Eosinophilic esophagitis in adults: what is the clinical significance?

Eosinophilic esophagitis is a condition that is being increasingly recognized in adults. The main presenting symptoms are dysphagia (93 %), food impaction (62 %), and heartburn (24 %). A history of allergy is obtained in 52 % of patients and peripheral eosinophilia is found in 31 % of patients with this condition. Esophageal manometric studies have provided evidence of a nonspecific motility disorder in 40 % of patients. Endoscopic findings include mucosal fragility or edema (59 %), solitary or multiple concentric rings (49 %), strictures (40 %), whitish pinpoint exudates or papules (16 %), and a small-caliber esophagus (5 %); 9 % of patients present with a normal endoscopy. Esophageal dilation in adults with eosinophilic esophagitis has limited efficacy and is associated with an increased complication rate compared with dilation in patients with benign strictures. The administration of inhaled or systemic corticosteroids results in symptomatic improvement in nearly 95 % of patients. A trial with corticosteroids before bougienage may reduce active inflammation and therefore the complication rate of the procedure.

Clinical outcome of patients with Helicobacter pylori infection: the bug, the host, or the environment?

It is well established that only a minority of patients with Helicobacter pylori infection develop severe inflammation leading to peptic ulcer or gastric cancer. Recent evidence suggests that the virulence factors of the organism do not seem crucial in the progression of inflammation towards a more severe disease. It seems probable that other host derived and environmental factors are more significant in determining clinical outcome but additional studies are needed to clarify the underlying mechanisms involved in the pathogenesis of infection.

Endoscopic ultrasonography in the diagnosis and management of portal hypertension. Where are we next?

Endoscopic ultrasonography has recently emerged as an accurate, non-invasive and reproducible alternative means of providing data for patients with portal hypertension. It is well established that endoscopic ultrasonography is more sensitive than endoscopy in the diagnosis of gastric varices. Dilated venous abnormalities outside the gastrooesophageal lumen, which cannot be diagnosed by endoscopy, are readily visible with endoscopic ultrasonography or miniature probes. Endoscopic ultrasonography is also useful to predict the risk of variceal recurrence and thus the risk of rebleeding after endotherapy which cannot be reliably predicted using endoscopy alone. The introduction of echo endoscopes equipped with Doppler facilities has allowed the sonographic visualisation of the vessels and the evaluation of vascular blood flow along with possible morphologic and haemodynamic changes after endoscopic or pharmacological therapy. However, despite its theoretical advantages, relative evidence suggests that in the clinical setting of portal hypertension, endoscopic ultrasonography remains an investigational tool with limited clinical applications.

Somatostatin and its analogues in peptic ulcer bleeding: facts and pathophysiological aspects.

Peptic ulcer bleeding remains a common medical emergency and despite recent advances in management is still associated with high mortality. Endoscopic treatment remains the cornerstone for the effective management of high-risk patients. Recent evidence suggests that potent antisecretory drugs that inhibit gastric acid secretion, such as proton pump inhibitors, may be of help alone or in combination with endotherapy in the management of peptic ulcer bleeding. Somatostatin appears to offer a distinct advantage over antisecretory drugs, as it inhibits both acid and pepsin secretion and combines these effects with a reduction in gastroduodenal mucosal blood flow which seems to be important in the pathophysiology of peptic ulcer bleeding. Additionally, the inhibition of pepsin secretion might induce a decreased proteolytic activity preventing the dissolution of freshly formed clots at the site of bleeding. Despite its theoretical advantages, there has been very little evidence in the recent past in setting of randomised, controlled, clinical trials. In reviewing the available data, we found that the efficacy of somatostatin and its analogue octreotide are different in the control of peptic ulcer bleeding and this might be due to the different distribution of its receptors through the GI tract. Further studies are needed to define the exact role, if any, of somatostatin and its analogues, in high-risk patients with peptic ulcer bleeding and this might be a rather interesting area for future research.

Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: a prospective, randomised, placebo controlled trial.

BACKGROUND AND AIMS: Conservative therapy for patients with acute colonic pseudo obstruction (Ogilvie's syndrome) may be successful initially but relapses are common. The aim of the present study was to evaluate the effect of polyethylene glycol (PEG) electrolyte balanced solution on the relapse rate of the syndrome after initial resolution with neostigmine or endoscopic decompression. PATIENTS AND METHODS: The study was performed on 30 consecutive patients who presented with abdominal distension and radiographic evidence of colonic dilation, with a caecal diameter > or = 10 cm, that resolved conservatively. Patients then were randomised to receive daily 29.5 g of PEG (n = 15) or similar placebo (n = 15). Patients were monitored daily for a seven day period for stool and flatus evacuations, and colonic diameter on abdominal radiographs. Administration of the test solutions and assessment of patient symptoms and x rays were performed in a blinded fashion. A caecal diameter > or = 8 cm with a concomitant > or =10% increase after initial successful therapeutic intervention was considered as a relapse and these patients, after a second therapeutic intervention, were eligible to receive open label PEG. RESULTS: Twenty five patients received neostigmine as the initial therapeutic intervention which resulted in resolution of colonic dilation in 88% of cases. Eight patients had successful endoscopic decompression. Five (33.3%) patients in the placebo group had recurrent caecal dilation compared with none in the PEG group (p = 0.04). Therapy with PEG resulted in a significant increase in stool and flatus evacuations (p = 0.001 and 0.032, respectively) as well as in a significant decrease in the diameter of caecum, ascending and transverse colon, and abdominal circumference (p = 0.017, 0.018, 0.014, and 0.008, respectively). CONCLUSIONS: Administration of PEG in patients with Ogilvie's syndrome after initial resolution of colonic dilation may increase the sustained response rate after initial therapeutic intervention.

Clinical significance of cytotoxin-associated gene A status of Helicobacter pylori among non-steroidal anti-inflammatory drug users with peptic ulcer bleeding: a multicenter case-control study.

BACKGROUND: The role of Helicobacter pylori infection and especially of the cytotoxin-associated gene A (CagA) product strain in peptic ulcer bleeding among non-steroidal anti-inflammatory drugs (NSAIDs) users remains controversial. METHODS: A case-control study was carried out including 191 consecutive chronic NSAIDs users admitted to hospital because of peptic ulcer bleeding. Peptic ulcer was verified by endoscopy. Controls comprised 196 chronic NSAIDs users without signs of bleeding of similar age and gender to cases. Multivariate regression analysis was performed for further evaluation of the relationship between H. pylori, CagA status and other risk factors. RESULTS: H. pylori infection was present in 121 (63.4%) cases compared with 119 (60.7%) controls (odds ratio (OR) = 1.14, 95% CI, 0.76-1.72). CagA-positive strains were found to be significantly more frequent in cases than in controls (65/106 versus 41/99 P = 0.008). Current smoking (OR = 2.65; 95% CI, 1.14-6.15; P= 0.02), CagA status (OR = 2.28; 95% CI, 1.24-4.19; P = 0.008), dyspepsia (OR = 6.89; 95% CI, 1.84-25.76; P = 0.004) and past history of peptic ulcer disease (OR=3.15; 95% CI, 1.43-6.92; P=0.004) were associated significantly with increased risk of bleeding peptic ulcer. CONCLUSIONS: The results suggest that CagA-positive H. pylori infection is associated with a more than 2-fold increased risk of bleeding peptic ulcer among chronic NSAIDs users.