Complications during colonoscopy: prevention, diagnosis, and management.

Colonoscopy is largely performed in daily clinical practice for both diagnostic and therapeutic purposes. Although infrequent, different complications may occur during the examination, mostly related to the operative procedures. These complications range from asymptomatic and self-limiting to serious, requiring a prompt medical, endoscopic or surgical intervention. In this review, the complications that may occur during colonoscopy are discussed, with a particular focus on prevention, diagnosis, and therapeutic approaches.

A pilot study on the effect of a symbiotic mixture in irritable bowel syndrome: an open-label, partially controlled, 6-month extension of a previously published trial.

BACKGROUND: In recent years, the efficacy of probiotics has received considerable attention in the treatment for irritable bowel syndrome (IBS). In this regard, a symbiotic mixture (Probinul(®)) has shown beneficial effects. The aim of this study was to extend the previously published 4-week randomized, double-blinded, placebo-controlled study of this symbiotic mixture. METHODS: This is an open-label prospective, partially controlled, 6-month extension period pilot study in which patients continued to receive the symbiotic mixture (Group 1) or were switched from placebo to symbiotic mixture (Group 2) using cyclic administration (last 2 weeks/month). The primary endpoints were the overall satisfactory relief of bloating and flatulence (assessed as proportions of responders). The secondary endpoints were evaluation of the symptom severity scores (bloating, flatulence, pain and urgency) and bowel function scores (frequency, consistency and incomplete evacuation). RESULTS: Twenty-six IBS patients completed the 6-month extension period (13 patients in Group 1 and 13 patients in Group 2). In the per-protocol analysis, the proportions of responders across time were not significantly different in the groups but in Group 2, there was an increased percentage of responders for flatulence (p = 0.07). In addition, the score of flatulence was reduced significantly during the 6-month treatment period in Group 2 (p < 0.05), while no other significant differences were detected. CONCLUSIONS: Treatment with this symbiotic mixture was associated with persistence of relief from flatulence or new reduction in flatulence in the present 6-month long extension study. These results need to be more comprehensively assessed in large, long-term, randomized, placebo-controlled studies.

Colonic gas transit in patients with bloating: the effect of an electromechanical stimulator of the abdominal wall.

BACKGROUND: The aim of our study was to evaluate gas retention, abdominal symptoms and changes in girth circumference in females with bloating using an active or sham abdominal wall mechanical stimulation. METHODS: In 14 female patients, complaining of bloating (11 with irritable bowel syndrome and 3 with functional bloating according to the Rome III criteria) a gas mixture was continuously infused into the colon for 1 h (accommodation period). Abdominal perception and girth were measured. At the beginning of the 30-min period of free rectal gas evacuation (clearance period), an electromechanical device was positioned on the abdominal wall of all patients. The patients were randomly assigned to an active or a sham stimulation protocol group. Gas retention, perception and abdominal distension were measured at the end of the clearance period. RESULTS: All patients tolerated the volume (1,440 ml) of gas infused into the colon. Abdominal perception and girth measurements was similar in both groups during the accommodation period. At the end of the clearance, the perception score and the girth changes in the active and sham stimulation groups were similar (2.8 ± 2.0 vs. 1.4 ± 1.2, p = 0.2 and 4.9 ± 4.5 vs. 2.8 ± 2.3 mm, p = 0.3 active vs. sham, respectively). Furthermore, the mechanical stimulation of the abdominal wall did not significantly reduce gas retention (495 ± 101 ml vs. 566 ± 55, active vs. sham, p = 0.1). CONCLUSIONS: An external mechanical massage of the abdominal wall did not improve intestinal gas transit, abdominal perception and abdominal distension in our female patients complaining of functional bloating.

Intestinal tone and gas motion.

The intestine propels and evacuates large gas loads without detectable phasic contractions by manometry. We hypothesized that intestinal gas motion is produced by changes in gut tone and capacitance. In 13 healthy subjects, changes in duodenal tone were measured by a barostat during continuous perfusion of lipids (Intralipid, 1 kcal min(-1)) into the duodenum for 60 min. In separate groups, the effects of jejunal gas infusion (N2, CO2 and O2 in venous proportions at 12 mL min(-1) starting after 15 min lipid perfusion) and sham infusion were tested. Gas outflow was collected continuously via an intrarectal cannula. Duodenal lipid perfusion produced a rapid duodenal relaxation (volume increased by 48 +/- 18%; P < 0.01 vs basal). Gas infusion increased gas evacuation (184 +/- 59 mL), and this was associated with a tonic contraction of the duodenum (R = 0.86; P < 0.01) that completely reverted the lipid-induced duodenal relaxation (volume decreased by 42 +/- 13%; P < 0.05). During sham infusion only 52 +/- 28 mL of gas were evacuated (P < 0.05 vs gas infusion), and the duodenum remained relaxed due to the effect of lipids (0 +/- 1% volume reduction; ns). In conclusion, intestinal gas propulsion and clearance is associated with a tonic contraction of the gut wall and reduced gut capacitance.

Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure.

There is an increased prevalence of gastro-oesophageal reflux and symptoms in obese patients. Information about the proximal stomach in obese patients with reflux is lacking. Gastric volume and compliance are similar between obese and lean subjects. To study the proximal stomach function and perception in obese patients with normal or abnormal oesophageal acid exposure, thirty-one obese patients, with normal or abnormal oesophageal acid exposure, underwent medical evaluation of oesophageal and gastrointestinal symptoms by a questionnaire and measurement of proximal stomach function and perception by an electronic barostat and a standardized questionnaire. Nineteen obese patients had abnormal oesophageal acid exposure. The percentage of total time with pH <4 is significantly related to the presence of hiatal hernia, the oesophageal intensity-frequency symptom score and gender, i.e. higher percentage in men. The perception cumulative score was significantly different between patients with normal and abnormal oesophageal acid exposure after adjusting for covariates (gender, body mass index, age, minimal distending pressure, gastric tone and gastric compliance). Gastric tone and compliance were significantly related to the perception cumulative score. In conclusion, patients with abnormal oesophageal acid exposure have increased gastric perception. A significant relation among gastric tone, gastric compliance and upper gastrointestinal sensations was shown.

Objective diagnosis of micrognathia in the fetus: the jaw index.

OBJECTIVE: To provide an objective and accurate tool to diagnose micrognathia in the fetus. METHODS: The anteroposterior and laterolateral diameter of the mandible were measured in 262 normal fetuses between 12 and 37 weeks' gestation and plotted against gestational age and biparietal diameter (BPD). The jaw index (anteroposterior mandibular diameter/BPD x 100) was then tested against the usual subjective method for diagnosing micrognathia, consisting of the evaluation of the facial profile, in a population of 198 malformed fetuses, 11 of which had micrognathia at necropsy or birth. RESULTS: The mandibular growth was linearly correlated with gestational age and BPD. Using a cutoff level of less than 23, the jaw index had a 100% sensitivity and 98.1% specificity in diagnosing micrognathia, in comparison with 72.7% and 99.2% shown by the subjective evaluation of the fetal profile. With a cutoff of 21, it yielded a positive predictive value of 100%. CONCLUSION: We demonstrated the linear relationship between mandibular growth and gestational age or BPD. In addition, we validated the jaw index as an objective tool for diagnosis of micrognathia in the fetus.

Abnormal esophageal acid exposure is common in morbidly obese patients and improves after a successful Lap-band system implantation.

BACKGROUND: The relation between gastro-esophageal reflux disease (GERD) and obesity is controversial. The laparoscopic adjustable gastric band (LAGB) procedure is effective for morbid obesity. Its indication in the presence of GERD, however, is still debated. This study aimed to investigate esophageal symptoms, motility patterns, and acid exposure in morbidly obese patients before and after LAGB placement. METHOD: For this study, 43 consecutive obese patients were investigated by a standardized symptoms questionnaire, stationary manometry and 24-h ambulatory pH-metry, and 16 patients with abnormal esophageal acid exposure were reevaluated 18 months after LAGB placement. RESULTS: Symptom scores and abnormal esophageal acid exposure were found to be significantly higher, Lower Esophageal Sphincter (LOS) pressure was significantly lower in obese patients than in control subjects. After LAGB, esophageal acid exposure was significantly reduced in all but two patients, who presented with proximal of gastric pouch dilation. CONCLUSIONS: There is a high prevalence of GERD in the obese population. Uncomplicated LAGB placement reduces the amount of acid in these patients with abnormal esophageal acid exposure.

[Cystic adenomatoid malformation of the lung at the fetal stage. Ultrasonographic diagnosis and counseling]. / Malformazione adenomatoide cistica del polmone in epoca fetale. Diagnosi ecografica e counseling.

BACKGROUND: The aim of this study was to report the series of cystic malformation of the lung (CAML) detected at the Center for Prenatal Diagnosis of the University of Naples Federico II and compare the data with the current literature. METHODS: In the period 1994-1997, ten cases of CAML have been detected at our unit. For each case, the following parameters were recorded: size of the cysts (according to the Stocker classification), side, presence of mediastinal shift, hydrops. For confirmation, necropsies and post natal files were sought. RESULTS: CAML was type I in 3 cases, type II in 3, and type III in 4 cases. mediastinal shift was present in 7 cases, hydrops in 2 and bilateral renal agenesis in 1. Seven cases underwent termination of pregnancy, 2 are currently alive and thriving after surgery and one pregnancy is ongoing at 36 weeks of gestation. The diagnosis was straightforward in all cases, and there were no problems of differential diagnosis. CONCLUSIONS: From an analysis of the data published in recent literature, it can be affirmed that hydrops but not mediastinal shift have negative prognostic significance. The abortion rate of 70% in our series, including 4 cases with a good prognosis, is somewhat frustrating. This figure underlines the need for a multidisciplinary counseling in which the pediatric surgeon, the psychologist and the sonographer may support the couple in overcoming the stress related to the acknowledgement of the lesion in order to reach the final decision about the outcome of the pregnancy.

[Effects of ipriflavone on bone loss induced by GnRH analog]. / Effetti dell'ipriflavone sulla perdita ossea indotta da un analogo del GnRH.

The aim of this study is to evaluate the association between GnRH analogues and ipriflavone, drug modulating the bone turnover limiting the negative bone effects of analogue. Thirty patients (33 +/- 5.4 years, mean +/- SD) affect by benign gynecological conditions in which there was an indication to use GnRH analogs have been treated with leuprolide acetate at the monthly intramuscular dose of 3.75 mg, for six months. Fifteen of these patients also received 600 mg/day per os of ipriflavone (group A), while the other 15 patients have been treated exclusively with leuprolide acetate (group B). Before and after treatment, radial bone mineral density (BMD) and main markers of bone turnover were measured in all patients. Before treatment no difference in the considered parameters could be detected between the two groups. In group A, after 6 months of treatment no significant decrease in BMD and no variations in the bone turnover parameters. On the contrary, in group B, after six months of treatment, a significant decrease (p < 0.05) in BMD was observed in comparison to basal and group A values. In the same group alkaline phosphatase, osteocalcin and urinary calcium/creatinine and hydroxyproline/creatinine ratio proved significantly increased in comparison to basal and group A values (both with p < 0.05). Ipriflavone, therefore, seems to be effective in counteracting the negative effects of GnRH-a induced on bone.

Irritable bowel syndrome in childhood: visceral hypersensitivity and psychosocial aspects.

Visceral hypersensitivity is often considered to play a major etiologic role in the pathophysiology of irritable bowel syndrome in adults, and some authors argue that this increased sensitivity is mainly due to psychological factors. In contrast, there are no data in children with irritable bowel syndrome which confirm this relationship. The aim of the study was to evaluate the relationship between psychosocial aspects and sensorymotor function in children affected by irritable bowel syndrome. Ten children fulfilling the Rome II criteria for irritable bowel syndrome and seven healthy controls were enrolled. We studied the thresholds and the perception of visceral stimuli in the rectum by means of an electronic barostat (isobaric phasic distentions, 3 mmHg/1 min, interval 1 min) and a validated questionnaire. Personality features were evaluated by means of the Big Five Questionnaire for Children. Sleep, mood disturbance, anxiety and individual performance (missed school days, school results and social activities) were also evaluated. Children with irritable bowel syndrome showed significantly lower thresholds for discomfort (14.8 +/- 3.5 vs 22.3 +/- 6.9 mmHg, P = 0.010) and a higher cumulative perception score (28.2 +/- 11.1 vs 12.3 +/- 8.0, P = 0.005) compared with healthy controls. A higher emotional instability (57.8 +/- 7.0 vs 48.7 +/- 10.1, P = 0.047), sleep disturbance (7.2 +/- 1.0 vs 9.3 +/- 0.5, P = 0.004) and anxiety (6.3 +/- 2.0 vs 2.3 +/- 1.7, P = 0.009) were observed in irritable bowel syndrome patients. Moreover, in a multivariate analysis, the cumulative perception score was significantly related to emotional instability (P = 0.042). In conclusion children with irritable bowel syndrome exhibit visceral hypersensitivity and psychosocial impairment. Emotional instability, as a personality feature in these children, seems to modulate the perception response to visceral stimulations.

Impaired reflex control of intestinal gas transit in patients with abdominal bloating.

BACKGROUND: Patients with abdominal bloating and distension exhibit impaired transit of intestinal gas which may lead to excessive gas retention and symptoms. Furthermore, we have previously shown that intestinal gas transit is normally accelerated by rectal distension. We hypothesise that in patients with functional bloating this modulatory mechanism fails and impairs gas transit. METHODS: In 12 healthy subjects and eight patients with abdominal bloating we compared, by paired studies, the effect of rectal versus sham distension on intestinal gas transit. Gas was infused into the jejunum (12 ml/min) for three hours with simultaneous perfusion of lipids into the duodenum (Intralipid 1 kcal/min) while measuring evacuation of gas per rectum. RESULTS: In healthy subjects, duodenal lipid infusion produced gas retention (409 (68) ml) which was prevented by rectal distension (90 (90) ml; p<0.05 v sham distension). In contrast, rectal distension in patients with abdominal bloating failed to reduce lipid induced gas retention (771 (217) ml retention during rectal distension v 730 (183) ml during sham distension; NS; p<0.05 v healthy controls for both). CONCLUSION: Failure of distension related reflexes impairs intestinal gas propulsion and clearance in patients with abdominal bloating.

Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder.

Fibromyalgia (FM) syndrome and irritable bowel syndrome (IBS) are functional disorders in which altered somatic and or visceral perception thresholds have been found. The aim of this study was to evaluate the prevalence of FM in a group of patients with IBS and the possible association of FM with patterns and severity of the intestinal disorder. One hundred thirty consecutive IBS patients were studied. The IBS was divided into four different patterns according to the predominant bowel symptom and into three levels of severity using a functional severity index. All patients underwent rheumatological evaluation for number of positive tender points, number of tender and swollen joints, markers of inflammation, and presence of headache and weakness. Moreover, patients' assessments of diffuse pain, mood and sleep disturbance, anxiety, and fatigue were also measured on a visual analogue scale. The diagnosis of FM was made based on American College of Rheumatology classification criteria. Nonparametric tests were used for statistical analysis. Fibromyalgia was found in 20% of IBS patients. No statistical association was found between the presence of FM and the type of IBS but a significant association was found between the presence of FM and severity of the intestinal disorder. The presence of FM in IBS patients seems to be associated only with the severity of IBS. This result confirms previous studies on the association between the two syndromes.

A new fluoride preparation for the prevention of postmenopausal osteoporosis: calcium monofluorophosphate.

Fifty-six postmenopausal women aged 52.4 +/- 6.7 years (SD) were treated for 12 months with L-glutamine calcium monofluorophosphate. Each patient received four tablets/day, providing a total dose of 20 mg of fluoride and 600 mg of elemental calcium. Bone mineral density was measured at baseline and after 6 and 12 months of treatment by dual photon absorptiometry of the distal forearm. At these times, serum levels of alkaline phosphatase and osteocalcin, and urinary concentrations of hydroxyproline and calcium, were also assayed. Results were compared with a control group of 50 untreated postmenopausal women with similar clinical characteristics. Forty-nine patients completed the study. Bone mineral density in the treated patients showed a significant increase after 6 months in comparison with both baseline (p < 0.01) and controls (p < 0.01). After 12 months no significant further increase in bone mineral density was detected. In the control group, a significant decrease of bone mineral density was observed at this time (p < 0.01). After 6 months, serum osteocalcin levels were significantly increased in the treated group (p < 0.01 vs. basal and controls). The other biochemical parameters did not show any significant variations. After 12 months, all the biochemical parameters evaluated, with the exception of serum alkaline phosphatase, were significantly different in comparison with the control group (p < 0.01). Osteocalcin levels also increased in comparison with the basal value (p < 0.01). Adverse effects were mild. However, seven patients stopped the treatment before the 6th month because of gastrointestinal complaints.(ABSTRACT TRUNCATED AT 250 WORDS)

Proximal stomach function in systemic sclerosis: relationship with autonomic nerve function.

Gastrointestinal involvement is frequent in patients with systemic sclerosis (SSc); however, studies on the proximal stomach and its regulation are lacking. It has been hypothesized that the primary event in the pathogenesis of gastrointestinal involvement in SSc is an early neural lesion. This study investigates proximal stomach function and its relation to autonomic nerve function in SSc. Twenty SSc patients classified in to clinical subsets, underwent measurement of proximal stomach function with and without glucagon by electronic barostat and an assessment of autonomic nerve function. SSc patients were not significantly different from 11 controls for gastric compliance (59.5+/-5.0 vs 47.7+/-4.2 ml/mm Hg, P = 0.1). The pressure-volume curves in each participant with and without glucagon were significantly different (P < 0.001). A significant positive association was found between gastric compliance and autonomic nerve function (P < 0.05). The change in gastric compliance during glucagon administration was significant-associated with autonomic function (P < 0.05). The perception cumulative scores did not differ between SSc patients and control subjects (P = 0.2). In conclusion, proximal stomach function is associated with autonomic nerve function in SSc patients. This confirms the frequent association of motility disorders with autonomic dysfunction in SSc.

Loss of oestrogen receptor beta, high PCNA and p53 expression and aneuploidy as markers of worse prognosis in ovarian granulosa cell tumours.

AIMS: Ovarian granulosa cell tumour (OGCT) is a sex-cord stromal tumour with a general trend toward late relapse and/or metastasis. However, mortality rate corrected for long-term follow-up shows that about 50% of patients die within 20 years of diagnosis. Classical clinicopathological parameters are unable to predict the biological behaviour of OGCT. The involvement of a recently characterized subtype of oestrogen receptor, ERbeta, in ovarian carcinogenesis has been hypothesized. METHODS AND RESULTS: We examined by immunohistochemistry the expression of ERbeta, proliferating cell nuclear antigen (PCNA) and p53 in a selected series of 30 OGCT, to evaluate their role in the prognostic evaluation of this tumour. Immunohistochemistry was performed on formalin-fixed paraffin-embedded sections. Results were compared with the DNA-ploidy of the tumours (evaluated by image analysis) and with the follow-up data of the patients. CONCLUSIONS: Loss of ERbeta expression, high PCNA expression and aneuploidy, characterized a subgroup of OGCT with a worse outcome. The identification of a high-risk subclass of OGCT may be of primary importance in addressing appropriate therapeutic strategies, offering the chance to prevent relapses and metastases by using adjunctive, specifically targetted, more aggressive therapies.