Oral administration of non-absorbable delayed release 6-mercaptopurine is locally active in the gut, exerts a systemic immune effect and alleviates Crohn's disease with low rate of side effects: results of double blind Phase II clinical trial.

Therapy for Crohn's disease (CD) with thiopurines is limited by systemic side effects. A novel formulation of fixed-dose, delayed-release 6-mercaptopurine (DR-6MP) was developed, with local effect on the gut immune system and minimal absorption. The aim of this study was to evaluate the safety and efficacy of DR-6MP in patients with moderately severe CD compared to systemically delivered 6-mercaptopurine (Purinethol). Seventy CD patients were enrolled into a 12-week, double-blind controlled trial. The primary end-point was the percentage of subjects with clinical remission [Crohn's Disease Activity Index (CDAI) < 150] or clinical response (100-point CDAI reduction). Twenty-six (56·5%) and 13 (54·2%) subjects from the DR-6MP and Purinethol cohorts, respectively, completed the study. DR-6MP had similar efficacy to Purinethol following 12 weeks of treatment. However, the time to maximal clinical response was 8 weeks for DR-6MP versus 12 weeks for Purinethol. A higher proportion of patients on DR-6MP showed clinical remission at week 8. A greater improvement in Inflammatory Bowel Disease Questionnaire (IBDQ) score was noted in the DR-6MP group. DR-6MP led to a decrease of CD62(+) expression on T cells, implying a reduction of lymphocyte adhesion to site of inflammation. DR-6MP was safer than Purinethol, with significantly fewer adverse events (AEs). There was no evidence of drug-induced leucopenia in the DR-6MP group; the proportion of subjects who developed hepatotoxicity was lower for the DR-6MP. Non-absorbable DR-6MP is safe and biologically active in the gut. It is clinically effective, exerting a systemic immune response with low systemic bioavailability and a low incidence of side effects.

[Watermelon stomach: a cause of chronic blood loss in the elderly].

Watermelon stomach, or gastric vascular ectasia, is a relatively new, distinct clinical entity. This rare vascular abnormality of the stomach causes severe chronic blood loss and iron-deficiency anemia, particularly in the elderly. Endoscopically it is characterized by longitudinal antral folds which contain visible vessels radiating from the pylorus, and resembling the dark stripes on the surface of some watermelons. This endoscopic picture may easily be misinterpreted as antral hemorrhagic gastritis. The specific histologic features which establish the diagnosis on endoscopic biopsy are dilation and thrombosis of mucosal capillaries and fibromuscular hyperplasia of the lamina propria. Associated diseases, including achlorhydria, pernicious anemia and chronic liver disease have been reported. We recently encountered 2 cases of watermelon stomach associated with pernicious anemia and hypothyroidism. This entity should be considered in the differential diagnosis of iron-deficiency anemia.

[Primary gastric tuberculosis].

Intestinal tuberculosis (TB) comprises 5% of all cases of TB and may be a major problem in immigrant communities, although the incidence of pulmonary TB is declining. Gastric TB is rare, constituting 0.1-2% of all cases of TB. Gastric TB usually develops secondary to other tuberculous lesions, most commonly pulmonary. On endoscopy antral infiltrative lesions are found. Primary gastric TB is very rare, only 8 cases having been reported in the English literature. We report a case of primary gastric TB in a 55-year-old woman who presented with abdominal pain and gastric outlet obstruction. The diagnosis was confirmed by endoscopic biopsies which showed granulomas, but no acid-fast bacilli. The Mantoux test was positive, acid-fast bacilli were found in the gastric juice, and a positive culture for TB was obtained on gastric lavage. There was an excellent response to antituberculous chemotherapy. With the relative rate of extra-pulmonary TB increasing, primary gastric TB should be taken into account in the differential diagnosis of infiltrative lesions of the antrum.

[Transient thyroid dysfunction during chronic viral hepatitis treated with alpha-interferon].

2 patients with chronic viral hepatitis were treated with alpha-interferon and developed thyroid dysfunction. Both patients were previously euthyroid and had thyroids of normal size. 1 developed hypothyroidism (FT4 0.49 micrograms/dl; TSH 26.8 mIU/ml) and the other developed hyperthyroidism (FT4 2.72 micrograms/dl; T3 366 ng/ml; TSH 0.15 mIU/ml) 4 and 6 months, respectively, after commencing interferon. Interferon was discontinued, and thyroid function tests returned to normal within 1 and 2 months, respectively, and have remained normal for over a year. Antimicrosomal antibodies in the hypothyroid patient were positive (1:6400), but became negative after 4 months. No specific therapy for the thyroid disorders was given. These findings suggest that alpha-interferon induced transient thyroid dysfunction in patients who were previously euthyroid and were negative for thyroid autoantibodies.

Celiac disease as a cause of transient hypocalcemia and hypovitaminosis D in a 13 year-old girl.

We report a thirteen year-old girl with symptomatic hypocalcemia secondary to celiac disease. Serum vitamin D levels [25OH-VitD3 and 24,25(OH)2-VitD3] were low, whereas 1,25(OH)2D3 and PTH levels were higher than normal. Shortly after introducing a gluten-free diet, the patient became asymptomatic, regaining normal growth and pubertal development and serum calcium levels returned to normal.

[Endoscopic drainage of pancreatic pseudocyst: endoscopic cysto-enterostomy].

Pancreatic pseudocysts occur in 20% of cases of chronic pancreatitis. Spontaneous resolution is seen in about 9% of the cases, but most cysts persist and frequently cause complications, such as compression of adjacent organs or infection. Endoscopic cysto-enterostomy has recently been reported as a new nonsurgical invasive approach. We present a 40-year-old alcoholic man with a large pancreatic pseudocyst compressing the distal choledochus and pancreatic duct, who was treated successfully by endoscopic cysto-duodenostomy.

A 10 year single centre experience of percutaneous and endoscopic extraction of bile duct stones with T tube in situ.

A non-randomised single centre study of 226 consecutive patients referred over 10 years with retained common bile duct stones and a T tube in situ or a cholecystostomy tube are reported. Percutaneous extraction was attempted in 204 and endoscopic extraction in 68 patients. Percutaneous clearance was achieved in 158 (77.5%) patients and endoscopic clearance in 52 (76.5%) patients. Six of 153 (3.9%) patients followed after percutaneous treatment suffered major complications (pancreatitis, cholangitis, or tract perforation). Three of 67 (44%) patients followed after endoscopic treatment suffered major complications (pancreatitis, cholangitis, or bleeding). When the initial method of treatment failed, the alternative was used, resulting in an overall success rate of bile duct clearance of 94.3%. It is concluded that percutaneous and endoscopic methods of bile duct clearance in patients with a T tube in situ are equally effective, carrying similar complication rates. This study has helped to clarify the indications and efficacy of these alternative treatments.

[Nonsurgical treatment of bile duct stones].

Despite advances in intraoperative choledochoscopy and cholangiography, it is still common for bile duct stones to remain after common bile duct (CBD) exploration. The incidence of bile duct calculi in those undergoing cholecystectomy ranges from 7-15%, and that of retained stones immediately after CBD exploration, from 10-13%. Re-exploration carries a postoperative mortality varying from 3-28%. Treatment by T-tube flushing with heparinized saline, cholate or mono-octanoin is of limited value. Flushing with methyltertiarybutyl ether via a nasobiliary drain was recently reported to be successful in 80%, but confirmation of its efficacy and lack of toxicity is still pending. Continuous infusion via a nasobiliary tube of modified mono-octanoin alternating with EDTA solution may dissolve calcium bilirubin stones. Endoscopic sphincterotomy is successful in 95%. Extraction of CBD stones by either basket or balloon catheter is possible in 85-90% of cases at the time of endoscopic sphincterotomy. Large stones remaining are treated by mechanical lithotripsy with a success rate of 82%, which raises the overall success rate of endoscopic CBD stone extraction after endoscopic sphincterotomy to 97%. However, when stones exceed 25 mm in diameter, the success rate is lower. Electrohydraulic lithotripsy (EHL) may damage the CBD wall because the exact site of spark discharge is under fluoroscopic, not direct endoscopic control. In the near future, applying EHL under direct vision via peroral cholangioscopy should decrease the hazards of this method.(ABSTRACT TRUNCATED AT 250 WORDS)

Exogastric neurilemmoma presenting as acute abdomen: role of computed tomography in diagnosis.

A case of subserosal gastric neurilemmoma is hereby presented. This reported case is unique in its clinical presentation including the appearance of acute abdomen and fever subsequent to unremarkable and uneventful upper gastrointestinal endoscopy. The tendency of neurilemmoma to cause mucosal ulceration with fistula formation probably led to this clinical presentation. The role of computed tomography in establishing diagnosis of exogastric tumor is emphasized.

Concurrent collagenous colitis and multiple ileal carcinoids.

A case of collagenous colitis in a patient with ileal carcinoid is described. Considerable fibrofatty thickening of the small bowel mesentery was present. The association of these findings appears to be unprecedented. Further observations are required to ascertain that collagenous colitis is one of the protean manifestations of carcinoid tumor.

Familial achalasia with absent tear production.

Three of five siblings were evaluated because of dysphagia and failure to thrive. Radiologic and manometric studies were consistent with achalasia of the cardia. All of these siblings had deficient tear production. This report documents the unusual association of familial achalasia and deficient tear production, which is probably an autosomal recessive inherited syndrome.

Secretory piece and IgA deficiency in a patient with Waldenstrom's macroglobulinemia.

A case of a patient suffering from Waldenstrom's macroglobulinemia who developed diarrhea and mild steatorrhea is described. Laboratory studies revealed low serum IgA, intestinal secretory IgA deficiency, and small intestine bacterial overgrowth as demonstrated by the C14-cholylglycine breath test. These findings suggest that selective IgA deficiency and secretory component deficiency may be contributing factors in the development of diarrhea in Waldenstrom's macroglobulinemia.

[Eosinophilic granuloma of the stomach associated with polyarthritis]. / Il granuloma eosinofilo dello stomaco associato ad una poliartrite.

Eosinophilic granulomas of the stomach, also known as inflammatory pseudotumours, are infrequently occurring lesions characterised histologically by local capillary and fibroblastic proliferation with infiltration of eosinophilic cells. This condition is benign and appears as a polypoid mass with or without ulceration. A case of association of a polyarthritis with a eosinophilic polypoid gastric granuloma is described. This was subsequently removed by endoscopic polypectomy.

Biopsy of ureteral tumor in patient with ileal conduit.

A patient with ileal conduit and recent dilation of the left upper collecting system had flexible fiberoptic endoscopy of the ileal loop. The entire lumen of the intestinal conduit and the ureteroileal anastomosis were visualized. In addition retrograde pyelography and direct vision biopsy of a tumor in the ureter were performed.