Diagnostic value of endoscopic markers for celiac disease in adults: a multicentre prospective Italian study.

AIM: Some endoscopic features of duodenal mucosa are marker of mucosal injury, the most common cause being celiac disease (CD). The aim of this study was to prospectively assess the diagnostic value of the endoscopic markers for the diagnosis of CD in the adult population undergoing routine upper endoscopy. METHODS: This was a prospective multicenter study conducted at 37 Italian endoscopic centers. A total of 509 consecutive patients submitted to routine upper endoscopy who presented one or more of following endoscopic markers were included: 1) mucosal mosaic pattern in the bulb and/or descending duodenum (DD); 2) nodularity in the bulb and/or DD; 3) scalloping of Kerkring's folds; 4) reduction in the number or absence of folds in the DD. 4 biopsies samples were taken from descending duodenum. In patients with histological findings consistent with CD, according to Oberhuber classification, sierologic test (EMA, tTGA) were performed for confirm the diagnosis. RESULTS: At endoscopy, 249 patients showed an isolated marker; 260 subjects showed a coexistence of more than one marker; 369 patients (72.5%) presented mucosal lesions at histological examination and in 347 of these patients the diagnosis of CD was confirmed by serologic markers (94.0%). For 10 patients the diagnosis remained uncertain because of negative sierology and exclusion of other other cause of mucosal lesions. The diagnosis of CD was made in 61.3% patients who showed the mosaic pattern, in 65.7% of patients with nodular mucosa, in 64.4% of patients with scalloping of folds, in 40.2% of patients with reduction of folds, and in 61.5% of patients with loss of folds and in 83.6% of patients who showed the coexistence of more than one marker. The endoscopic markers overall had a PPV of 68% for the diagnosis of CD; the markers that singularly have demonstrated a higher correlation with CD are: mosaic mucosa of DD (PPV 65.0%), nodular mucosa of the bulb and DD (PPV 75.5%), and scalloping of folds (PPV 64.4%). CONCLUSION: The study confirms the important role of endoscopy in the diagnostic process of CD not only for the bioptic sampling in patients with clinical suspicion of CD, but especially for the opportunity to evaluate alterations of the duodenal mucosa suggestive of CD in the general population and, consequently, to identify those patients who should undergo a duodenal biopsy.

Nodular hyperplasia of Brunner's glands.

A clinical, endoscopic, and histological study of 206 cases of nodular hyperplasia of Brunner's glands was carried out. Firm nodules with a reddened surface due to hyperplastic Brunner's glands were limited mainly to the first part of the duodenum and affected almost exclusively male patients. Gastric acid secretion after pentagastrin stimulation was significantly increased compared to normal. In most cases, biopsies of the nodule center revealed spreading of Brunner's glands from within the lamina propria to the surface epithelium, whereas in biopsies performed between nodules, Brunner's glands were limited to the deeper part of the mucosa. Thirty-six nodules completely removed by diathermy were composed almost entirely of Brunner's glands. The frequent association with duodenal ulcer, chronic gastric erosions, and cobblestone pattern of the gastric body mucosa, as well as the significant hypersecretory state, suggest that hyperacidity plays a role in the pathogenesis of nodular hyperplasia of Brunner's glands.

Polypoid lesions associated with diverticular disease of the sigmoid colon.

Colonscopy performed in five patients because of narrowing of the sigmoid colon with intramural diverticula revealed several bright red, slightly elevated patches. In three patients, some bright red polypoid structures 1 cm in size and hemispherical in shape were also present. On light microscopy the polyps showed the features of transitional mucosa but revealed a different pattern of mucus secretion.

Gastritis cystica polyposa: a possible precancerous lesion.

Twenty polypoid lesions at gastroenterostomy stomas (the so-called gastritis cystica polyposa-GCP) were endoscopically removed from gastroenterostomy stomas of 16 male and two female patients previously operated for benign lesions. The interval from surgery ranged from 3 to 40 years (mean: 16.2 years). At light microscopy GCP showed 2 histologic patterns: a) with cystic glands limited to the mucosal layer (gastritis cystica superficialis); b) with cystic glands also spreading into the submucosa (gastritis cystica profunda). Atrophy of specific gastric glands, intestinal metaplasia and dysplastic changes also occurred. Local chronic ischemia and inflammatory reaction as a consequence of gastric surgery and suture at gastroenterostomy together with bile reflux were considered responsible for the development of GCP. The sites and the histologic features of GCP resembled those of experimental stomal polyps preceeding carcinoma in rats after partial gastrectomy. The sites of formation, the sex incidence, the interval from previous operation as well as the histologic findings suggest that GCP is a possible precancerous lesion.

Prevalence of gastroduodenal lesions in uremic patients undergoing dialysis and after renal transplantation.

Upper gastrointestinal endoscopic examination showed lesions in 28 of 112 dialysis uremic patients and in 19 of 52 after renal transplantation. Most patients with and without lesions were symptom free. A significant increase in gastric acid secretion was found in patients with transplant as compared with dialysis uremic patients. The prevalence of ulcer in the dialysis group was not increased compared with the general population, whereas it was increased in the group with transplantation. An increase of duodenal and a decrease of gastric lesions (ulcers and erosions) in the group with transplantation compared with the dialysis group was found. The importance of a systematic upper gastrointestinal endoscopic survey in hemodialyzed and transplanted patients is stressed.

Chronic erosions of the stomach--a clinical, endoscopic and histological evaluation.

A clinical, endoscopic and histological study was performed in 300 patients with chronic gastric erosions. The male-female ratio was 4:1. The antrum was the preferential site of erosions. Chronic erosions were classified into two categories: "active" (with a dark clot or whitish coat of fibrin) and "inactive" (covered by a normal pink mucosa). All the lesions showed foveolar hyperplasia, partial obliteration of the lamina propria by fibrous and smooth muscle bundles, a greatly thickened muscularis mucosae and an increased number of submucosal thick-walled vessels. In the "active" stage the central umbilicated area was covered by a collection of granulocytes, while in some of the "inactive" erosions the central depression showed the presence of a channel-like structure penetrating into the lamina propria. In two cases the lesion mimicked a gastric adenomyoma. Gastric acid secretion was significantly increased in the tested patients as compared with normal. The similarity of the histological findings with those in ischemic conditions of the gastro-intestinal tract suggests that both hypersecretion and localized ischemia may play a role in the pathogenesis of chronic erosions.

Is the 14C-triolein breath test useful in the assessment of malabsorption in clinical practice?

A 14C-triolein breath test was carried out on 49 subjects suffering from chronic pancreatitis or from other digestive diseases, and its results were compared with the daily fecal fat excretion. The 14CO2 peak excretion was abnormal in all the subjects with a fecal fat excretion above 14 g/day, whereas individual values of 14CO2 peak excretion in subjects without steatorrhea and with a fecal fat excretion ranging from 7.1 to 14 g overlapped. The lowest value observed in patients not suffering from steatorrhea was chosen as the lower normal limit of 14CO2 peak excretion. A test sensitivity as high as 64% was attained. The correlation between fecal fat and 14CO2 peak excretion was highly significant (r = 0.802; p less than 0.0001), and it followed a negative exponential function. Therefore, small variations in the 14CO2 peak excretion can be associated with a wide range of fecal fat excretion. Well-compensated diabetes secondary to pancreatitis did not interfere with the results of the test. In conclusion, in our experience this test proved to be a qualitative diagnostic tool with a low sensitivity.

Squamous papillomas of the esophagus.

Fifteen cases of squamous papilloma of the esophagus were found in 20,000 upper gastrointestinal endoscopies. Squamous papillomas are usually incidental findings; symptoms are related to associated esophageal or gastrointestinal lesions. Chronic irritation from gastric acid reflux may play an etiological role.

[The biological results of duodenocephalopancreatectomy. Clinical evaluations based on a long-term follow-up]. / Le conseguenze biologiche della duodenocefalopancreatectomia. Valutazioni cliniche sulla base di un follow-up a distanza.

The authors discuss the main features of the complex pathophysiology of patients subjected to duodenocephalopancreatectomy, and particularly the difficulties inherent in clinical assessment of the digestive and metabolic impairment consequent upon the duodeno-gastro-pancreatic mutilation. Out of a total of 57 cases of this description, they singled out for recheck 23 patients who had undergone duodenocephalopancreatectomy not less than six months and not more than seven years before (chronic pancreatitis, 11 cases; various malignancies of the periampullar area, 10 cases; Zollinger-Ellison syndrome, 1 case; retroperitoneal lymphoma, 1 case). Seventy-six per cent of patients who had been gainfully employed were able to resume their jobs after surgery. Steatorrhea, assessed in terms of fecal fats, was present in all cases; notwithstanding, 70% of the patients gained weight (average increase 7 kg). All patients were on enzyme replacement therapy. Only 4% developed diabetes, and none developed postoperative peptic ulcers. Conversely there was a high incidence (65%) of bone structure reshuffling, signally osteoporosis, probably imputable to steatorrhea and vitamin D malabsorption, plus the often associated increase of serum alkaline phosphatase activity.