Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD.

BACKGROUND: High-resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance-pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance-pH findings in patients with reflux symptoms. METHODS: Consecutive patients with suspected gastroesophageal reflux disease (GERD) were enrolled. All patients underwent HRM and impedance-pH testing off-therapy. EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and <2 cm); Type III, ≥ 2 cm separation. We measured esophageal acid exposure time (AET), number of total reflux episodes and symptom association analysis. KEY RESULTS: We enrolled 130 consecutive patients and identified 46.2% Type I EGJ, 38.5% Type II, and 15.4% Type III patients. Type III subjects had a higher number of reflux episodes (61 vs 45, p < 0.03, vs 25, p < 0.001), a greater mean AET (12.4 vs 4.2, p < 0.02, vs 1.5, p < 0.001) and a greater positive symptom association (75% vs 72%, p = 0.732 vs 43.3%, p < 0.02) compared with Type II and I patients, respectively. Furthermore, Type II subjects showed statistically significant (overall p < 0.01) increased reflux when compared with Type I patients. Type III and II EGJ morphologies had a more frequent probability to show a positive multichannel intraluminal impedance pH monitoring than Type I (95% vs 84% vs 50%, p < 0.001). CONCLUSIONS & INFERENCES: Increasing separation between LES and CD can cause a gradual and significant increase in reflux. EGJ morphology may be useful to estimate an abnormal impedance-pH testing in GERD patients.

Altered chemokine signalling in endothelial progenitor cells from acute ulcerative colitis patients.

Ulcerative colitis (UC) is a chronic, idiopathic, inflammatory bowel disease, characterized by alternating stages of clinically active and inactive disease. UC exhibits several inflammatory characteristics, including immune activation, leukocyte infiltration, and altered vascular density. In UC, many of the upregulated inflammatory cytokines are proangiogenic and are released by diverse cell populations, such as infiltrating immune cells and endothelial cells (EC). Increasing evidences suggest that neovascularisation may involve also endothelial progenitor cells (EPCs). In this study we evaluated EPCs recruitment and homing, assessed by CXCR4 expression, in both acute and remitting phase of UC. We report an overall decrease of EPCs in UC patients (controls = 97,94 ± 37,34 cells/mL; acute = 31,10 ± 25,38 cells/mL; remitting = 30,33 ± 19,02 cells/mL; P < 0.001 for both UC groups versus controls). Moreover CXCR4(+)-EPCs, committed to home in inflammatory conditions, were found to be reduced in acute UC patients compared to both remitting patients and controls (acute = 3,13 ± 4,61 cells/mL; controls = 20,12 ± 14,0; remitting = 19,47 ± 12,83; P < 0,001). Interestingly, we found that administration of anti-inflammatory drugs in acute UC is associated with an increase in circulating EPCs, suggesting that this therapy may exert a strong influence on the progenitor cells response to inflammatory processes.

In vivo molecular imaging of HER2 expression in a rat model of Barrett's esophagus adenocarcinoma.

Human epidermal growth factor receptor 2 (HER2) is involved in the malignant progression of several human cancers, including esophageal adenocarcinoma (EAC). The purpose of this study was to evaluate HER2 overexpression and to explore the feasibility of confocal laser endomicroscopy for in vivo molecular imaging of HER2 status in an animal model of Barrett's-related EAC. Rats underwent esophagojejunostomy with gastric preservation. At 30 weeks post-surgery, the esophagus of 46 rats was studied; endoscopic and histological findings were correlated with HER2 immunofluorescence on excised biopsies and gross specimens. At this age, 23/46 rats developed Barrett's esophagus (BE), and 6/46 had cancer (four EAC and two squamous cell carcinomas). A significant overexpression of HER2 was observed in esophageal adenocarcinoma compared with normal squamous esophagus (9.4-fold) and BE (6.0-fold). AKT and its phosphorylated form were also overexpressed in cancer areas. Molecular imaging was performed at 80 weeks post-surgery in four rats after tail injection of fluorescent-labeled anti-HER2 antibody. At this age, 3/4 rats developed advance adenocarcinoma and showed in vivo overexpression of HER2 by molecular confocal laser endomicroscopy with heterogeneous distribution within cancer; no HER2 signal was observed in normal or Barrett's tissues. Therefore, HER2 overexpression is a typical feature of the surgical induced model of EAC that can be easily quantified in vivo using an innovative mini-invasive approach including confocal endomicroscopy; this approach may avoid limits of histological evaluation of HER2 status on 'blinded' biopsies.

Parathyroid carcinoma: case report.

The authors present a case of parathyroid carcinoma in a patient with primary hyperparathyroidism. Following a literature review, the clinical and diagnostic profile, treatment and prognosis of this rare disease are discussed.

Pancreatic pseudocyst: case report and short literature review.

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.

Liver trauma. Diagnosis and treatment.

The authors summarize the essential steps in liver surgery. Modern imaging techniques are of great help in establishing a circumstantiated diagnosis of post-traumatic lesions of the intra-abdominal parenchymatous organs, and especially the liver. Such diagnosis must always be based on the AAST (American Association for the Surgery of Trauma) classification, essential for a correct approach. Each therapeutic choice must be based on a careful clinical evaluation to establish whether emergency exploration of the abdomen or simple patient monitoring is indicated. Organ injuries and consequent hemoperitoneum must be found and quantified. In any case, diagnosis and treatment must only begin once all measures have been taken to ensure the maintenance of vital functions and the normalization of the main blood chemistry parameters.

Nonadherent behaviors after solid organ transplantation.

BACKGROUND AND AIM: The effectiveness of any treatment depends not only on the choice of therapy, but also, to a large extent, on the patient's active cooperation. Adherence to medical prescriptions and particularly to immunosuppressive therapy is crucial to prevent medical complications that negatively influence graft function and patient survival after organ transplantation. The aim of this study was to assess, among patients who underwent solid organ transplantation, nonadherent behaviors (NAB) to immunosuppressive therapy, to correct lifestyle, and to general medical prescriptions. MATERIALS AND METHODS: We evaluated patients who underwent solid organ transplantation from March 2008 to June 2009. All participants completed an anonymous 15-item questionnaire to assess NAB. RESULTS: We enrolled 218 organ transplant patients: 103 liver, 50 kidney, 52 heart, and 13 lung. There were 152 men and the overall age was 52.2 ± 0.8 years (mean ± standard deviation [SD]) time from transplantation, 83.6 ± 4.5 months (mean ± SD). Overall 37.9%, 38.8%, and 12.8% of patients reported nonadherence to immunosuppressive therapy, to correct lifestyle, and to general medical prescriptions, respectively. Considering nonadherence to immunosuppressive therapy and to general prescriptions, the percentage of kidney transplant patients who referred NAB was significantly lower compared with other organ transplant patients (P = .008 and P = .04, respectively). Nonadherent patients to immunosuppressive therapy and to general medical prescriptions displayed a longer interval from transplantation compared with adherent patients (P = .02 and P = .03, respectively). Among patients nonadherent to the correct lifestyle, the rates of men and of patients with disability pension were significantly higher compared to adherent patients (P = .001 and P = .002, respectively). CONCLUSIONS: Poor adherence to medical prescriptions and to adequate lifestyle is common among organ transplant patients, especially those who have undergone liver transplantation. Psychoeducational interventions for transplanted patients and their families are needed to improve adherence.

Mucocele of the appendix. Two case reports.

The authors present two cases of mucocele of the appendix and discuss them in relation to the literature and the clinical features of this disease. They clarify the definition of mucocele as an intraluminal accumulation of mucus in the appendix, and concentrate on the observable pathological processes, agreeing on the higher frequency of mucinous cystadenoma and the possibility that mucocele can develop into peritoneal pseudomyxoma or degenerate into cystadenocarcinoma. They also note that most diagnoses are made intra-operatively during appendectomy, and that, in cases suspected preoperatively, thorough investigation with imaging techniques is very important in order to plan the best treatment.

[Acute typhlitis associated with taxane-based chemotherapy]. / Tiflite acuta dopo trattamento chemioterapico con taxani.

A rare case of acute typhlitis is reported. The patient had undergone chemotherapy for a breast cancer. Clinical and diagnostic tools as well as general and topical care are examined.

Clinical trial: ulcerative colitis maintenance treatment with 5-ASA: a 1-year, randomized multicentre study comparing MMX with Asacol.

BACKGROUND: 5-ASA-MMX (1.2 g/tablet) is a 5-aminosalicylic acid formulation, designed for once-daily dosing in the treatment of ulcerative colitis. AIM: To evaluate the efficacy and safety of 5-ASA-MMX (2.4 g/day, once daily), compared with Asacol (2.4 g/day, twice daily) in the maintenance of left-sided UC, through a double-blind, double-dummy, parallel-group, randomized, comparator study. METHODS: In all, 331 patients with UC were randomized to receive either 5-ASA-MMX 2.4 g/day, once daily, or Asacol 2.4 g/day, twice daily, for 12 months. All patients were in remission for >or=1 month prior to the trial, with >or=1 documented relapse in the previous year. The co-primary endpoints of this study were the proportion of patients in clinical, and clinical and endoscopic remission following 12 months' treatment. RESULTS: In the intent-to-treat population, excluding those with major protocol deviations, 68.0 and 65.9% patients in the 5-ASA-MMX and Asacol groups, respectively, were in clinical remission (P = 0.69), and 60.9 and 61.7% of patients, respectively, were in clinical and endoscopic remission (P = 0.89). Diary card data revealed statistically significant treatment differences favouring 5-ASA-MMX. Both treatments were similarly tolerated. CONCLUSIONS: Once-daily 5-ASA-MMX is similarly effective with a comparable safety profile to Asacol administered twice daily, for the maintenance treatment of ulcerative colitis.

Articular manifestations in inflammatory bowel disease patients: a prospective study.

BACKGROUND AND AIMS: Rheumatic manifestations are frequent in inflammatory bowel disease (IBD) and are associated with a wide range of clinical patterns. METHODS: Articular symptoms and signs were investigated by questionnaire in a cohort of 651 pts, mean age 42+/-14 years, followed at two referral hospitals over a 12-month period. RESULTS: 142 ulcerative colitis (UC) and 120 Crohn's disease (CD) patients referred articular pain during their IBD history: in 46% this was associated with active IBD, in 56% symptoms were intermittent and in 19% symptoms preceded IBD diagnosis. 62 pts (28 UC, 34 CD) complaining of articular symptoms at the time of the interview, were investigated by the rheumatologist: arthropathy was axial in 52%, oligoarticular in 16% and polyarticular in 23%. Oligoarthritis commonly involved the lower limbs and was more commonly associated with UC. The mean number of small joints involved was significantly higher in CD than in UC pts (9.9+/-8.2 vs. 5.6+/-4.3; p<0.01). Bone scintigraphy was abnormal in 70% of pts. CONCLUSIONS: Prevalence of self-reported articular symptoms in IBD patients exceeds 40% with 9.5% incidence during 1-year follow up. Symptoms predict entheropatic involvement of the locomotor system.

The association of MYO9B gene in Italian patients with inflammatory bowel diseases.

BACKGROUND: Variants of myosin IXB (MYO9B) gene, encoding for a motor protein implicated in epithelial permeability, have been recently associated with inflammatory bowel disease. AIMS: To investigate the contribution of three polymorphisms of MYO9B gene for predisposition to Crohn's disease and ulcerative colitis, their association with clinical phenotypes, particularly intestinal permeability, and possible interaction with the CARD15 gene. METHODS: 549 Crohn's disease patients, 658 ulcerative colitis patients and 674 controls were genotyped for the rs962917, rs1545620 and rs2305764 single nucleotide polymorphisms. RESULTS: Highly significant genotypic association with Crohn's disease and ulcerative colitis was shown for all three single nucleotide polymorphisms, with odds ratio ranging from 1.5 to 1.7 (P-value: <0.01 to <0.002). A significant difference in allele frequencies was also observed in inflammatory bowel disease patients, with the single most significant association for rs1545620, detected in 47% of Crohn's disease, 47% of ulcerative colitis patients and 42% of controls (P < 0.005). No association with specific sub-phenotypes was found, with the exception of a trend towards an abnormal intestinal permeability (P = 0.043) in Crohn's disease carrying the rs1545620 risk allele. CONCLUSIONS: Our findings confirm the association between the MYO9B polymorphisms and susceptibility to both ulcerative colitis and Crohn's disease, with a weak influence on sub-phenotypic expression.

Risk factors for non-adherence to medication in inflammatory bowel disease patients.

BACKGROUND: Inflammatory bowel diseases are chronic conditions requiring medication throughout life to treat the disease and control the risk of relapse and colorectal cancer. Adherence to prescribed drugs is therefore crucial to their management. AIM: To identify determinants and potential risk factors of non-adherence in inflammatory bowel disease patients. METHODS: An anonymous 24-item questionnaire (available online as Supplementary material) was administered to 485 out-patients attending a tertiary referral centre. RESULTS: Sixty-one per cent of the patients reportedly adhered to their treatment. No differences emerged between inflammatory bowel disease and socio-demographic characteristics other than age, non-adherence being significantly associated with cases under 40 years (43% vs. 34%, P = 0.041). The most common reasons for non-adherence vs. adherence were forgetfulness (61% vs. 44%, P = 0.000), disease remission (25% vs. 10%, P = 0.000), recent diagnosis (24% vs. 15%, P = 0.000) and full-time employment (55% vs. 26%, P = 0.000). Oral therapy was associated with a significantly better adherence than rectal therapy (60% vs. 32%, P = 0.001). Communication affects patient adherence: a significant interaction was found for adherence and patients <40 years who had a good relationship with their doctors. CONCLUSIONS: Risk factors for non-adherence are younger age, busy working life, recent diagnosis and disease remission. Good communication with the doctor might improve adherence.

Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients.

BACKGROUND: The distribution of lesions in the gastrointestinal tract in patients with sporadic telangiectasia is at present unknown. PATIENTS AND METHODS: 75 patients with sporadic telangiectasia underwent esophagogastroduodenoscopy (EGD), capsule endoscopy, and colonoscopy. Endoscopic diagnosis of telangiectasia and gastrointestinal bleeding were required for enrollment in the study. Hemorrhagic diathesis, co-morbidity, number of blood transfusions, and subsequent management were also noted. RESULTS: 35 of the patients presented with gastroduodenal vascular lesions, 51 with small-bowel lesions, and 28 with colonic lesions. 67 % of patients in whom EGD found telangiectasia also presented small-bowel vascular lesions at capsule endoscopy and 43 % colonic lesions at colonoscopy. 54 % percent of patients with positive colonoscopy also presented gastroduodenal lesions and 48 % small-bowel lesions. Patients with known duodenal lesions were more likely to have small-bowel lesions at capsule endoscopy (odds ratio [OR] 10.19, 95 % CI 2.1 - 49.33, P = 0.003). Patients with associated diseases, such as liver cirrhosis, chronic renal failure, or heart valvulopathy, presented more severe disease requiring blood transfusions (OR 6.37, 95 % CI 1.39 - 29.2, P = 0.015). The number of blood transfusions correlated with the number of sites affected ( R = 0.35, P = 0.002). The detection of new lesions at capsule endoscopy allowed new treatment in 46 % of patients. Mean follow-up was 18 months. CONCLUSIONS: Sporadic telangiectasia is a multifocal disease potentially involving the whole digestive tract. Patients with duodenal telangiectasia show a higher risk of jejunal or ileal lesions. Capsule endoscopy is a useful diagnostic tool for the detection of such small-bowel vascular lesions, indicating a more specific prognosis and treatment strategy.

Use of alternative and complementary therapies by inflammatory bowel disease patients in an Italian tertiary referral centre.

BACKGROUND: Alternative and complementary therapies are increasingly used by patients with inflammatory bowel disease, but no data are available on their use in Italy. AIM: To ascertain the prevalence and pattern of the use of alternative and complementary therapies, and demographic and clinical factors associated with their use in a large sample of Italian inflammatory bowel disease patients. METHODS: A structured questionnaire was administered to a cohort of outpatients at a tertiary referral centre. RESULTS: Five hundred and fifty-two patients completed the questionnaire; 156 (28%) reported using alternative and complementary therapies, which mainly involved homeopathy (43.6%), followed by controlled diets or dietary supplements (35.5%), herbs (28.2%), exercise (25.6%) and prayer (14.7%). Alternative and complementary therapies were used to ameliorate intestinal symptoms (52.5%), in the hope of being cured (41%) and to reduce the intake of drugs (39.7%). An improvement in well-being (45.5%) and inflammatory bowel disease symptoms (40.3%) were the most commonly reported benefits. A higher education (p=0.027), a more frequently relapsing disease (p=0.001) and dissatisfaction with the doctor's communication (p=0.001) correlated with alternative and complementary therapy use. Non-compliance with conventional drugs, disease severity and curiosity regarding novel therapies were predictors of alternative and complementary therapy use. CONCLUSIONS: Alternative and complementary therapies are frequently used by Italian inflammatory bowel disease patients. Doctors should improve their empathy and their understanding about possible benefits of alternative and complementary therapies.

An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions.

PURPOSE: The purpose of this study was to assess the feasibility and clinical impact of the percutaneous removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE). MATERIALS AND METHODS: Over a period of 24 months, we observed eight patients (age 54-82 years; mean 65) with dysfunctioning PBE. After transhepatic cholangiography and bile duct catheterisation, the endoprostheses were grasped with a gooseneck snare and pushed into the duodenum using a long introducer sheath. Subsequently, we implanted six metallic stents in middle and distal occlusions and four plastic endoprostheses in two patients with proximal occlusion. Clinical and ultrasound followup was performed 1, 3 and 6 months after the procedure and then yearly. RESULTS: The procedure was technically successful in all patients. No major complication occurred. All patients were discharged without biliary drainage catheters. During the follow-up period (mean: 7.1 months), four patients died and two occlusions of metallic stents were treated by implanting a further metallic stent. CONCLUSIONS: Percutaneous removal of a dysfunctioning PBE is feasible and allows better quality of life owing to the absence of biliary drainage. Patency of metallic stents is higher than that of PBE. Larger studies are clearly required to validate this approach.

Wilson disease--a practical approach to diagnosis, treatment and follow-up.

Wilson disease is an inherited, autosomal recessive, copper accumulation and toxicity disorder that affects about 30 individuals per million. This rare disease is caused by mutations in the gene encoding a copper-transporting P-type ATPase, which is important for copper excretion into bile, leading to copper accumulation in the liver. Toxic copper concentrations can also be found in the brain and kidney, and clinical phenotypes include hepatic, haemolytic, neurologic and psychiatric diseases. Diagnosis is based on the combination of clinical features and findings such as increased urinary copper excretion, reduced levels of serum ceruloplasmin, high concentrations of copper in liver tissues and Kayser-Fleischer rings. Genetic studies are also becoming available for clinical use, but the utility of direct mutation analysis is limited. Wilson disease can be treated, and early diagnosis is essential: the goal of therapy is to reduce copper accumulation either by enhancing its urinary excretion or by decreasing its intestinal absorption. Medical therapies include penicillamine, trientine, zinc and tetrathiomolibdate. Liver transplantation is a relatively successful treatment option when medical therapy fails or in case of acute liver failure, even though it is also characterized by short- and long-term complications.

Interaction between rifaximin and dietary fibre in patients with diverticular disease.

BACKGROUND: Cyclic administration of rifaximin in association with dietary fibre achieves symptomatic relief in uncomplicated diverticular disease (DD) by means of a still undefined mechanism. AIM: To investigate the effects of a combination of rifaximin and fibre on both hydrogen production by intestinal microflora and oro-anal transit time. METHODS: In a controlled, double-blind crossover trial, 64 patients with uncomplicated DD were given bran (20 g/day) and randomly treated with rifaximin (1200 mg/day) or a placebo for 14 days. Evaluation was based on clinical status, breath test, oro-anal transit time and faecal weight. RESULTS: The global symptomatic score was significantly reduced after rifaximin (7.1 +/- 4.1 to 4.1 +/- 3.3; P < 0.005) but not after placebo (6.8 +/- 3.8 to 6.1 +/- 3.5). Hydrogen production significantly increased after placebo from 198 +/- 134 to 267 +/- 161 ppm/min, while Rifaximin reduced it from 222 +/- 187 to 166 +/- 131 ppm/min (P = 0.05). The total oro-anal transit time decreased from 56.1 +/- 28.2 to 51.3 +/- 28.0 h in placebo and from 54.4 +/- 31.9 to 45.1 +/- 32.4 h (P < 0.05) in rifaximin-treated patients. CONCLUSIONS: The administration of rifamixin improves the benefits of dietary fibre in uncomplicated DD by preventing its bacterial degradation.