Occult intestinal haemorrhage due to lipoma of the small bowel detected with the combined use of the new endoscopic techniques. A report of two cases.

We report two unusual cases of occult intestinal bleeding due to lipoma of the small bowel. Both the patients underwent several inconclusive endoscopic and radiological procedures before the diagnosis of these lesions that was possible using video capsule endoscopy and double balloon enteroscopy. In the first case, the finding of capsule endoscopy was confirmed using enteroscopy, allowing us to diagnose the ileal mass. In the second and more recent case, we used double balloon enteroscopy for the further characterisation and management of the ileal lipoma. Lipoma is a very rare cause of intestinal bleeding and we describe the management and the outcome of our patients.

Colorectal cancer screening: results of a 5-year program in asymptomatic subjects at increased risk.

BACKGROUND AND AIMS: The province of Ferrara has one of the highest incidences of colorectal cancer (CRC) in Italy. In January 2000, we set up a colonoscopy screening program focussing on first-degree relatives of CRC patients. We now report the results 5 years after the beginning of the project. SCREENEES AND METHODS: In October 1999, we started a campaign stressing the usefulness of colonoscopy for the first-degree relatives of CRC patients. Subjects included in the screening program were aged between 45 and 75 years with at least one first-degree relative affected by CRC. They were invited to an interview where a physician suggested colonoscopy as a screening option. RESULTS: In 5 years, 776 subjects were interviewed and 733 (94.4%) agreed to an endoscopic examination (M/F:375/401; mean age 55 years): 562 colonoscopies were performed. Adenomas and cancers were found in 122 (21.7%) and 12 (2.1%) subjects, respectively. Histological examination in 181 persons with lesions (32.8%) showed (most serious lesion quoted) 47 hyperplastic polyps (26% of all lesions), 2 serrated adenomas (1.1%), 68 tubular adenomas (48%), 24 tubulovillous adenomas (13.3%), 9 adenomas with high grade dysplasia (5%) and 12 adenocarcinomas (6.6%). The majority of the cancers were at an early stage (8 Dukes A and 3 Dukes B). Sedation was used in only 42 colonoscopies (7.5%). CONCLUSIONS: A colonoscopy-based screening in this selected high-risk population is feasible. Even without sedation subjects readily agreed to the endoscopic procedure. We identified a significant number of advanced neoplasms and cancers at an early stage suggesting that this could be a useful tool in early identification of CRC.

Evaluation of a new rapid immunoassay for the detection of Helicobacter pylori in faeces: a prospective pilot study.

BACKGROUND: Detection of Helicobacter pylori antigen in faeces is a valid method to diagnose H. pylori infection. Presently available stool tests are performed in the laboratory, and diagnostic report is delayed. AIM: To evaluate a new rapid stool test in a pre-treatment setting and to compare it with a validated laboratory stool test. METHODS: A total of 105 patients underwent gastroscopy with brush cytology, and biopsies for histology and rapid urease test, to assess H. pylori presence. Helicobacter pylori-status was considered positive if at least two tests were positive; negative if all tests were negative; indeterminate if one test was positive and two negative. Stool specimens were tested using either a rapid immunoassay kit (ImmunoCard STAT) or a laboratory enzyme immunoassay kit (Hp StAR). RESULTS: Sixty patients were infected with H. pylori, 44 non-infected, one indeterminate. The sensitivity and specificity of ImmunoCard STAT were 85 and 93%; those of Hp StAR were 88 and 100% (not significant). CONCLUSIONS: ImmunoCard STAT seems a reliable method for detecting H. pylori in untreated patients. It could replace laboratory stool tests, as it is easy and can be performed quickly. These characteristics might be a breakthrough for diagnosing H. pylori in the doctor's office.

Biliary sludge: the sluggish gallbladder.

Biliary sludge is a mixture of particulate matter which has precipitated from bile. It generally consists of cholesterol monohydrate crystals, calcium bilirubinate or other calcium salts. In a clinical setting, biliary sludge is almost always an ultrasonographic diagnosis. Although it is less clinically applicable, direct microscopic examination of gallbladder bile is far more sensitive than ultrasonography into sludge detection, and has to be regarded as the diagnostic gold standard. The overall prevalence of sludge in the general population is relatively low. However, several clinical conditions are associated with a particularly high prevalence of biliary sludge, including pregnancy, rapid weight loss, total parenteral nutrition, octreotide therapy, bone marrow or solid organ transplantation. The clinical course of biliary sludge varies, and complete resolution, a waxing and waning course, and progression to gallstones are all possible outcomes. It may cause complications usually associated with gallstones, such as biliary colic, acute cholecystitis, and acute pancreatitis. The main pathogenic mechanism involved in sludge formation is probably gallbladder dismotility, and in selected patients measures aimed to maintain adequate gallbladder contractions has been shown to effectively prevent sludge development.

[Endoscopic treatment of upper gastrointestinal non-variceal bleeding]. / Terapia endoscopica del sanguinamento non varicoso del tratto digestivo superiore.

BACKGROUND: Endoscopic hemostasis is the method of choice for the treatment of bleeding peptic ulcers. This retrospective study was carried out to evaluate its effectiveness in routine endoscopic practice. METHODS: The records of all patients with gastrointestinal bleeding undergoing esophagogastroduodenoscopy (EGDS) at the Endoscopy Center of Ferrara in the last year were retrospectively evaluated. For each patient with peptic lesions, the following data were recorded: demographic characteristics, use of NSAIDs, co-morbidity, hemodynamic conditions, blood transfusions before EGDS, time between onset of symptoms and EGDS, endoscopic findings, method of endoscopic haemostasis carried out, Rockall score and outcome. If re-bleeding occurred, the data concerning the second therapeutic intervention were recorded as well. RESULTS: Seventy-six males and 45 females (age 34-92 years) entered the study. In 22% of cases no co-morbidity was present. Active bleeding was observed in 38% of cases, features consistent with recent bleeding in 54% of cases, and no sign of bleeding in 6.6% of cases. Peptic ulcer was observed in 89% of cases. Hemostasis was carried out in 81 patients (76 had adrenalin infiltration, 2 had argon plasma coagulator [APC], and 3 had both treatments); 26 patients had re-bleeding. The probability of re-bleeding was related to female gender (p<0.05; OR: 3.74), time between onset of symptoms and EGDS >24 hours (p<0.01; OR: 8.67), and presence of non-ulcer peptic pathology (p<0.05; OR: 0.15). Seven re-bleeding patients underwent surgery, 19 had endoscopic treatment. In 11 of these patients second hemostasis was resolutive, 8 bled again. CONCLUSIONS: Endoscopic hemostasis of bleeding peptic lesions is effective also in routine clinical practice. Adrenalin infiltration is safe, easy to perform, cheap and repeatable, and in our opinion it should be considered the technique of first choice in endoscopic hemostasis.

Massive bleeding in an adult patient suffering from Meckel's diverticulum.

The case of a 22-year-old male who bled from a Meckel's diverticulum is described. The diagnosis was achieved after 99mTechnetium pertechnetate scintigraphy. With the administration of somatostatin very clear images were obtained. The histological examination confirmed the presence of ectopic gastric mucosa. The literature, over the last 10 years, has been reviewed to identify factors associated with bleeding in adults. Ectopic gastric mucosa is the most important factor predicting bleeding. The diagnostic approach to bleeding Meckel's diverticulum and the improvement in the quality of 99mTechnetium pertechnetate scintigraphy, following administration of somatostatin, is discussed.

Postprandial refilling and turnover: specific gallbladder motor function defects in patients with gallstone recurrence.

BACKGROUND AND AIMS: Impaired gallbladder motor functions are important in the pathogenesis of primary cholesterol gallstones, and possibly in the pathogenesis of recurrent gallstones. By using ultrasonography and cholescintigraphy simultaneously, we recently defined new parameters of gallbladder motor function (postprandial refilling and turnover in addition to emptying), which were markedly impaired in gallstone patients. The aim of this study was to assess the value of these new parameters in distinguishing patients with from those without gallstone recurrence. METHODS: We studied 11 patients with gallstone recurrence, 11 without gallstone recurrence (at least 40 months after complete dissolution by oral bile acids) and 11 healthy controls. Simultaneous measurements of gallbladder volume (ultrasound) and gallbladder counts (gamma-camera scintigraphy) were carried out in the fasting state and at 10 min intervals following meal ingestion, for a period of 90 min. Gallbladder refilling, turnover of bile and turnover index were calculated, as well as gallbladder emptying by both cholescintigraphy and ultrasound. RESULTS: Patients with gallstone recurrence had reductions in gallbladder emptying, postprandial refilling and gallbladder bile turnover. They also had a significant reduction in the turnover index (1.7 +/- 1.4) compared to controls (3.5 +/- 0.3, P < 0.01) and to patients without gallstone recurrence (3.1 +/- 1.5, P < 0.05). Patients without gallstone recurrence had only a small reduction in emptying and no reduction in postprandial refilling or turnover compared to controls. CONCLUSIONS: We conclude that impairment of gallbladder emptying persists in all patients after gallstone dissolution, albeit to a more pronounced extent in patients with recurrence; but that impairment of postprandial refilling and turnover are specific defects in patients with recurrence.

Biochemical assessment and clinical evaluation of a non-ionic adsorbent resin in patients with intractable jaundice.

We investigated in vitro and in vivo the ability of a non-ionic adsorbing resin (styrenedivinylbenzene copolymer) to remove bilirubin and bile acids from human plasma. In preliminary experiments, human plasma from healthy donors, enriched in conjugated bile acids and bilirubin, and pooled plasma from jaundiced patients were recirculated through the resin column. The removal of bilirubin and bile acids was evaluated at two different flow rates (200 ml/min and 40 ml/min), and compared to an activated charcoal column. Four patients with severe jaundice were subsequently treated by 4-hour plasmaperfusion through the resin. The in vitro studies showed that after 1 hour the removal of bile acids was almost complete and bilirubin level decreased significantly, reaching a plateau after 4 hours. In the in vivo study, all treatments were well tolerated. After plasmaperfusion, serum bile acid levels decreased by 64.9-94.6% and total bilirubin by 35.3-57.7%. No clinical or biochemical side effects were observed. Our data suggest that plasmaperfusion through this resin is safe and efficient for removal of bilirubin and bile acids in jaundiced patients. Thus, it may serve as a method of artificial liver support in the treatment of cholestatic syndromes.

Validation of the 13C-urea breath test for the diagnosis of Helicobacter pylori infection in children: a multicenter study.

OBJECTIVE: The 13C-urea breath test (13C-UBT) is a safe, noninvasive, and accurate test for the detection of Helicobacter pylori (H. pylori) infection in adults. The aim of this study was to evaluate sensitivity and specificity of 13C-UBT in children using different types of test meal, doses of 13C-urea and breath sampling intervals. As yet, a validated, standardized 13C-UBT protocol for children has not been formulated. METHODS: 13C-UBT was performed in 115 children and repeated within 3 days, modifying the test meal or the dose of 13C-urea. H. pylori status was assessed by histology and rapid urease test. 13C-UBT was performed using 100 mg or 50 mg of 13C-urea and a fatty test meal (100 FA; 50 FA), 50 mg of 13C-urea, and a carbohydrate test meal (50 CA). Breath samples were collected every 10 min for 60 min. RESULTS: The 13C-UBT in children was highly sensitive and specific with all three protocols used. The best combination of sensitivity (97.92%) and specificity (97.96%) was obtained with Protocol 50 FA at 30 min with a cut-off of 3.5 per mil. CONCLUSIONS: The 13C-UBT is an accurate test for the detection of H. pylori infection also in children. Administration of 50 mg of 13C-urea, a fatty test meal, and breath sampling at 30 min appears to be the most convenient protocol.

Mesalazine foam (Salofalk foam) in the treatment of active distal ulcerative colitis. A comparative trial vs Salofalk enema. The SAF-3 study group.

BACKGROUND: Mesalazine enemas are of well proven efficacy for the topical treatment of distal ulcerative colitis. Although new rectal formulations of mesalazine are not expected to be superior in efficacy and tolerability to standard formulations, they may offer secondary advantages in terms of overall acceptability. AIM: To compare the efficacy, tolerability and overall acceptability of a new mesalazine rectal foam (Salofalk foam) with mesalazine enema in the treatment of active distal ulcerative colitis. PATIENTS AND METHODS: A multicentre study was carried out in patients with active proctitis, proctosigmoiditis and left-sided ulcerative colitis as evaluated by the Clinical Activity Index (CAI > or =4) and Endoscopic Index (EI > or =6). Patients were randomly assigned to receive, in open-label fashion, either mesalazine foam 2 g twice a day or mesalazine enema (2 g/60 ml twice a day) for 3 weeks. Patients who did not achieve remission (defined as CAI <4 and EI <6) after 3 weeks continued the study receiving the alternative galenic formulation for a further 3 weeks. RESULTS: A total of 195 patients were enrolled. Characteristics at baseline were similar except for concomitant therapy with oral 5-ASA products: during the 1st treatment phase, 41% of patients on enema received such treatment vs only 29% of those on foam. Patients with at least one post-treatment efficacy evaluation were included in the intent-to-treat analysis (n=89 foam, n=96 enema). After 3 weeks of treatment, 112 patients were in remission and only 59 patients entered the 2nd treatment phase thus providing data on acceptability. Remission was achieved after 3 weeks in 54% of patients treated with foam and in 67% of those treated with enema. The 90% confidence interval for the difference in remission rates was 0 to 24 and thus within the clinically acceptable range of therapeutic equivalence. At the end of the 2nd phase, 70% of patients switched to foam were in remission vs 65% to the enema. Two patients discontinued treatment with foam prematurely due to anal burning. No clinically important changes were seen in the laboratory tests. CONCLUSIONS: Salofalk foam and enema are equally effective for the treatment of proctitis, proctosigmoiditis and left-sided ulcerative colitis. The new foam preparation is as well tolerated and accepted as enemas and can be used as a therapeutic alternative to conventional mesalazine enema formulations.

Nonsteroidal antiinflammatory drug use and gallstone disease prevalence: a case-control study.

OBJECTIVES: Conflicting results on the relationship between gallstone disease and the use of nonsteroidal antiinflammatory drugs (NSAIDs) have been reported, but studies on the effect of NSAID use in populations not selected on the basis of a high risk for gallstone development are still lacking. METHODS: We conducted a case-control study involving 216 patients, regular NSAID users (43 men and 173 women) consecutively admitted to a rheumatology department, suffering from rheumatoid arthritis (n = 147), osteoarthritis (n = 49), and ankylosing spondylitis (n = 20). Two-hundred sixteen patients who were not NSAID users, matched for gender, age, and body mass index, consecutively admitted to a medical department for various medical pathologies, acted as a control group. All patients underwent upper abdomen ultrasonography. RESULTS: The overall prevalence of gallstones was similar in the two groups: 24.0% in NSAID users (15.7% actual stones and 8.3% previous cholecystectomy) and 21.3% in controls (13.9% gallstones and 7.4% cholecystectomy). The prevalence of gallstone disease was significantly higher in women than in men, and the mean age was higher in gallstone patients than in gallstone-free patients, in both groups. No significant differences in type and duration of arthritis condition, type and dose of NSAID taken, and duration of treatment between gallstone patients and gallstone-free patients were found. On logistic regression analysis only female gender, aging, and family history of gallstone disease were significantly associated with the presence of gallstones, whereas no relationship between NSAID use and gallstone disease was found. CONCLUSIONS: Chronic NSAID ingestion does not seem to prevent gallstones in arthritis patients; in these patients gallstone disease is associated with classic risk factors (female gender and age).

Short-term low-dose pantoprazole-based triple therapy for cure of Helicobacter pylori infection in duodenal ulcer patients.

BACKGROUND: The eradication of Helicobacter pylori infection has been achieved using various therapy regimens, but the efficacy of the proton-pump inhibitor pantoprazole as part of these regimens has not yet been widely tested. AIM: To evaluate the efficacy and tolerability of a 1-week low-dose pantoprazole-based triple therapy in patients with H. pylori-positive duodenal ulcer. METHODS: In an open single-centre prospective study, 71 patients with endoscopically proven active duodenal ulcer and H. pylori infection received pantoprazole 40 mg o.m. for 4 weeks, and during the first week a combination antimicrobial treatment comprising tinidazole 500 mg b.d. plus clarithromycin 250 mg b.d. H. pylori eradication was defined as concordant negative histology and rapid urease test performed at endoscopy 4-6 weeks after the end of treatment, confirmed 4 weeks later by 13C-urea breath test. RESULTS: Sixty-six patients (93%) completed the trial and five patients were lost to follow-up. H. pylori infection was cured in 61 out of the 66 patients who completed the trial (per-protocol analysis: 92.4%, 95% CI: 83.2-97.5%; intention-to-treat analysis: 85.9%, 95% CI: 75.7-93.0%). At final endoscopy, 65 out of 66 patients had healed ulcer (98.5%). Mild adverse events occurred in six patients (9.1%). CONCLUSIONS: One-week low-dose pantoprazole-based triple therapy is a simple, effective and well-tolerated regimen for ulcer healing and H. pylori eradication in patients with duodenal ulcer.

[Dyspepsia: a reappraisal problem]. / La dispepsia: un problema da reimpostare.

Dyspepsia is a major public problem. It occurs in 25-40% of the general population negatively affecting the quality of life. 2-3% of the patients visited by the GP and up to 30% of those visited by the gastroenterologist have dyspepsia. Both diagnostic procedure and therapy are expensive. Definition, aetiology and pathogenesis of the disorder are not clear cut. The aim of this review is to outline the main trends in the relevant area of the clinical practice. The authors choose the most comprehensive definition among the thirty of the medical literature. To rule out, the most commonly and frequently wrong opinions risk factors have been examined. The authors distinguished between symptoms of function and organic dyspepsia and those of Irritable Bowel Syndrome and Gastro-Esophageal Reflux Disease, which often overlap and make difficult the management of the patient. The aetiology and pathogenesis have also been discussed, with particular emphasis on Hp. Advantages and drawbacks of different diagnostic approaches have been investigated. An age and symptoms related approach of the cases with dyspepsia is proposed, which allows to manage the patient without the necessity of invasive procedures. It is finally suggested that are cases which can be managed by the GP and others for whom the gastroenterologist intervention is mandatory.

Bile salt-induced cytotoxicity and ursodeoxycholate cytoprotection: in-vitro study in perifused rat hepatocytes.

OBJECTIVES: Membrane toxicity induced by hydrophobic bile salts may be important in liver diseases. Administration of ursodeoxycholate reduces serum liver enzymes in chronic liver diseases, but the nature of this effect is still unclear. We aimed at establishing a convenient in-vitro system for investigating the hepatotoxic properties of hydrophobic bile salts and the putative hepatoprotective effect of ursodeoxycholate. METHODS: About 100 mg of freshly isolated rat hepatocytes were suspended on a resin column (Bio-Gel P4 fine) and perifused with different concentrations of bile salts. The effluent was collected at 5-min intervals and assayed for lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activity. Enzyme leakage induced by bile salts was compared with that induced by Triton X-100 (Union Carbide, Danbury, CT, USA) at different concentrations. After perifusion, hepatocytes were collected for electron microscopic observation. RESULTS: Cytotoxicity of individual bile salts, assessed by enzyme release, was time and concentration dependent and corresponded to their hydrophilic-hydrophobic balance. Perifusion with hydrophilic bile salts, cholate and ursodeoxycholate, did not result in a significant enzyme release in concentrations up to 5 mmol/l, whereas hydrophobic bile salts, chenodeoxycholate and deoxycholate, induced significant enzyme leakage even in low concentrations, 0.5 and 0.1 mmol/l, respectively. Addition of ursodeoxycholate significantly reduced the hepatotoxic effect of deoxycholate. This protective effect was evident within minutes. The ultrastructural appearance of hepatocytes exposed to hydrophobic bile salts was very similar to the non-specific cellular lysis observed after exposition to Triton X-100, suggesting that they act mainly in a detergent-like fashion. CONCLUSION: Perifused rat hepatocytes seem a convenient in-vitro system for investigating the hepatotoxic properties of bile salts and hepatoprotective effect of ursodeoxycholate, offering the opportunity to investigate the effects of bile salts under dynamic conditions, mimicking the in-vivo situation, and allowing continuous enzyme release monitoring. Hydrophobic bile salts seem to act mainly in a detergent-like fashion; ursodeoxycholate-related hepatoprotection could be due not only to a dilution effect of toxic bile salts, but also to a direct cytoprotective effect.

Brush cytology: a reliable method to detect Helicobacter pylori.

This study was conducted to verify the reliability of brush cytology in detecting Helicobacter pylori in an unselected group of patients with duodenal ulcer (DU) and nonulcer dyspepsia (NUD). Endoscopy was performed on 416 consecutive patients: group A, 94 with active DU; group B, 176 patients with DU after omeprazole (n = 78), ranitidine (n = 43), or triple anti-H. pylori therapy (n = 55); and group C, 146 patients with NUD. During endoscopy, the gastric mucosa was brushed and two biopsy samples from the antrum and body were obtained for histology. In 65 patients, culture of the brush-collected materials also was performed as was that from of biopsy samples. The overall frequency of H. pylori presence detected by brush cytology was significantly higher compared with that of histology (p < 0.001), particularly in group A (p < 0.05), group C (p < 0.05), and in patients with DU after omeprazole treatment (p < 0.01), but not in patients with DU after ranitidine or anti-H. pylori treatment. The overall frequency of H. pylori-positive cultures from the brush-collected material was higher compared with cultures from the biopsy samples (38.5% vs. 24.6%), particularly in the NUD group (32.6% vs. 16.3%). Brush cytology is more sensitive than histology, besides being faster and cheaper, for the assessment of H. pylori infection, particularly when the density of the bacteria is low.

Quality improvement in gastrointestinal endoscopy: microbiologic surveillance of disinfection.

BACKGROUND: Cleaning and disinfection procedures play an essential role in the prevention of infection transmission in gastrointestinal endoscopy. In spite of published detailed guidelines, several variants and weak points still exist. METHODS: Cleaning-disinfection procedures were carried out according to "Working Party, Sydney 1990." A microbiologic surveillance protocol tested the contamination of endoscopes and of automatic washing machines. To assess and improve the efficacy of disinfection, we adopted a quality assurance program. RESULTS: During a 2-year follow-up, the outside surfaces of gastroscopes were contaminated in 60.5% and channels in 41.3%; the outside areas of colonoscopes were contaminated in 62.3% and channels in 40.3%. Isolated bacteria were gram-negative organisms, particularly Pseudomonas species, and gram-positive organisms, mostly Staphylococcus species. The water reservoirs of automatic washing machines were frequently contaminated by Pseudomonas aeruginosa. The disinfection of washing machines and alcohol rinsing of endoscopes after standard procedures significantly reduced the bacterial contamination. CONCLUSIONS: The microbiologic surveillance pointed out the main weak points that could be improved by the adoption of corrective interventions. Quality assurance is a feasible method to assess the efficacy of cleaning-disinfection, and its wide application would improve quality of care.

High effectiveness and safety of one-week antibiotic regimen in Helicobacter pylori eradication.

BACKGROUND: Helicobacter pylori is strongly associated with peptic ulcer: H. pylori eradication markedly decreases the recurrence rate of duodenal and gastric ulcer, but the optimum length of antibiotic therapy in the eradication of H. pylori is still unclear. AIM: To verify the effectiveness and side-effect profile of an eradicating regimen consisting of omeprazole 20 mg daily for 4 weeks and, during the first week, combination antimicrobial treatment with tinidazole 500 mg b.d. plus clarithromycin 250 mg b.d. in patients with active duodenal and gastric ulcer. METHODS: One hundred and ninety-six duodenal ulcer patients and 27 gastric ulcer patients with H. pylori infection were admitted into an open prospective study. Compliance was assessed by an accurate interview. RESULTS: Overall, H. pylori was successfully eradicated in 201 of 223 patients (intention-to-treat 90.1%; 95% CI = 85-94%): 176 of 196 duodenal ulcer patients became H. pylori-negative (89.8%; CI = 85-94%) as well as 25 of 27 gastric ulcer patients (92.6%; CI = 76-99%). Compliance was excellent in 221 of 223 (99.1%) patients evaluated as having taken all the medication as prescribed. Sixteen patients (7.2%) developed mild side effects during treatment. CONCLUSION: This combination treatment had excellent results with almost absolute compliance and a very low rate of minor side effects.