Corpus-predominant gastritis as a risk factor for false-negative 13C-urea breath test results.

BACKGROUND: Urea breath test sensitivity seems affected by increased intragastric acidity during therapy with antisecretory drugs. Intragastric pH is increased in patients with corpus gastritis with/without atrophy. AIM: To test the hypothesis that urea breath test results may also be affected by this gastritis phenotype. METHODS: 123 untreated patients underwent gastroscopy plus biopsies and intragastric pH measurement. The study included 82 endoscopically proven Helicobacter pylori-positive patients who were offered urea breath test with an acidic meal. Histological findings, urea breath test results and intragastric pH were compared in 66 of the subjects. RESULTS: 21 of 66 (31.8%) patients had a false-negative urea breath test. In these patients corpus-predominant gastritis (85.7% vs. 37.7%; P = 0.0004) and fundic atrophy (66.6% vs. 17.7%; P = 0.0001) were more frequent than in patients with true-positive urea breath test. Intragastric pH was higher in false-negative patients (mean 6.3 vs. 4.4; P = 0.001). In a multivariate analysis, the only risk factor for a false-negative urea breath test was the presence of corpus-predominant gastritis (OR = 5.6; 95% CI: 1.1-27). There was a negative correlation between the intragastric pH and the delta over baseline values (r = -0.378; P = 0.0023). CONCLUSIONS: Our results support the hypothesis that the pattern of gastritis can affect the sensitivity of urea breath test, and suggest that patients with corpus-predominant gastritis have a high risk of false-negative urea breath test results.

Unawareness of gastrointestinal symptomatology in adult coeliac patients with unexplained iron-deficiency anaemia presentation.

BACKGROUND: Most adults with coeliac disease have a subclinical form of the disease and iron-deficiency anaemia may be the sole presenting symptom. AIM: To evaluate demographic, clinical and biochemical characteristics of adult coeliac disease patients presenting with iron-deficiency anaemia. PATIENTS: A total of 108 iron-deficiency anaemia patients in whom coeliac disease has been diagnosed were studied. As a control group 108 non-coeliac iron-deficiency anaemia patients, comparable for sex and age, were studied. RESULTS: Of the 108 coeliac disease patients, 95 (88%) were female (mean age 34 years, range 19-72) and 13 (12%) were male (mean age 33 years, range 15-65). The median duration of iron-deficiency anaemia before diagnosis was 66 months in coeliac disease patients and 14 months in the iron-deficiency anaemia control group (P = 0.0001). The occurrence of at least one gastrointestinal symptom, not spontaneously reported, was observed in 92 (85%) patients with coeliac disease and in 67 (62%) patients in the control group (P = 0.001). The concomitant presence of diarrhoea, abdominal pain and abdominal bloating was detected in 14% patients with coeliac disease with respect to 3% in the control group (P = 0.005). CONCLUSIONS: The vast majority of coeliac disease patients with iron-deficiency anaemia presentation were unaware of the gastrointestinal symptoms and this relationship is useful for diet compliance.

Relationship between gastrointestinal and extra-gastrointestinal symptoms and delayed gastric emptying in functional dyspeptic patients.

AIM: Delayed gastric emptying and an enlarged fasting gastric antrum are common findings in functional dyspepsia but their relationship with gastrointestinal (GI), and the frequently associated extra-GI symptoms remains unclear. This study evaluated the relationship between GI and extra-GI symptoms, fasting antral volume and delayed gastric emptying in functional dyspepsia. METHODS: In 108 functional dyspeptic patients antral volume and gastric emptying were assessed with ultrasonography (US). Symptoms were assessed with standardized questionnaire. The association of symptoms and fasting antral volume with delayed gastric emptying was estimated with logistic regression analysis. RESULTS: Delayed gastric emptying was detected in 39.8% of the patients. Postprandial drowsiness (AOR 11.25; 95%CI 2.75-45.93), nausea (AOR 3.51; 95%CI 1.19-10.32), fasting antral volume (AOR 1.93; 95%CI 1.22-3.05), were significantly associated with delayed gastric emptying. Symptoms, mainly the extra-GI ones as postprandial drowsiness and nausea, combined with fasting antral volume predicted the modality of gastric emptying with a sensitivity and specificity of 78%. CONCLUSION: In functional dyspeptic patients, (1) an analysis of fasting antral volume and of symptoms can offer valuable indication on the modality of gastric emptying, and (2) it seems appropriate to inquire on postprandial drowsiness that showed the best correlation with delayed gastric emptying.

Large hiatal hernia in patients with iron deficiency anaemia: a prospective study on prevalence and treatment.

BACKGROUND: Although large hiatal hernia may cause bleeding from Cameron erosions, its role in iron deficiency anaemia has been debated, and no data are available on the treatment of these patients with proton pump inhibitors. Aims : To determine the prevalence of large hiatal hernia in out-patients with iron deficiency anaemia and the role of proton pump inhibitors in the prevention of recurrence of anaemia. METHODS: Two hundred and twenty-eight out-patients underwent upper/lower endoscopy. Those with large hiatal hernia were given an oesophagogram, discontinued iron supplementation and received proton pump inhibitor treatment with (group 1) or without (group 2) surgery. Anaemia was re-assessed during 1 year of follow-up. RESULTS: Large hiatal hernia was the likely cause of anaemia in 21 patients (9.2%). The median haemoglobin and ferritin values at the diagnosis of anaemia were 7.9 g/dL and 6 micro g/L, respectively. Cameron erosions were found in 33% of patients. Ten and eleven patients were included in groups 1 and 2, respectively. Haemoglobin values were 13.8 g/dL and 13.4 g/dL at 3 months of follow-up, and 13.4 g/dL and 13.8 g/dL at 1 year of follow-up, in groups 1 and 2, respectively. CONCLUSIONS: Large hiatal hernia may cause iron deficiency anaemia, even without Cameron erosions. Surgery in combination with proton pump inhibitor therapy is no better than proton pump inhibitor therapy alone in preventing the recurrence of anaemia.

Prevalence of sexual and physical abuse and its relationship with symptom manifestations in patients with chronic organic and functional gastrointestinal disorders.

UNLABELLED: A history of physical and/or sexual abuse is a frequent occurrence in patients referred for chronic gastrointestinal disorders and it may predispose to the development of functional gastrointestinal disorders, and multiple medical complaints. This study was aimed to determine: (a) prevalence of abuse history in Italian patients with chronic gastrointestinal disturbances, and (b) relationship between abuse history and clinical manifestations. SUBJECTS AND METHODS: Consecutive gastrointestinal out-patients filled in a self-administered standardised questionnaire, made up of two separate sections: (1) a medical section enquiring on gastrointestinal and extra-gastrointestinal symptoms, and (2) a section on abuse enquiring on the presence and type of abuse suffered during their lifetime. Associations between number of symptoms and abuse history were evaluated using univariate and multivariate logistic models. RESULTS: Questionnaires were handed out to 260 patients; 13% of whom did not fill in the questionnaires. Functional gastrointestinal disorders were diagnosed in 72.5% of patients and organic gastrointestinal diseases in 27.5%. A total of 31% of patients with organic gastrointestinal diseases and 32% of those with functional gastrointestinal disorders referred to a history of sexual or physical abuse. Histories of physical plus sexual abuse, sexual abuse, childhood abuse and female gender, were statistically associated with an increased number of gastrointestinal and extra-gastrointestinal symptoms irrespective of functional or organic disorders, whereas there was no statistical association with physical abuse only. Furthermore, diagnosis of functional gastrointestinal disorders was associated with a significantly (p<0.001) greater number of gastrointestinal symptoms than the diagnosis of organic gastrointestinal diagnosis. A total of 10 patients met the diagnostic criteria of somatization disorder. Of these, eight reported a history of severe physical and sexual abuse that had occurred, in all but one, during childhood. CONCLUSIONS: A history of physical and/or sexual abuse has a high prevalence in Italian patients with chronic gastrointestinal disorders, irrespective of organic or functional diagnosis. Abuse history has no relevant role in the pathogenesis of either functional or organic chronic gastrointestinal disorders but it can affect their clinical expression irrespective of functional or organic diagnosis. Severe physical and sexual abuse and childhood abuse were found in patients who met diagnostic criteria for somatization disorder, suggesting a role of abuse history in this subset of patients.

Unlabelled somatostatin analogues in treatment of digestive endocrine tumours.

Somatostatin analogues are considered first-line therapy in patients with digestive endocrine tumours. Indeed, several studies have investigated their efficacy in the control of specific symptoms and in the decrease of tumour markers. However, randomised controlled trials are needed in order to better define their role in non functioning tumours and their effect on tumour growth, which have seldom been assessed. Several new drugs have been developed over the last few years such as, for example, new long-acting formulations, universal analogues binding to all five somatostatin receptors subtypes, and cytotoxic analogues, all of which offer a promising therapeutic tool in the near future, even if further studies are needed to determine their efficacy and safety in man.

Role of small bowel investigation in iron deficiency anaemia after negative endoscopic/histologic evaluation of the upper and lower gastrointestinal tract.

BACKGROUND: The usefulness of small bowel investigation in iron deficiency anaemia (IDA) patients is controversial. AIM: To evaluate the presence of small bowel lesions likely to cause IDA in patients with unexplained IDA after negative gastroscopy with biopsies and colonoscopy (CS). METHODS: A total of 117 outpatients, referred for unexplained IDA, underwent gastroscopy with biopsies and colonscopy. In 17 (14.5%) patients, endoscopic/histological investigations were negative. Of these patients, 13 underwent small bowel follow-through (SBFT) and if necessary to confirm the diagnosis, further gastrointestinal (GI) investigations. RESULTS: Small bowel lesions likely to cause IDA were found in five (38%) patients. Four of these lesions were detected by SBFT, two of them were malignant. These findings, confirmed at surgery and ileoscopy (IS), led to the final diagnoses ofjejunal and ileal adenocarcinoma, idiopathic ileal ulcers and ileal Crohn's disease. In one case, after negative SBFT, jejunal angiodysplasia was detected by video capsule endoscopy (VCE). Faecal occult blood test (FOBT) was positive in four (31%) patients, all of whom presented lesions likely to cause IDA, detected in three cases by SBFT and in one case by VCE. CONCLUSIONS: This study shows the importance of investigating the small bowel in IDA patients after negative upper and lower GI endoscopy, particularly if FOBT is positive.

Contrast ultrasonography of the normal small bowel.

In basal conditions, the small bowel loops cannot be properly visualized by means of real-time ultrasound (US). Aims of this study were: 1. to assess whether an isosmolar solution containing a nondigestable, nonabsorbable and nonfermentable hydrophilic macro molecule, such as polyethylene glycol (PEG), can be profitably used as a contrast agent to visualize the entire small intestine with US (small intestine contrast ultrasonography, SICUS); and 2. to define the normal US values of wall thickness and luminal diameter of the jejunum, ileum and terminal ileum. Real-time ultrasonography was performed in 10 healthy volunteers with 4-and 5-MHz linear-array transducers in basal fasting conditions and after ingestion of an isosmolar PEG solution. In basal fasting conditions, only a few segments of jejunum and/or ileum could be visualized in some of the investigated subjects. After ingestion of the contrast solution, the entire small bowel could be visualized in any single subject. A contrast sonography of the entire small bowel could be satisfactorily performed with 200 mL-820 mL of contrast solution in a time period that did not exceed 65 min. Luminal diameter at the level of the jejunum (19 +/- 2.3 mm) and proximal ileum (18 +/- 1.8 mm) was significantly greater (p < 0.01) than at the level of distal ileum (16.4 +/- 2.8 mm). Wall thickness was greater at the level of the terminal ileum (2 +/- 0.4 mm) than of the jejunum (1.6 +/- 0.5 mm) but the difference did not reach statistical significance. Details such as valvulae conniventes and multilayered structure of the wall could be recognized. In conclusion, after the ingestion of an isosmolar PEG electrolyte balanced solution, it is possible to visualize with ultrasonography the entire small intestine and to measure wall thickness and luminal diameter of the jejunum, the ileum and the terminal ileum. Such a noninvasive, inexpensive method can be used to investigate the morphological aspects of the small bowel.

Small intestine contrast ultrasonography (SICUS) in the diagnosis of small intestine lesions.

After the ingestion of iso-osmolar polyethylene glycol solution, the small bowel can be visualized on ultrasonography. The aim of this study was to assess sensitivity and specificity of SICUS in diagnosis of small bowel lesions. A total of 53 consecutive patients with suspected intestinal pathology underwent a diagnostic workup, including a small bowel follow-through and SICUS performed by independent operators. The sonologist was unaware of the clinical data. Diagnostic sensitivity and specificity were assessed using radiologic findings. Diagnostic sensitivity of SICUS was 100%, with a specificity of 97%. The concordance index was 0.956 (p < 0.003, kappa statistics) and the conformity between SICUS and radiology was 1. The diagnostic accuracy of SICUS to detect small bowel lesions is comparable to that of small bowel follow-through. Results of this study support the use of noninvasive, widely available, inexpensive, and nondemanding SICUS as an initial investigation in patients with suspected small bowel disease.

Small intestine contrast ultrasonography.

The entire small bowel can be visualized on ultrasonography after ingestion of nonabsorbable, isosmotic polyethylene glycol electrolyte balanced oral solution, termed small intestine contrast ultrasonography. The aims of this study were to assess whether the ingestion of different volumes of sonographic contrast solution may differently affect (1) small bowel distention and thus its sonographic appearance and (2) the time to visualize the entire small intestine. An additional aim was to identify the minimal amount of contrast solution necessary to visualize the entire small bowel. An ultrasonographic examination of the abdomen was performed twice in six healthy subjects after the ingestion of the isosmotic polyethylene glycol solution. During the first investigation each subject was asked to drink increasing amounts of sonographic contrast solution until the jejunum was visualized at ultrasonography. During the second investigation each subject was asked to drink increasing amounts of sonographic contrast solution, not to exceed a total volume of 260 ml. At the first examination the entire small bowel was visualized 39.3 +/- 17 min after ingestion of 647 +/- 105 ml of contrast solution. At the second examination the entire small bowel was visualized 43.5 +/- 13.5 min (not significant with respect to the first study) after the ingestion of 239 +/- 32 ml of contrast solution (P < 0.01 versus the first study). The mean luminal diameter and wall thickness at three intestinal levels did not differ in the two studies and were not statistically related to the amount of ingested sonographic contrast solution. Loose stools were the only side effect and were reported after the ingestion of more than 600 ml. Ultrasonography offers reproducible information on the morphology of the contrast agent-filled small bowel after ingestion of a wide range of volumes (175 to 820 ml) of isosmotic polyethylene glycol electrolyte balanced solution. On average, the entire small intestine could be visualized on ultrasonography by about 45 min after the ingestion of 600 ml or less of contrast solution without any side effects.