this unexpected finding. There was some speculation on whether HELPY UREB(22-36) might act as a cross-reactive CD4 T-cell epitope. All seven PBC patients, tested in a standard proliferation assay against PDC-E2(212-226), gave a positive response. All seven were unresponsive to HELPY UREB(22-36). The pattern of reactivity to HELPY antigens by immunoblot was similar between anti-PDC-E2-positive and negative PBC cases, as well as between PBC patients and controls. CONCLUSION: Contrary to common belief, extensive sequence homology (molecular mimicry) between self and microbe does not necessarily result in cross-reactivity. It is therefore likely that, when present, cross-reactivity between self and microbes is of biological importance.