Gastric ciliated metaplasia. A study of 3406 gastrectomy specimens from dwellers of the Atlantic and the Pacific basins.

BACKGROUND: Ciliated cells in gastrectomies from patients dwelling in the Pacific and Atlantic basins have been reported previously. AIM: To compare all the results in an attempt to explain the findings. METHODS: Sections from 3406 gastrectomies were reviewed: 1966 and 1440 from the Atlantic and Pacific basins, respectively. Ciliated cells and intestinal metaplasia (IM) were recorded; IM was classified into focal or extensive IM. The total number of sections/gastrectomy was noted. RESULTS: In the Atlantic basin, 5% of specimens had ciliated metaplasia (CM); it was more frequent in intestinal carcinoma (IC; 9%) than diffuse carcinoma (DC; 3%) or miscellaneous gastric diseases (MGD; 3%). In the Pacific basin, the frequency of specimens with CM was 29%: it was more frequent in IC (43%) than in DC (16%) or MGD (10%). The difference between the frequency of CM in specimens with IC or with DC/MGD in the Atlantic and the Pacific basins was significant (p < or = 0.05). The presence of CM was influenced by age and the extent of IM in both basins, but not by sex or the number of sections investigated. CONCLUSIONS: CM-apparently an independent microscopic marker-was significantly higher in the Pacific than in the Atlantic basin. Environmental carcinogens involved in the evolution of IM and IC seem to be implicated in gastric ciliogenesis. Carcinogens that differ in nature and/or in strength in both basins might activate the latent natural genes encoding ciliated processes in gastric cells in patients subsequently developing gastric carcinoma, more notably of intestinal type.

Gastric glassy cells: a study of 3202 gastrectomy specimens from dwellers of the Atlantic and Pacific basins.

Fifteen years ago we detected gastric cells with glassy cytoplasm (GCs) in the human pyloric antrum. The frequency of these cells was subsequently investigated in sections from gastrectomies carried on in populations dwelling on the rim of the Atlantic and Pacific basins. In this work we compared the results obtained in these disparate geographic regions. We reviewed sections from 3203 gastrectomies (1942 in the Atlantic basin and 1261 in the Pacific basin). In the Atlantic basin 12/1942 (0.6%) of the gastrectomies had GCs, whereas in the Pacific basin 26/1261 (2.1%) of the gastrectomies had GCs. The difference was significant (p<0.05). The proportion of gastrectomies with GCs was higher in patients in Vancouver, Canada, than in New York, and higher in Santiago de Chile than in Buenos Aires, despite the fact that these populations reside at approximately the same geographic latitude. Previous studies with the same material indicated that both the extension of intestinal metaplasia and the frequency of ciliated metaplasia were significantly higher in the Pacific than in the Atlantic basin. Hence, the difference in the frequencies of GCs appears to be a new indication that dissimilar environmental exposures in the two basins might have influenced the histological make-up of the gastric mucosa.

Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial.

BACKGROUND: Pouchitis has been suggested to be a recurrence of ulcerative colitis in a colon-like mucosa. Topical steroids are a valid therapeutic alternative for distal forms of ulcerative colitis. AIM: To investigate the efficacy and tolerability of budesonide enema in the treatment of pouchitis compared with oral metronidazole. MATERIALS AND METHODS: Twenty-six patients with an active episode of pouchitis (defined as a pouchitis disease activity index score >or= 7) and no treatment during the previous month were randomized to receive either budesonide enema (2 mg/100 mL at bedtime) plus placebo tablets or oral metronidazole (0.5 g b.d.) plus placebo enema in a prospective, double-blind, double-dummy, 6-week, controlled trial. RESULTS: Based on the intention-to-treat principle, we detected a significant improvement in disease activity at the end of the first week with both drugs (P < 0.01). After that, improvement was moderated until stabilization at 4 weeks in both treatments. The per protocol analysis showed that both drugs had similar efficacy in terms of disease activity, clinical and endoscopic findings. Fifty-eight per cent and 50% of patients improved (decrease in pouchitis disease activity index >or= 3) with budesonide enema and metronidazole, respectively (odds ratio, 1.4; confidence interval, 0.2-8.9). Adverse effects were observed in 57% of patients given metronidazole and in 25% of patients given budesonide. CONCLUSIONS: Budesonide enemas are an alternative treatment for active pouchitis, with similar efficacy but better tolerability than oral metronidazole.

Gastric carcinomas of intestinal type concur with distant changes in the gastric mucosa. A multicenter study in the Atlantic basin.

Population studies in the Pacific Basin showed that gastric carcinomas of intestinal type often concur with distant mucosal changes (DMCs). In the present work, the presence of DMCs was investigated in populations dwelling in the Atlantic Basin. A total of 1737 gastrectomy specimens were reviewed: 627 in New York, 435 in Reykjavik, 198 in Buenos Aires, 186 in Florence, 174 in London and the remaining 117 in Stockholm. A total of 17,282 sections were carefully scrutinized. The following DMCs were investigated: intramucosal glandular cysts, gastric cells with ciliated metaplasia, with large or small mucus negative vacuoles, and extensive intestinal metaplasia (IM). The highest frequencies of DMCs were found in Florence for specimens with intestinal type carcinoma: 41.3% had intramucosal cysts, 22.4% had cells with ciliated metaplasia, 12.9% cells with large vacuoles, and 50.9% had high IM. The highest frequency of gastric cells with small vacuoles was recorded in New York (9.1%), also in specimens with intestinal type carcinoma. Significantly lower DMCs percentages were found in specimens with carcinomas of diffuse type, and miscellaneous gastric diseases. The occurrence of DMCs was not influenced to a significant degree by the number of sections available per gastrectomy. Since environmental factors trigger the evolution of intestinal type carcinomas and as DMCs also occurred in specimens without carcinoma-although at a significantly lower rate--it is conceivable that DMCs are also evoked by environmental factors (before a gastric carcinoma ensues). DMCs were found in specimens having intestinal carcinomas either in the cardia, the corpus or the antrum. Thus, DMCs seem to provide the adequate "soil" for the development of gastric carcinomas of intestinal type, independently of the future localization of that tumor in the stomach.

Faecal alpha 1-antitrypsin concentration in the diagnosis and management of patients with pouchitis.

OBJECTIVE: To investigate the role of faecal alpha 1-antitrypsin concentration in the diagnosis and management of patients with ileal pouch-anal anastomosis. DESIGN: Prospective study. METHODS: Fifty-two measurements of faecal alpha 1-antitrypsin concentration were taken from 33 patients operated on for ulcerative colitis. RESULTS: Patients with active pouchitis (44.4 +/- 7.1 mg%) had a three-fold higher mean faecal alpha 1-antitrypsin concentration than patients in remission (13.7 +/- 1.3 mg%; P < 0.0001), than patients who had never had pouchitis (14.4 +/- 2.3 mg%; P < 0.003) and than patients with incontinent ileostomies (12.7 +/- 1.3 mg%; P < 0.004). Faecal alpha 1-antitrypsin measurements were 80% sensitive and 97% specific for active pouchitis. A significant positive correlation between the pouchitis disease activity index and faecal protein loss was observed (r = 0.702; P < 0.0001). The correlations between protein loss and other parameters were weaker (protein loss versus clinical score, r = 0.309; versus endoscopic score, r = 0.583; and versus histologic score, r = 0.558). CONCLUSION: Faecal alpha 1-antitrypsin concentration is a good indicator of the degree of intestinal inflammation in pouchitis and may be useful as a quantitative index of disease activity in prospective studies.

Increased mucosal levels of leukotriene B4 in pouchitis: evidence for a persistent inflammatory state.

DESIGN AND METHODS: In order to evaluate its possible role in the pathogenesis of pouchitis we measured the release, into the incubation medium of leukotriene B4 from mucosal samples from patients with ileal pouch-anal anastomosis and correlated release with clinical, endoscopic and histological features. RESULTS: Leukotriene B4 release was significantly elevated in patients with active pouchitis in comparison to those with a normal pouch mucosa (P < 0.007). No overlap was observed between leukotriene B4 levels from patients with active pouchitis samples and those obtained from individuals without pouchitis. Effective treatment of pouchitis was associated with a significant reduction in leukotriene B4 mucosal release to the incubation medium (P < 0.03). However, even in remission, levels of leukotriene B4 release remained significantly increased in these patients in comparison to people who never experienced pouchitis (P < 0.003). A modest correlation was observed between pouchitis disease activity index and leukotriene B4 release (r = 0.596; P < 0.01). CONCLUSION: These results suggest that the increased production of leukotriene B4 may be implicated in the pathogenesis of pouchitis. The persistence of an increased mucosal release of leukotriene B4 in pouchitis patients during clinical remission suggests the presence of a chronic, ongoing, underlying inflammatory process.

Serological markers identify histologically latent coeliac disease among first-degree relatives.

BACKGROUND AND AIM: Serological markers detect asymptomatic coeliac disease among first-degree relatives of patients with sprue. However, some relatives with coeliac disease-related antibodies have 'normal' jejunal mucosa by conventional histology. Whether these serological abnormalities represent false-positives or are consequences of gluten sensitivity is not known. Our aim was to evaluate, through quantitative histology, intestinal biopsies of asymptomatic relatives of probands seeking abnormalities consistent with latent coeliac disease. MATERIALS: Fifty-nine intestinal biopsies obtained from asymptomatic relatives were evaluated; 40 samples were suitable for histological quantification. Seven samples showed severe mucosal atrophy (coeliac disease) and 33 were considered as 'normals'. In the 'normal' group, nine samples were obtained from patients with one or more positive serological tests and 24 from those with negative tests. Morphometry was compared for samples obtained from healthy control individuals (n = 10) and for those from coeliac patients (n = 7). METHODS: Serological tests used were: antigliadin antibodies type immunoglobulin (Ig)A and IgG (enzyme-linked immunosorbent assay), antirrecticulin antibody (immuno-fluorescence) and endomysial antibody (immunofluorescence). Biopsy samples were obtained with endoscopic forceps from the distal duodenum (second portion). Quantitative histology of duodenal biopsies was performed with a computerized image analysis system. RESULTS: Relatives with positive serology showed shorter villi (P < 0.05) and higher number (P < 0.01) and numerical density (P < 0.01) of intraepithelial lymphocytes in crypts than healthy controls. Numerical density of intraepithelial lymphocytes in crypts in antibody-positive patients was significantly higher than that observed in relatives with negative serology (P < 0.03). Four of nine (44%) relatives with positive serology had a number of intraepithelial lymphocytes in crypts within the range of coeliac disease patients. However, only one patient with negative serology (4%) was in this range. CONCLUSION: Our study shows quantitative histological evidence that relatives of probands with positive coeliac disease-related serology are not false-positives, and that they should be considered as individuals with latent coeliac sprue.

A combined laparoscopic and endoscopic approach to acute primary gastric volvulus.

We describe the combined use of laparoscopic and endoscopic techniques in a case of acute primary gastric volvulus. Once the diagnosis is confirmed with a water-soluble upper gastrointestinal series, prompt intervention is required. With an atraumatic bowel grasper the stomach is re-oriented with the greater curvature in its normal anatomic position. Two transabdominal wall sutures are placed along the greater curvature to fix it to anterior abdominal wall. Upper endoscopy is then performed. Once confident that the gastric mucosa is viable, a 20F "pull-type" gastrostomy tube is placed endoscopically, guided by the external illumination and probing by the laparoscope. The gastrostomy tube now acts as an anterior anchor for the stomach allowing repositioning of the gastropexy sutures if necessary. Endoscopy confirms the placement of a broad, properly aligned gastropexy. Classically, gastric volvulus has been treated by laparotomy. Both endoscopic and laparoscopic techniques have been individually reported in the treatment of acute and chronic gastric volvulus, however, each has as its limitations. By combining the procedures we were able to better assess both the intra-abdominal and the intraluminal status of the stomach and its position before, during, and after fixation to the anterior abdominal wall. The postoperative stay seen with the combined technique was less than has been reported in patients treated by open surgery or by either the endoscopic or laparoscopic methods alone. The combined laparoscopic and endoscopic approach to acute gastric volvulus provides the benefit of a minimally invasive approach, to a better anterior gastropexy. This procedure should be considered when confronted with patients with acute primary, gastric volvulus.

[Synchronous lesions in advanced colorectal cancer]. / Lesiones sincrónicas en el cáncer colorrectal avanzado.

From jan '82 to jun '91 were done 3701 colonoscopic procedures. Of these, we arrived to cecum in 283 patients (pat) (51.1%) (male: 175 pat; female: 108 pat) in the first six months after the diagnostic of the colorectal cancer (CRC). The localization of the primary CRC was: rectum: 17.7%; left colon: 37.8% and right colon: 44.5%. 105 synchronical polyps (p) were seen in 87 pat (30.7%): 61 pat with 1p; 16 pat with 2 p and 10 pat with 3 p. Adenomas: 50/105 p (56.19%). Early cancer was histologically confirmed in 11/105 p (11/59 p adenomas). The distribution of early were 5/11 in the same colon segment ant 6/11 in the different colon segment. 1 pat has 3 early cancer. Synchronic advanced colorectal cancer (ACC) was seen in 9 pat (M/F = 2/1). All of these in different segments. In conclusion, the high frequency of the premalignant (adenomas) an malignant (early and advanced cancer) lesions, and the high risk of these in different segments of the large bowel, shows the colonoscopy is the most efficient method in the detection of the synchronical lesions of the colorectal cancer.

[Helicobacter pylori in Barrett esophagus]. / Helicobacter pylori en esófago de Barrett.

The authors evaluated the prevalence of colonize by Helicobacter Pylori in 21 adults patients with Barrett's esophagus; 12 males and 9 females; with ranges of age from 21 to 81 years and a medium of 56.4 years old. It was detected in 23.8% that Helicobacter Pylori was positive in Barrett's esophagus, being quite higher, 26.6% in patients over 50 years old. In the five cases with positive Helicobacter Pylori, the Barrett esophagus presented a fundic gastric mucosa and no one intestinal metaplasia. Helicobacter Pylori was not seen in esophageal biopsies from patients with reflux esophagitis without Barrett's esophagus. The clinical value of the Helicobacter Pylori finding in Barrett's esophagus and its importance of the following at long term must be explained and studied in the future, by the evaluation in numerous patients groups and prolonged follow-up.

[Achalasia and esophageal cancer]. / Acalasia y cáncer de esófago.

During the period included between January 1970 and December 1990, we studied 242 patients with manometric and radiological diagnosis of esophageal achalasia. Eight of these patients (3.3%) developed during the evolution of their disease an esophageal carcinoma. Eight cases showed histologic type of epidermoid carcinoma: 3 differentiated, 3 semi-differentiated and 2 anaplastic. Therapy for achalasia was: one patient, Heller myotomy, 4 patients, dilatations with bougies in numerous opportunities, and the other two patients receive no treatment for achalasia. Two patients reported tracheobronchial fistulas as complication of carcinoma. Treatment received for carcinoma included: three patients, radiotherapy (4000 rads); one patient, chemotherapy; one patient, chemotherapy and radiotherapy, one resection surgery and two patients feeding gastrostomy. All of the eight patients died within the year of diagnosis of epidermoid carcinoma.

[Primary lymphoma of the small bowel and malabsorption]. / Linfoma primario de intestino delgado y malabsorción.

Between 1974 and 1984 we saw 69 patients with lymphoma that involved the gastrointestinal tract. In ten patients the lymphoma compromised the small bowel and were associated to malabsorption. Seven patients fulfilled the criteria to be considered as primary small bowel lymphoma. We presumed the intestinal origin in the other 3 patients, but it was impossible to confirm it. The peroral small bowel biopsy showed histological findings compatible with celiac disease in 7 patients. Other particular histological signs were patchy alterations, inconstant epithelial pseudo-stratification and ulcerations. In 2 cases we found findings that suggested the diagnosis of lymphoma. In 50% of patients we found unspecific malabsorption signs in the small bowel radiology. We found giant ulcers and stenosis too. The gluten-free diet or the steroid therapies resulted in temporary or inconstant improvement. The laparotomy was the most effective diagnostic approach. It was performed electively in 6 patients and in 1 because of a small bowel perforation. The primary small bowel lymphoma is an entity of difficult diagnosis. The most important trouble is to differentiate it with celiac disease.

[Evaluation of sensitivity, specificity and predictive value of six qualitative serological methods for the detection of Helicobacter pylori antibodies]. / Evaluación de sensibilidad, especificidad y valor predictivo de seis métodos serológicos cualitativos para la detección de anticuerpos contra el Helicobacter Pylori.

Screening tests for IG g antibodies against Helicobacter pylori are usefull for a long follow up of patients who were well eradicated. The aim of this study was to determinate and compared sensibility, specificity, positive and negative predictive value of six qualitative serological tests for IG g antibodies detection in the diagnosis of H. Pylori infections. Between May and October 1996 52 patients (30 males and 22 females; median age 42.4 years, range 21-68) with H. Pylori infection assessed on two antral and two corpus biopsies by means of Giema stain and a rapid urease test were tested for IG g antibodies detection. The serological tests used were: Inmunocomb II (Orgenics) Enzimo Inmuno Assay Inmunoadsorbent qualitative, Flex Pack (Smith Kline Diagnostics, Abbott) inmunocromatographic cualitative, Pylori Stat test (Biowhittaker) Enzimo Inmuno Assay (ELISA) qualitative, Premier (Meridian Diagnostics) Enzimo Inmuno Assay ELISA) qualitative. Pyloristest (Orion Diagnóstica) latex aglutination qualitative, H. Pylori (Bio Tre) Enzimo Inmuno Assay cualitative. 10 healthy subjects with negative gastric biopsies and negative rapid ureasa test were used as control group. The six evaluated serological tests have a comparable sensibility (89-95%) and specificity (77-83%) for the diagnosis of HP infection. The presence of specific HP antibodies in infected patients revealed a strong correlation with the histological demonstration of the microrganisms. We can recommend this qualitative serological tests due to their high sensibility and specificity, simplicity and low cost.

[Detection of Helicobacter pylori by polymerase reaction in bile samples from gallbladder and bile stones]. / Deteccion del Helicobacter pylori por reacción en cadena de la polimerasa en muestras de bilis de pacientes con litiasis vesicular y coledociana.

Some papers report helicobacter pylori existence in bile from surgical specimens obtained during gallbladder or bile ducts surgery. The aim of this work was search by PCR, H. Pylori presence in bile specimens from patients suffering of gallbladder stones or by bile ducts stones. Bile samples were obtained by gallbladder punction during cholecystectomy in 26 patients, 19 of them with gallbladder stones and 7 also with gallbladder stones and bile duct stones. Age ranged from 22-69 years old, median 49.6 years old. Samples were sent to specialized biomolecular laboratory to perform PCR techniques. Two of 26 patients (7.6%) had positive reaction for the presence of DNA of H. Pylori in bile samples. Our research suggest that DNA of H. Pylori can be founded in bile samples patients with gallbladders and duct stones in Argentina.

[Absence of bleeding recurrence of peptic ulcer after long term follow-up of successful eradication of Helicobacter pylori]. / Ausencia de recidiva de sangrado por úlcera péptica en el largo plazo luego de una erradicación exitosa del Helicobacter pylori.

Helicobacter pylori (HP) eradication reduces dramatically the peptic ulcer relapse rate, but information regarding recurrence of peptic ulcer bleeding after eradication is still scanty. Available data show rebleeding rates of 0-3% per year in successfully eradication patients, compared with figures between 12 and 33% among the non eradicated ones. The aim of this study was to determine the rebleeding rate among successfully eradicated patients with a prior history of rebleeding peptic ulcer. 42 patients (34 male, mean age 49, range 18-74) hospitalised for Hp positive bleeding peptic ulcer undergoing conservative treatment, were given as soon as oral route was re-established, a one-week eradication treatment, followed by the same proton pump inhibitor for three or five weeks for duodenal and gastric ulcer healing respectively. No maintenance antiulcer therapy was indicated. Patients were advised not to take nonsteroideal anti-inflammatory drug. Ulcer healing and Hp eradication was confirmed in all 42 patients by means of endoscopy and biopsies for urease rapid test and histology four weeks after completion of the treatment. After this patients were invited to enter a long-term follow-up program with periodical visits. End point of the study was occurrence of rebleeding. Further endoscopies were planned when rebleeding or symptomatic relapse. Median follow-up time was 24.02 months, ranging from 3 up to 27 months. All patients were compliant with the follow-up visits. None of the patients presented with symptoms suggestive of ulcer relapse or upper gastrointestinal bleeding. Our data suggest, that Hp eradication can prevent bleeding relapses in patients with Hp positive bleeding peptic ulcers.

[Is dental plaque a normal Helicobacter pylori reservoir?]. / Es la placa dentaria reservorio habitual de Helicobacter pylori?

The mechanisms of transmission and reservoir of Helicobacter pylori is still unclear; even it has been suggested that dental plaque could be the bacterial reservoir and one important factor in the reinfection. The aim of the study was to evaluate the prevalence of Helicobacter pylori in dental plaque in 20 patients with non ulcer dyspepsia (12 females, 7 males; mean age 40.5 years) and antral infection; and to establish the presence of bacteria in dental plaque and gastric mucosa after eradication. Gastric colonization in all of them was confirmed by five samples (three of antrum and two of body) with Giemsa conventional technique, clotest and culture. When clotest was positive in gastric mucosa, we performed the scrape of dental plaque and sending the material for culture. All patients were treated with a scheme of seven days with one protom pump inhibitor and two antibiotics. After four weeks all the patients were controlled with endoscopy and culture of dental plaque to confirm eradication. Dental plaque culture was positive in 1/20 patients (5%), and this results was similar to developed countries, using as detection method culture or polymerase chain reaction (PCR).

[Helicobacter pylori detection by polymerase chain reaction in gastric juice and its correlation with the histology (Giemsa)]. / Detección del Helicobacter pylori por reacción en cadena de polimerasa en jugo gástrico y su correlación con la histología (GIEMSA).

HP infection is involved in the pathogenesis of several gastroduodenal diseases, as type B chronic gastritis, duodenal and gastric ulcer, MALT lymphoma and gastric cancer. The recent availability of molecular techniques, specifically the PCR, allow us to detect very low amounts of the bacterium. The aim of the study is to evaluate the presence of HP in gastric juice by PCR technique and to correlate this findings with histology (Giemsa) of gastric mucosa. Gastric juice PCR positive findings were found in 10/31 (32.3%) HP positive patients at histology. We concluded that HP in gastric juice is possible to detect by molecular techniques. In our study 32.3% of the patients showed the presence of HP in gastric juice.

[A new method for detection and erradication of Helicobacter pylori infection by stool antigens test]. / Nuevo mètodo para detecciòn de infecciòn y erradicaciòn del Helicobacter pylori (Hp) por determinaciòn de antìgenos en materia fecal.

Nowadays technics for Helicobacter pylori detection in stools like culture, and PCR, are expensive and difficult to perform. The aim of this study was to evaluate ELISA test efficacy for detection of H. Pylori antigens in stools comparing this results with standarized technics like histology (Giemsa), ureasa test and UBT C 14. 26 patients were evaluated in this study, ages between 15-75 with upper gastrointestinal symptoms; all of them required gastroduodenal endoscopy, status H. Pylori was determined with methods upon mentioned. 24 hours after endoscopy H. Pylori antigens in stools with the technique Premier Platinum Htsa, Elisa were determined. The detection of H. Pylori antigens in stools accurately identified active H. Pylori infection. The performance characteristics of this non-invasive method was similar in sensibility and specificity to conventional tests.