Does intestinal obstruction influence hypo-albuminemia: assessment of the physio-pathogenesis of protein-losing enteropathy with literature review.

BACKGROUND: Non-steroidal anti-inflammatory drug (NSAID) use may cause diaphragm-like lesions in the bowel. Although NSAID-enteropathy is among the causes of protein-losing enteropathy (PLE), intractable hypoalbuminemia is rare. CASE REPORT: Here, we discuss a case of NSAID-enteropathy with a diaphragm-like disease that presented with Protein Losing Enteropathy (PLE) rather than obstruction. The hypoalbuminemia recovered immediately after resection of the obstructive segment, despite ongoing annular ulcerations in the early postoperative period. Thus, it was not clear whether obstructive mechanisms influenced resistant hypoalbuminemia besides the ulcers. We also reviewed the English-written literature for "diaphragm-type lesion, NSAID-enteropathy, obstruction, and protein-losing enteropathy". We noted that the role of obstruction in the pathophysiology of PLE was not clear. CONCLUSIONS: As our case and a couple of cases reported in literature, slow-onset obstructive pathology seems to contribute to well-known factors: inflammatory response, exudation, tight-junction dysfunction, and increase in permeability in the physiopathology of NSAID-induced PLE. Factors such as distention-induced low-flow ischemia and reperfusion, cholecystectomy-related continuous bile flow, bacterial overgrowth-related bile deconjugation and concomitant inflammation are among other potential influencers. The possible role of a slow-onset obstructive pathology in the physiopathology of NSAID-induced and other PLE needs to be further elucidated.

Anti-Saccharomyces cerevisiae (ASCA) and anti-neutrophil cytoplasmic (ANCA) antibodies are not increased in Takayasu arteritis.

OBJECTIVES: Takayasu arteritis (TA) may be associated with inflammatory bowel disease (IBD). As there is such an overlap and since both diseases show granulomatous histopathological lesions we reasoned similar biological pathways might be implicated in both conditions. Therefore, we investigated the prevalence of anti-Saccharomyces cerevisiae (ASCA) and anti-neutrophil cytoplasmic (ANCA) antibodies - serological markers for IBD-among patients with TA. METHODS: Thirty-two patients with TA, 21 with Crohn's disease (CD), 17 with ulcerative colitis (UC) and 34 healthy controls were studied. Among 32 patients with TA, 2 had CD and one had UC concomitantly. ASCA Ig A and Ig G antibodies were analyzed using a commercial ELISA kit. Immune fluorescence analysis (IFA) was used to assess the presence of ANCA antibodies. RESULTS: Only patients with CD had significantly higher levels of both ASCA Ig A and Ig G, compared to patients with TA and healthy controls. Similarly, the frequency of ASCA positive patients was higher only among patients with CD. ASCA Ig A and Ig G antibodies were found in 16 % (5/32) of patients with TA. Among 3 patients, in whom TA and IBD co-existed, only one (one with CD) had positive ASCA Ig G and A antibodies. The p-ANCA antibodies were present among patients with UC (35 %) and CD (10 %). CONCLUSION: ASCA positivity in TA was similar to that found in UC and healthy controls. No ANCA antibodies were detected among patients with TA.

Frequency of pathergy phenomenon and other features of Behçet's syndrome among patients with inflammatory bowel disease.

OBJECTIVE: Crohn's disease (CD) and ulcerative colitis (UC) share common clinical features with Behçet's syndrome (BS). We surveyed UC and CD patients for pathergy phenomenon and features of BS with the aim of determining how much overlap is present between these 2 entities in a setting where BS is relatively common, the frequency of pathergy positivity in inflammatory bowel disease (IBD) patients and evaluating how International Study Group (ISG) criteria perform in differentiating IBD from BS. METHODS: This study was conducted among patients with CD and UC attending the gastroenterology outpatient clinic of a university hospital which is also a referral center for BS. Consecutive CD and UC patients were screened for BS using ISG criteria. Pathergy test was performed and evaluated by 2 independent observers in a masked manner. RESULTS: Ninety-three patients with CD and 130 with UC were surveyed. None of the CD patients fulfilled ISG criteria for BS while 2 of 130 UC patients did. Twenty CD patients had oral ulcers while 4 reported having genital ulcers but no scars could be observed. Twenty-two CD patients had papulopustular lesions, 2 had nodular lesions, 3 had arthritis and none had uveitis. Thirty-two UC patients had oral ulcers, none had genital ulcers, 23 had papulopustular lesions, 3 had nodular lesions, 2 had arthritis and 2 had uveitis. Pathergy test was positive according to at least one of the observers in 10/93 CD and 8/130 UC patients and according to both observers in 4/130 UC patients. CONCLUSION: Despite similarities between the clinical features of CD and UC with BS, coexistence is uncommon. ISG criteria perform well in differentiating these diseases. About 8% of IBD patients show the pathergy phenomenon.

Follow-up of a patient with chronic hepatitis C-associated cryoglobulinemia during four and a half years of maintenance interferon treatment.

In this report, we present a patient with chronic hepatitis C-associated cryoglobulinemia who was kept on maintenance interferon treatment because of flare-ups in cryoglobulinemia-associated signs and hepatitis after withdrawal, dose reduction, and increase in dose intervals of interferon. This type of interferon use for treatment of cryoglobulinemia gave us a chance to observe the long-term effects of interferon on cryoglobulinemia and chronic hepatitis C remission for biochemical, virologic, and histologic aspects.

Helicobacter pylori-induced gastritis may contribute to occurrence of postprandial symptomatic hypoglycemia.

In our clinical experience, postprandial symptomatic hypoglycemic (PSH) patients with H. pylori gastritis showed a substantial improvement in their hypoglycemic symptoms after the eradication of H. pylori. Therefore, in this study we have investigated whether H. pylori gastritis may contribute to the occurrence of PSH. For this purpose, we have evaluated the following parameters in 12 PSH patients with H. pylori gastritis before and one month after the eradication therapy: (1) the number and severity of PSH attacks that occurred in a one-month period using a 30-day diary, (2) the total symptom score following a mixed meal using a visual analog scale questionnaire (VASQ), and (3) the glucose and insulin responses to the mixed meal. After the eradication of H. pylori, the serum insulin responses at 30 and 60 min decreased (P < 0.001 in both), whereas the plasma glucose levels at 150, 180 and 210 min increased significantly (P < 0.001 for 180 min and P < 0.01 in others) following the mixed meal. The number and severity score of PSH attacks that occurred in a one-month period and the area under curve for symptom score in VASQ decreased significantly (P < 0.001 in all). These results suggest that H. pylori gastritis may contribute to the occurrence of PSH.

Primary splenic tuberculosis in a patient with nasal angiocentric lymphoma: mimicking metastatic tumor on abdominal CT.

Tuberculosis may be difficult to diagnose when it presents in an uncommon extrapulmonary site. The authors report a case of splenic tuberculosis mimicking metastatic tumor on computed tomography in a 60-year-old woman who had been treated with combination chemotherapy for nasal angiocentric lymphoma. Diagnostic splenectomy revealed multiple necrotic masses in the spleen, which were consistent with caseating granulomas microscopically. Diagnosis was confirmed by positive cultures in Lowenstein medium, which grew typical Mycobacterium tuberculosis organisms. Following splenectomy, the patient was also treated with a triple-drug antituberculosis regimen with no recurrence of her symptoms.

A case of fibrosing mediastinitis with obstruction of superior vena cava and downhill esophageal varices: a rare cause of upper gastrointestinal hemorrhage.

Fibrosing mediastinitis (FM) is an excessive fibrotic reaction that occurs in the mediastinum and may lead to compression of mediastinal structures (especially vascular or bronchial). In the present study we describe the first case report of FM, in a patient who developed downhill esophageal varices and bleeding, which was secondary to superior vena cava obstruction.

Does Helicobacter pylori-induced gastritis enhance food-stimulated insulin release?

The fact that H. pylori gastritis results in an increased secretion of basal and meal-stimulated gastrin, which is also a physiologic amplifier of insulin release directed us to investigate whether H. pylori gastritis may lead to an enhancement of nutrient-stimulated insulin secretion. For this purpose, we have investigated the insulin responses to both oral glucose and a mixed meal in 15 patients with H. pylori gastritis before and one month after the eradication therapy and also in 15 H. pylori-negative control subjects. The areas under the curve (AUC) for serum insulin following both oral glucose and a mixed meal in the patients with H. pylori gastritis before the eradication were significantly (P < 0.05) higher than those in the H. pylori-negative controls. After the eradication of H. pylori, the AUC for serum insulin following oral glucose and mixed meal decreased by 9.4% and 13.1%, respectively (P < 0.001 in both), and serum basal and meal-stimulated gastrin levels decreased significantly (P < 0.001). These results suggest that H. pylori gastritis enhances glucose and meal-stimulated insulin release probably by increasing gastrin secretion.

Hereditary proctalgia fugax and constipation: report of a second family.

A second family with hereditary proctalgia fugax and internal anal sphincter hypertrophy associated with constipation is described. Anorectal ultrasonography, manometry, and sensory tests were conducted in two symptomatic and one asymptomatic subjects within the same family and further clinical information was obtained from other family members. The inheritance would correspond to an autosomal dominant condition with incomplete penetration, presenting after the second decade of life. Physiological studies showed deep, ultraslow waves and an absence of internal anal sphincter relaxation on rectal distension in the two most severely affected family members, suggesting the possibility of a neuropathic origin. Both of these patients had an abnormally high blood pressure. After treatment with a sustained release formulation of the calcium antagonist, nifedipine, their blood pressure returned to normal, anal tone was reduced, and the frequency and intensity of anal pain was suppressed. These together improved the quality of the patients' sleep, which had previously been very troubled because of night time attacks of anal pain.

The effect of oral vancomycin on chronic idiopathic constipation.

BACKGROUND: A case study reporting the efficacy of oral vancomycin in a patient with chronic idiopathic constipation prompted this prospective trial of oral vancomycin in eight female patients (aged 21-61 years) with severe constipation resistant to the action of dietary fibre. METHODS: The trial was divided into two consecutive 14-day periods. During the first period, each patient was given ispaghula, 3.5 g twice a day, and during the subsequent period they took 250 mg vancomycin t.d.s. per os, as well as the fibre supplement. During both periods they collected stools and recorded daily bowel symptoms (stool frequency, straining, stool consistency, subjective stool volume) in a diary. At the end of each period whole gut transit time and the breath hydrogen response to a standard meal, giving oro-caecal transit time, were measured along with gastrointestinal symptoms which were assessed on visual analogue scales. RESULTS: Vancomycin caused a significant improvement in stool frequency, consistency, ease of defecation and the amount of stool patients felt they produced (all P < 0.05), but objective measures of daily stool weight and whole gut or oro-caecal transit time were not significantly different. Basal breath hydrogen levels were higher after vancomycin treatment in seven out of eight patients. One patient experienced a complete remission of symptoms when she took vancomycin and remains in remission after 14 months. This patient showed no elevation in basal breath hydrogen level. CONCLUSION: Although this study does not support the use of vancomycin for most patients with constipation, the results suggest that modification of the intraluminal flora may be of value in the treatment of the occasional case of idiopathic constipation.