[Dietary treatment of celiac disease]. / Kostbehandling ved cøliaki.

Life-long gluten-free diet is the established therapy of coeliac disease. Patients suffering from dermatitis herpetiformis benefit from the same treatment. In Norway the gluten-free diet has excluded oats as well as wheat, rye and barley. The basis for this recommendation was a 1972 report indicating that ten out of 23 children consuming oats as part of their gluten-free diet for at least 18 months developed signs of damage to the intestinal mucosa. During the last decades, the clinical picture of coeliac disease has changed as a result of better diagnostic tools. Controlled clinical trials during the last few years indicate that some patients may tolerate small amounts of oats in their gluten-free diet. As a consequence, patients may be confused with regard to what dietary regime is recommended in coeliac disease. Compliance with gluten-free diet is important to secure growth and development, the all-round condition, fertility, bone density and a reduced risk of nutrient deficiency and malignancy. Consensus on dietary treatment is essential. A number of controlled trials are under way and the outcome of these studies will in a few years determine whether oats might be included in the standard gluten-free diet. So far oats are not recommended. The physician who makes the diagnosis is responsible for all patients getting adequate dietary counselling and management. Dietary advice given by health personnel must be consistent.

[Guidelines for diagnosis and follow-up of patients with celiac disease. Norwegian Coeliac Association]. / Retningslinjer for diagnose og oppfølging av cøliaki.

The incidence and prevalence of coeliac disease in Norway is probably much higher than previously recognized. A prevalence of 1 per 676 individuals has been reported among adults in Norway. A much higher incidence has been documented in Sweden, both among children (one per approximately 300 liveborns) and among adults (1:256 healthy blood donors). Similar prevalence figures have been reported from Italy among young students. Eight new, biopsy-proven cases of coeliac disease were recently found by screening 2296 blood donors in Bergen (1:287). The symptoms of coeliac disease are often vague. Oligo- and asymptomatic cases often occur. The advisory council of the Norwegian Coeliac Association has established guidelines for the diagnostic work-up and for follow-up of patients with coeliac disease, in order to raise awareness of the disease, achieve a standardized work-up procedure and improve follow-up.

The natural course of peptic ulcer disease and its predictors.

BACKGROUND: Little is known about today's natural course of peptic ulcer disease (PUD). METHODS: A follow-up study based on a structured telephone interview was attempted in 728 patients with an endoscopic diagnosis of peptic ulcer in 1980-84. RESULTS: Seven patients (1%) died because of PUD during the 8- to 10-year follow-up period. Of the 441 interviewed patients 15.2% had experienced no further clinical manifestations of PUD, 10.9% had had bleeding and 0.7% perforation, and 17.5% had been operated on. The operated patients reported fewer symptoms (p < 0.01) during the last 2 weeks before the interview than those not operated on. On an average the unoperated patients had had symptoms and had used histamine-2-receptor antagonists (H2RA) 12 and 10 weeks per year, respectively. Long-term treatment with H2RA was reported by 18%. More than one-third (36%) of the unoperated patients stated that the symptoms had had a significant negative impact on their lives. Age at onset of disease and index ulcer, family history, use of anti-inflammatory drugs and alcohol, bleeding, and another chronic disease were found to be significant predictors of the course. CONCLUSION: In more than one-third of the patients with PUD the course is still burdened with many symptoms and complications.

Can NSAIDs cause acute biliary pain with cholestasis?

Two patients had many acute episodes of biliary pain with elevated liver function tests 12-48 h after the last ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) (including paracetamol) alone or in combination with codeine. One had known intolerance to NSAIDs, but paracetamol had not been previously incriminated in the pathogenesis of the attacks. In this patient the combined use of paracetamol and codeine probably also increased the severity of the episodes. We conclude that in some patients in whom endoscopic cholangiography is normal, biliary pain and abnormal liver function tests could be the result of NSAIDs. A thorough drug history is required in such cases.

The predictive value of history in dyspepsia.

Symptomatic patients referred to an open-access upper gastrointestinal endoscopy completed a detailed, self-administered questionnaire aimed at assessing the predictive value of history in dyspepsia. Nine hundred and thirty patients were suitable for analysis. Of these, 29% were found to have organic dyspepsia. A substantial overlap of symptoms and demographic data was found among the various endoscopic diagnoses. Discriminating variables were identified by stepwise logistic regression analysis and included in predictive score models. Pain relieved by antacids, age above 40 years, previous peptic ulcer disease, male sex, symptoms provoked by berries, and night pain relieved by antacids and food were found to predict organic dyspepsia with a sensitivity and specificity of approximately 70%, when applied on the observed material. Similar probabilities were found for score models of peptic ulcer and esophagitis. In general, the low prevalence of organic diseases resulted in low positive and high negative predictive values. Accordingly, the main impact of the predictive models may be to reduce the number of negative endoscopies rather than to predict a precise diagnosis. Independent of disease category and age, 41% of the subjects expressed a fear of malignancy, emphasizing the value of reassurance from a negative endoscopy.

The benefit of colonoscopy.

In a prospective study involving 833 consecutive outpatient and open-access colonoscopies, attempts were made to characterize the benefit of colonoscopy in terms of both predicted and unpredicted findings and therapeutic procedures. The endoscopist therefore predicted the endoscopic findings before the endoscopy. The results were compared for the different indications for colonoscopy. The overall agreement between the predictions and the colonoscopic findings was 61%. Clinically significant abnormalities were found in about half the examinations. The most frequent abnormal findings were benign polyps (24%), inflammatory bowel disease (17%), and malignancy (5%). In about half the patients with a malignancy the indication for colonoscopy was rectal bleeding, and half of the malignancies were not predicted. The greatest benefit of colonoscopy was found in patients referred because of overt rectal bleeding or occult faecal blood, and abnormal barium enema or endoscopy findings. The importance of complete colonoscopy in connection with operation for colorectal carcinoma is emphasized.

Optimal assessment of gastrointestinal side effects induced by non-steroidal anti-inflammatory drugs. Endoscopic lesions, faecal blood loss, and symptoms not necessarily correlated, as observed after naproxen and oxindanac in healthy volunteers.

Gastrointestinal side effects caused by naproxen and oxindanac (a developmental non-steroidal anti-inflammatory drug) were compared by combined endoscopy and determination of faecal blood loss in 16 healthy male volunteers in a randomized, double-blind, crossover study. Individual daily faecal blood loss was determined by means of 51Cr-labelled erythrocytes. Gastroduodenoscopy was performed before and after administration of naproxen, 750 mg/day, and oxindanac, 600 mg/day, for 1 week each. A washout period of at least 3 weeks was inserted between drug periods. Visual analogue scales (VAS) were used for endoscopic assessment of lesions and subjective complaints. Mean faecal blood loss increased from a base line 0.48 ml/24 h to 1.59 ml/24 h with naproxen (p less than 0.01) and from 0.56 ml/24 h to 1.31 ml/24 h with oxindanac (p less than 0.01). VAS scores for gastroduodenal lesions increased significantly with both drugs. Naproxen caused a significantly greater increase than oxindanac (p less than 0.05). There was no correlation between gastrointestinal blood loss and endoscopic findings. Subjective symptoms were correlated to faecal blood loss with naproxen, but not to endoscopic findings. No such correlations were observed for oxindanac. Naproxen caused a significant prolongation of bleeding time (p less than 0.01), whereas the increase caused by oxindanac was not significant (p = 0.09).

Do we need to listen to the patient? The predictive value of symptoms.

We have previously shown that the endoscopist is able to predict the endoscopic diagnosis in about two thirds of the patients. We report some preliminary findings from two different studies on the ability of symptoms to predict endoscopic findings. Comparison with similar studies in Glasgow and Huddinge suggests that the predictive value of symptoms probably varies between countries and depends on the population dealt with as well as on the methods used for symptom evaluation. Predictive models for peptic ulcer or endoscopic esophagitis based on symptoms showed at best an about 60-70% sensitivity and specificity. We strongly feel that future studies on the predictive value of symptoms should be more focused on the first step in the decision process in general practice.

Screening for occult faecal blood loss in a community by means of Hemoccult II slides and a tetramethylbenzidine test.

A total of 754 persons statistically selected from the age group 54-64 years were asked by letter to provide faecal samples for screening of occult blood during dietary restrictions. A total of 413 persons (55%) returned an average of 5.8 (range, 1-6) faecal samples each. All the faecal specimens were analysed with Hemoccult II slides and the 3,3',5,5'-tetramethylbenzidine (TMB) test 0.10%. For technical reasons, however, the Hemoccult test could not be evaluated. The TMB test showed faecal blood in 50 persons. A case history was obtained in 49 persons, of whom 47 agreed to further clinical, radiological, and endoscopic investigations. The most important findings in these examinations were resectable colonic carcinoma (Dukes's stage B) in 1 subject, a gastric ulcer in 1, haemorrhagic gastritis in 1, duodenal ulcers in 2, and colorectal polyps in 11 persons. The cost of the study was estimated to be NOK 114,000 (about USD 16,000).

Occult faecal blood loss determined by a 51Cr method and chemical tests in patients referred for upper gastrointestinal endoscopy.

In 119 patients referred for upper gastrointestinal endoscopy, the faecal blood loss was determined by a 51Cr method and 7 chemical tests. For patients with negative upper endoscopy (no. = 8), atrophic gastritis (no. = 30), gastric ulcer (no. = 31), or gastric cancer (no. = 23), the median 51Cr-determined faecal blood loss was 0.51, 0.61, 0.83, and 2.68 ml/24 h, respectively. For all chemical tests, the results were highly influenced by the upper time limit for positive reaction. Mixing of faecal specimens before testing did not prove essential. By repeated analyses of faecal samples stored for 3 days, the benzidine test showed a decreased sensitivity (p less than 0.01), whereas Fecatwin and Fecatwin sensitive showed an increased number of positive tests (p less than 0.01). Of cases of gastric cancer, tetramethylbenzidine tests including Hemo-Fec Test, benzidine test, Fecatwin sensitive, Hemoccult II, and Fecatwin could detect about 85%, 80%, 60%, 55%, and 30%, respectively.

Occult faecal blood loss determined by a 51Cr method and chemical tests in patients referred for colonoscopy.

In 67 patients referred for colonoscopy the faecal blood loss was determined by a 51Cr method and 7 chemical tests. For patients with negative colonoscopy (no. = 10), colorectal polyps (no. = 24), rectal cancer (no. = 8), or colonic cancer (no. = 12), the median 51Cr-determined faecal blood loss was 0.67, 0.74, 1.26, and 2.18 ml/24 h, respectively. For all chemical tests the results were highly influenced by the upper time limit for a positive reaction. Mixing of faecal specimens before testing proved unimportant. Fecatwin sensitive showed more positive tests in delayed compared with immediate analyses (p less than 0.01). Of cases of colorectal polyps, tetramethylbenzidine (TMB) tests including Hemo-Fec Test could detect half, the benzidine test 2 of 5. Fecatwin sensitive and Hemoccult II 1 of 4, and Fecatwin 1 of 24. Of cases of colorectal cancer, TMB tests, the benzidine test, Fecatwin sensitive, Hemoccult, and Fecatwin could detect about 85%, 85%, 85%, 80%, and 45%, respectively. All chemical tests detected faecal blood loss from colorectal lesions more easily than from gastric lesions.

Acetylsalicylic acid-induced prolongation of bleeding time in healthy men.

Bleeding times were determined in 25 healthy men using the Thrombolette bleeding time device. The median bleeding times prior to low and high doses of acetylsalicylic acid (ASA), 245 and 230 s, were not significantly different (P = 0.12). 2 h after randomized ingestion of 0.44 and 3.96 g ASA, the median bleeding times rose to 450 and 430 s, respectively. Both increased in bleeding time were significant (P less than 0.001), but the difference was not significant (P = 0.29). The maximum increase in bleeding time was estimated to occur 2.6 h after ingestion of a single low ASA dose, and 2.4 h after a single high dose. Following ingestion of 0.44 as well as 3.96 g ASA the bleeding time returned to basal levels within 5-6 d. Compared to the younger ones, volunteers with a higher age showed a tendency to have lower plasma salicylate levels as well as smaller increases in bleeding times following ASA ingestion.

Occult faecal blood loss determined by chemical tests and a 51 Cr method.

Stools from volunteers participating in an acetylsalicylic acid (ASA) study were examined during periods with restrictive and liberal diets. With 51Cr-determined faecal blood less than 2 ml/100 g, the rates of positive benzidine and 3,3' ,5,5'-tetramethylbenzidine (TMB) tests were about 5% and 25% for periods with restrictive and liberal diets, respectively. Similarly, Fecatest showed 2% positive tests on a restrictive and 8% on a liberal diet, whereas Hemoccult II slide and BM-test-Hemafecia showed less than 5% positive tests on both diets. When ASA-induced blood loss (mainly gastric) exceeded 5 ml/100 g faeces, the rate of positive benzidine and TMB tests, including the Hemo-Fec Test, varied from 87% to 100%. Fecatest detected half of these cases, whereas Hemoccult II and BM-test-Hemafecia were positive in less than one third. By repeated analyses of faecal specimens stored for 3 days, Fecatest showed a substantially increased sensitivity. We assume that benzidine and TMB tests are sensitive enough to detect occult blood loss from all levels of the gastrointestinal tract, but dietary restrictions are essential to reduce the rate of false-positive tests. Guaiac tests, perhaps with the exception of Fecatest, should be reserved for the detection of occult blood loss from the lower gastrointestinal tract.

Acetylsalicylic acid-induced gastrointestinal bleeding determined by a 51Cr method on a day-to-day basis.

The daily gastrointestinal blood loss caused by plain and microencapsulated acetylsalicylic acid (ASA) tablets was compared. Fourteen healthy, male volunteers participated in a double-blind, cross-over study, lasting 38 days. Before drug administration a median gastrointestinal bleeding of 0.9 ml/24 h was observed. During oral intake of 1.5 g ASA twice a day for 5 days, an increased faecal blood loss was seen in all volunteers. The increase was significant for both plain and microencapsulated ASA (p less than 0.01). Plain ASA tablets, however, caused a greater faecal blood loss than the microencapsulated tablets (p = 0.05), maximum median levels being 6.2 ml/24 h and 3.9 ml/24 h, respectively. An optimal design of radiochromium studies for determination of drug-induced gastrointestinal blood loss is discussed.