Emergency gastric ulcer complications in elderly. Factors affecting the morbidity and mortality in relation to therapeutic approaches.

AIM: In elderly the incidence of the emergency gastric ulcer complications, perforation and bleeding are increasing, with a difficult management of these patients for their concomitant diseases. The aim of this work is to analyze the therapeutical approach of emergency gastric ulcer complications in elderly patients, in order to establish the factors affecting the morbidity and mortality. METHODS: Patients older than 70 years, presenting gastric ulcer, observed in a tertiary University Hospital from 1995 to 2003, have been considered for the present study. Two groups of diseases have been examined: ulcer perforation and bleeding ulcer. Age, sex, risk factors, comorbidity, methods of diagnosis, ulcer characteristics, treatment, morbidity, mortality, hospitalization time and follow-up have been considered in each group. RESULTS: Thirteen elderly patients with perforated gastric ulcer have been observed: 9 (69.2%) females and 4 (30.8%) males with a mean age of 80.5 years (range 70-90). Four patients were hospitalized in suburban hospital with an average time between the diagnosis and the surgery of 36 h, while the remnants were hospitalized directly in our Department with a medium waiting time of about 2 h. The surgical procedures were: simple closure with omentum patch in 11 cases (84.6%), and antrectomy in 2 cases (15.4%), in which the antrum was multiply perforated. Two patients presented an ulcer larger than 2 cm treated with simple suture and omental patch without morbidity and mortality. Three patients (23%) died postoperatively, due to septic shock, ventricular fibrillation and intraoperative massive haemorrhage, 2 of these patients came from other hospitals. Twenty-eight elderly patients with bleeding gastric ulcer have been observed during the same period: 13 (46.4%) females and 15 (53.6%) males with a mean age of 79.6 years (range 71-91). Except 2 patients submitted to endoscopic treatment both with adrenaline injection, all the remnant patients were managed with medical therapy (H2-receptor antagonist or proton pump inhibitors and in 7 patients [24.1%] antihaemorrhage drugs), and clinical observation, with a endoscopic control 3-4 days after from the first endoscopy. One of the 2 patients endoscopically treated developed a ulcer perforation after 11 days, and the other one rebled, without possibility of any kind of treatment due to his instable condition of health. Three patients (10.7%) died during their hospital stay not for causes strictly due to the gastric haemorrhage. CONCLUSIONS: Our results suggest that the early diagnoses and early treatment are 2 basic factor on the prognosis of elderly patients with perforated gastric ulcer. The choice between simple closure, with or without vagotomy, or gastrectomy depends from preoperative and operative health conditions of the patient. In patients with ulcer larger than 2 cm, Graham's technique can be performed safely if the preoperative and intraoperative conditions are favourable. Elderly patients with gastric ulcer bleeding show an high risk of morbidity and mortality, related to the risk factors like non steroid anti-inflammatory drugs (NSAIDs) intake or smoke. Repeated endoscopy and antiulcer drugs can manage the high stage patients of Forrest's classification with a low rate of morbidity and mortality. According to literature surgical treatment should be reserved after the second failure of endoscopic treatment.

[Characterization and prognostic value of colorectal adenomas with molecular genetic markers]. / Caratterizzazione e valore prognostico degli adenomi colorettali mediante marcatori genetici molecolari.

AIM: The study analyses the expression of DNA-ploidy, ki-67, PCNA and p-53 and their role as potential markers of the development of colorectal adenomas. METHODS: 34 adenomas of the large intestine were analysed using endoscopic exeresis in 15 males and 13 females with a mean age of 64 years (range 42-80). Flow cytometric analysis was carried out to calculate the DNA-index and immunohistochemical tests were used to evaluate ki-67, PCNA and p-53. Statistical analysis was based on chi 2 test and Student's "t"-test. RESULTS: The DNA index was not statistically correlated with the histotype and grading. Ki-67 was highly positive in 5 adenomas, 2 aneuploids and 3 diploids, but did not show a clear relationship with other growth parameters. On the contrary, p-53 was statistically correlated with the more advanced degenerative state of adenomas, being pathological in 6 cases (30%), all with marked aneuploidy (p < 0.02) and severe dysplasia (p < 0.004). PCNA, which was also pathological (> 40%) in 4 (23.5%) aneuploid adenomas with severe dysplasia (2 villous and 2 tubulo-villous), appeared to be significantly correlated with the DNA index (p < 0.005), showing a proliferative index of exceptional clinical importance. CONCLUSIONS: The results of this study show that p-53 and PCNA are two parameters that contribute to the definition of the degenerative risk and allow patients to be selected for constant monitoring, although additional follow-up data are essential to enable the clinical verification of these results.

Vigabatrin as a first-choice drug in the treatment of West syndrome.

This is a prospective study designed to evaluate the efficacy and safety of vigabatrin as first-choice monotherapy in infants with West syndrome. One hundred sixteen patients with newly diagnosed West syndrome were studied in Argentina, from June 1994 to April 1998. The follow-up ranged from 17 to 40 months (mean, 23 months). Vigabatrin was administered upon diagnosis, starting with a 50-mg/kg/day dose and increasing 50 mg/kg every 48 hours to reach a maximum dose of 200 mg/kg/day. Twenty-nine percent of cases were considered to be cryptogenic or idiopathic West syndrome, while 70.7% were symptomatic. Response to vigabatrin treatment was measured according to five categories: (1) seizures free: 61.8% of cases for cryptogenic and 29.3% for symptomatic West syndrome, (2) more than 75% reduction in the number of infantile spasms: 14.7% for cryptogenic and 26.8% for symptomatic West syndrome, (3) from 50% to 74% reduction in the number of infantile spasms: 11.8% for cryptogenic and 24.4% for symptomatic West syndrome, (4) poor or null response: 11.8% for cryptogenic and 18.3% for symptomatic West syndrome, and (5) increase in the number of infantile spasms: one symptomatic case (1.2%). All seizure-free cryptogenic cases showed normal neuropsychic development. The most effective dose of vigabatrin was 150 mg/kg of body weight per day. The most frequent adverse events were somnolence in 19 cases and irritability in 15 cases, but none required treatment interruption.

Oesophageal perforation after sclerotherapy. Description of a case.

Surgery is considered mandatory for major oesophageal perforations but the operative risk in cirrhotic patients is very high. The best treatment of these perforations is unknown as these have been always analyzed together with all other kinds of oesophageal perforations. A case is reported of spontaneous healing of severe postsclerosal perforation in an aged cirrhotic patient treated conservatively who otherwise should have been treated surgically. Conclusions are that due to the rarity and the cirrhosis, the common guidelines for the treatment of major esophageal perforations are not to be automatically extended to these perforations as postsclerosal perforation is clinically particular, etiologically and prognostically different than all other oesophageal perforations. Conservative but active treatment is to be tried first also with major postsclerosal oesophageal perforations.

[The topical therapy of ulcerative colitis. A multicenter study with beclomethasone dipropionate foam]. / Terapia topica della colite ulcerosa. Studio multicentrico con beclometasone dipropionato schiuma.

BACKGROUND AND AIMS: The use of steroids was recently extended to the various forms of ulcerative rectocolitis by the introduction of topical formulations, above all steroids with an hepatic "first pass" devoid of systemic interference. The aim of this study was to evaluate the efficacy and tolerability of Beclomethasone dipropionate (BDP) in a rectal foam formulation, in the treatment of patients suffering from ulcerative colitis. METHODS: The experimental protocol took the form of a 28-day open prospective trial using BDP rectal foam in patients suffering from ulcerative colitis. Endoscopic, histological, clinical and tolerability parameters were evaluated. The centres taking part in the trial collected data for 60 cases out of a total of 80 patients enrolled in the study, of both sexes and aged between 20 and 81 years old, suffering from proctosigmoiditis (46.7%) and ulcerative rectocolitis (53.3%). RESULTS: Endoscopic parameters showed an improvement after 28 days of treatment in 74.5% of patients; a clinical improvement was achieved in 65.2% of cases. In percentage terms of the mean value of all the improved parameters, histological parameters were altered in 56.9% of patients. With regard to tolerability 82% of patients judged the treatment to be good/excellent. CONCLUSIONS: In conclusion, in line with recent reports regarding other pharmaceutical forms of BDP, including the use of rectal foam, these data confirm the efficacy and tolerability of this molecule and emphasise the validity of its use in the treatment of ulcerative colitis and proctosigmoiditis.

Intraluminal hamartoma of the ileum in a child: a rare cause of intestinal occlusion.

A case of small-intestinal obstruction in a 12-year-old boy caused by an intraluminal hamartoma of the ileum is reported. The rarity of the lesion, its location, symptomatology, histology, and diagnosis are discussed.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

[A proposed clinico-instrumental protocol for diagnostic guidance in breast lumps]. / Proposta di protocollo clinico-strumentale di orientamento diagnostico negli addensamenti mammari.

Women who practice self-examination of the breast often believe to identify lumps which produce much concern; in many cases differential diagnosis with cancer is therefore necessary. The authors propose a clinical-instrumental protocol as a guide to the right diagnosis in these patients.

The gene for SP-40,40, human homolog of rat sulfated glycoprotein 2, rat clusterin, and rat testosterone-repressed prostate message 2, maps to chromosome 8.

Sulfated glycoprotein 2 (SGP-2) is a rat glycoprotein that is particularly abundant in seminal fluid, where it is found associated with the acrosome and the tail of mature spermatozoa; for this reason it has been suggested that it has an important role in spermatogenesis. On the basis of nucleotide sequence homology, it has been proposed that the orthologous human gene is that coding for serum protein-40,40 (SP-40,40), a serum protein also called complement lysis inhibitor (CLI), SP-40,40 has been shown to act as a control mechanism of the complement cascade: in fact, it prevents the binding of a C5b-C7 complex to the membrane of the target cell and in this way inhibits complement-mediated cytolysis. SGP-2 and SP-40,40 seem then to be part of different biological systems. Furthermore it has been shown that another protein, testosterone-repressed prostate message 2 (TRPM-2), shares sequence homology with SGP-2 and SP-40,40. TRPM-2 is expressed at high levels and in a temporally precisely defined manner in dying cells, an observation that would suggest its involvement in the cascade of events leading to cell death. We have used a large panel of 24 mouse/human hybrid cell lines and a cDNA for SGP-2, which is also highly homologous to that for rat clusterin, to map the chromosomal location of the orthologous human gene. The mapping data and the Southern analysis presented in this paper, in addition to the data available from the literature, strongly suggest that in the human genome there is a single locus homologous to the probe used and that it codes for the protein which has been called, in different species, SP-40,40, SGP-2, clusterin, and TRPM-2. The chromosomal mapping of the locus for this multiname protein should facilitate its cloning and a better understanding of the apparently many biological functions of its product.