Instruments and accessories for diagnostic endoscopic ultrasound (radial scanning and miniprobes).

Endoscopic ultrasound (EUS) is a relatively new technology developed in the early 80's, but introduced into the clinical practice only in the late 80's. Nowadays there is an increase in demand for EUS examinations and services, because this technique is more and more recognized as an important and integral part in the diagnostic and staging algorithm of many gastrointestinal (GI) and nongastrointestinal pathologies. Even if today the EUS panorama enrich itself with a large number of different instruments, mechanical and electronic scopes, radial and linear ones, several types of miniprobes and specialty probes, for diagnostic purposes the dedicated radial scanning instruments remain the more adopted choice while miniprobes can have applications only in niche areas, like superficial GI cancers staging, small subepithelial lesions evaluation or intraductal ultrasound and some technological advances are needed to solve the potential drawbacks of this miniaturized probes. At last the EUS equipment borrowed most of the electronic sophistication from the mainstream ultrasonography, this made the choice of an EUS instrument even more difficult and challenging, but you must consider that there is no right or wrong equipment, there is only the right instrument for that specific clinical need or situation.

Role of endoscopic ultrasound in biliary and unexplained pancreatitis.

In the Western world, gallstone disease accounts for approximately half of the cases of acute pancreatitis. The benefit of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been clearly proven for this disease. On the basis of history, laboratory, and noninvasive imaging studies, about 10-30% of patients with acute pancreatitis have no apparent aetiology. This is critical because it limits the optimal therapeutic management and the prevention of recurrence. Endoscopic ultrasound (EUS) has emerged as an important procedure to clarify the aetiology of acute pancreatitis. After extensive investigation that included EUS, 8-20% of episodes remained idiopathic. Moreover, EUS carried minimal risk when compared to ERCP. The present short review attempts to update on the indications for the employment of EUS in the diagnosis of biliary stones as well as in the clarification of aetiology in the case of unexplained pancreatitis.

Updated review (2006) on Helicobacter pylori as a potential target for the therapy of ischemic heart disease.

UNLABELLED: Despite knowledge about the classical risk factors for ischemic heart disease (IHD) has increased, all the differences in morbidity as well as mortality from this disease cannot be fully explained. Hence the importance of looking for other causal mechanisms. Numerous infectious agents have been linked to IHD and among these also Helicobacter pylori (H. pylori). However, a number of studies have reported conflicting RESULTS: The present review attempts to highlight on the update pertaining a potential etiologic role of H. pylori infection in the pathogenesis of IHD. Some new evidences have emerged in the last years in literature. While epidemiological approach seems to confirm previous uncertainties (hypothetical role of the bacterium in the acute phase), experiments have demonstrated the presence of bacterial DNA in the plaque. Furthermore, the most encouraging evidence of a possible association emerges from an intervention small trial showing a significant reduction of coronary events after H. pylori eradication. Because IHD is the outcome of a multiciplity of factors, many of which with only a limited individual effect, complete understanding of causation is difficult. It may be possible to identify some factors, such as H. pylori, the effects of which are large enough to be potential target for prevention. This is of major public health importance, since the eradication of the infection is easy and certainly much less expensive than long-term treatment for other risk factors. Prospective population-based studies and interventional trials, focusing on the advantage of the eradication of H. pylori infection on the prevention or the reduction of recurrence in subjects with IHD, should be performed in order to provide support of a causal relationship. This represents a promising direction for future studies.

Autoimmune manifestations during interferon therapy in patients with chronic hepatitis C: the hepatologist's view.

In face of numerous benefits induced by therapy based on interferon (IFN) associated with ribavirin for the treatment of chronic hepatitis C, there is an increasing concern regarding its tolerance, which can, in some cases, reduce the quality of life as well as compliance of patients. Among the less common side effects, there are the autoimmune ones which can be globally divided into appearance or increase in titres of auto-antibodies and/or manifestation of overt autoimmune pathologies. Whereas the former may concern more than 50% of treated subjects, the latter is reported in only 1-2% of patients under therapy. Thyroid dysfunction represents the well-studied autoimmune disorder. The presence of pre-existing anti-thyroid antibodies and being of female sex, constitute relevant risk factors for the development of a disease involving this gland. Often the treatment of thyropathy must be continuous in spite of IFN discontinuation because the disturbance usually does not abate with stopping antiviral therapy. Some observations have pointed out to the fact that IFN can lead to the development of insulin-dependent diabetes mellitus. Sometimes, during, as well as after IFN treatment, the appearance of anti-islet cell antibodies has been shown, but its interrelationship with the development of disease is uncertain. While being treated with IFN for chronic hepatitis C, the finding of non-organ specific antibodies at baseline can increase the likelihood of the development of autoimmune hepatitis. However, their presence does not constitute an absolute contraindication to the treatment, except in case of high titre. Other disorders, such as a lupus erythematosus-like syndrome, haemolytic anaemia, and immune-mediated thrombocytopenia have been reported. In conclusion, although the presence of auto-antibodies is considered to be an epiphenomenon without pathogenic significance in most patients suffering from chronic hepatitis C, it poses a problem when they need to be treated with IFN. This antiviral drug can induce or exacerbate a multitude of autoimmune-related disorders, however, clinically overt immune-mediated diseases are rare and affect a subset of subjects who have an underlying autoimmune diathesis.

The importance of endoscopic ultrasonography in the management of low-grade gastric mucosa-associated lymphoid tissue lymphoma.

BACKGROUND: Anti-Helicobacter pylori therapy has been reported to cause regression of low-grade gastric mucosa-associated lymphoid tissue lymphoma in a high percentage of patients. However, in some patients, these lesions persist despite antibiotic treatment. AIM: To determine the various endosonographic findings that may predict the regression of low-grade gastric mucosa-associated lymphoid tissue lymphoma post-antibiotics. METHODS: Seventy-six patients with Helicobacter pylori-positive gastric mucosa-associated lymphoid tissue lymphoma were studied. Follow-up data were available on 51 patients. All patients were treated with antibiotics. Participants underwent pre- and post-anti-Helicobacter pylori therapy endoscopy with gastric biopsies, followed by endoscopic ultrasonography examination of the stomach. RESULTS: Helicobacter pylori was eradicated in 45 of 51 (88%) patients. At the 2-year follow-up, complete regression of mucosa-associated lymphoid tissue lymphoma was seen in 28 of 51 (55%) patients: 12 of 16 (75%) patients in stage T1m N0, 11 of 19 (58%) patients in stage T1sm N0, four of eight (50%) patients in stages T1m N1 and T1sm N1, and one of four (25%) patients in stage T2 N0. None of the stage T2 N1 patients achieved clinical regression. CONCLUSIONS: Endoscopic ultrasonography evaluation of gastric mucosa-associated lymphoid tissue lymphoma plays a pivotal role in the initial staging and post-treatment follow-up evaluation of these lesions. Accurate staging is essential in the determination of the optimal treatment modality.

The effect of the eradication of Helicobacter pylori infection on hemorrhage because of duodenal ulcer.

The cost of a recurrently bleeding duodenal ulcer (DU) is very high, both from a human and an economic point-of-view. Helicobacter pylori infection plays an important role in the pathogenesis of DU disease and its complications, such as bleeding. Cure of H. pylori infection is recommended in patients with DU and its complications, although in the latter case, the most efficient management is not yet a defined issue. In particular, acid secretion inhibitors may not contribute to long-term cure. Our aims were to ascertain whether the recurrence of bleeding because of DU could be prevented by H. pylori eradication and whether long-term inhibition of gastric acid output is needed to prevent recurrence. Eighty-four patients (65 men; mean age, 55.1 years), who had bled because of recurrent DU, were followed after the cure of H. pylori infection. None of the patients were on therapy with nonsteroidal antiinflammatory drugs. Successful cure of H. pylori was determined by gastroscopy, histology, and serology performed at 3, 6, 12, 24, and 48 months after the eradication treatment. A 13C urea breath test was performed when the results of serology were unclear and also at recurrence of DU or bleeding. After the antibiotic treatment, 46 patients stopped all medications, whereas 38 continued long-term therapy with histamine type 2 receptor antagonists. During a mean follow-up period of 47.2 months (range, 37-65 months), recurrence of DU at endoscopy was observed in three patients in each group (p = 0.56), but none bled again. We conclude that H. pylori eradication prevents DU recurrence and rebleeding, that reinfection rate by H. pylori after cure was nil at 4 years, and that long-term inhibition of acid secretion may not improve outcome after cure of H. pylori, even in patients whose DU was complicated by hemorrhage.

A twelve-month follow-up after Helicobacter pylori eradication. A clinical and histological evaluation.

To evaluate a twelve-month effect of Helicobacter pylori eradication, 258 consecutive out-patients with H. pylori related active duodenal ulcer were given a ten-day eradicating treatment. After healing no maintenance antiulcer medication was given. On entering the study and then 2, 6 and 12 months after the completion of therapy patients were scored for symptoms and underwent endoscopy to assess the presence of duodenal ulcer and to score antrum and corpus gastritis. Statistical analysis was performed by means of the chi 2 test. Histological eradication, defined as the inability to detect H. pylori six months after the completion of the eradication course, was proved in 85 subjects while the 123 non-eradicated ones were considered as the control group. Ulcer relapse rate and ulcer-like symptoms were significantly less frequent among eradicated than non eradicated throughout the follow-up. As compared to non eradicated, gastritis significantly improved among eradicated in both antrum and corpus. H. pylori eradication may be recommended since, by reducing ulcer relapse rate and related symptoms, there is no need for further antiulcer maintenance therapy with a significant drop in socioeconomic costs.

Reinfection or recrudescence after apparently successful eradication of Helicobacter pylori infection: can the type of gastritis solve the problem?

Unexpectedly high early reinfection rates are reported in duodenal ulcer patients in whom Helicobacter pylori infection had been considered eradicated two months (T2) after appropriate therapy. Since some of these re-conversions to Helicobacter pylori positivity were probably recrudescences of a latent infection rather than reinfections, studies were performed to evaluate whether the type of antral gastritis could predict the infection outcome. In 142 eradicated patients at T2, endoscopies were repeated 6 (T6), 12 (T12) and 24 (T24) months after therapy to assess Hp status and to score antral gastritis. Re-conversion to Hp positivity occurred in 14.79% between T2/T6, in 5.40% between T6/T12 and 11.11% between T12/T24. The absence of active antral gastritis at T2 with its 87.31% negative predictive value was a fairly good marker of subsequently confirmed eradication (p = 0.017). It is suggested that, evaluation of antral gastritis soon after an eradicating course, could be a reliable parameter in assessing "true" Hp eradication.

Helicobacter pylori infection: comparison among four different therapeutic regimens.

Helicobacter pylori is both virulent and pathogenic, yet it is not clear what is the best way to treat the infection. This study compares the ability of 4 regimens of colloidal bismuth subcitrate (CBS) 120 mg q.i.d. for 4 weeks, combined with one or two antibiotics, to eradicate helicobacter pylori and assesses the outcome of eradication on antral gastritis and on symptoms of non-ulcer dyspepsia in 140 consecutive subjects (44 duodenal ulcers and 96 non ulcer dyspepsia). Endoscopy with antral biopsies was repeated in all patients before (T0) and one month after stopping treatments (T2) while duodenal ulcers were endoscoped also at the completion of treatments (T1). The four regimens showed similar eradication and ulcer healing rates (p = ns). After treatments (T1), about 60% of dyspeptic patients achieved a subjective improvement, not significant despite therapeutic regimen, and persisting at T2. Antral gastritis significantly improved after treatments (p less than 0.0001), even with the persistence of the infection (p less than 0.001). The 4 regimens are relatively safe, as no abnormality in laboratory assessment was found, albeit the frequency of side effects (most of whom tinidazole related) and the difficulty of the schedules (6-10 tablets/day) may limit patient compliance.

Serum group I pepsinogens level in cystic fibrosis.

Fasting serum pepsinogen 1 level was determined by radioimmunoassay in 30 patients with cystic fibrosis and in on equal number of age-matched healthy children. Serum pepsinogen 1 basal levels were significantly higher (49 +/- 18 ng/ml; p less than 0.01) in cystic fibrosis patients than in controls (38 +/- 12 ng/ml). The increased pepsinogen 1 level did not correlate with the levels of Po2 and Pco2 tensions, fat balance or basal and maximum acid outputs. It is concluded that the mechanisms which lead to a rise of serum pepsinogen 1 in cystic fibrosis are unknown. However these findings could provide useful information with regard to the biology of a disease whose physiopathology is still unknown.

Diagnostic usefulness of serum group I pepsinogen determination.

In order to evaluate its clinical usefulness, serum pepsinogen I level was measured in a prospective study in unselected patients affected by endoscopically and histologically confirmed gastric or duodenal diseases. The mean level in controls was 63 +/- 26 ng/ml (M +/- SD) with no statistical difference between males and females, while it was significantly higher in smokers than in non-smokers (respectively 69 +/- 25 and 56 +/- 25 ng/ml). On the average in gastric ulcer patients it overlapped with controls (69 +/- 34 ng/ml), but in prepyloric ulcers its value was higher (81 +/- 45 ng/ml) than that found in ulcer of the gastric corpus (66 +/- 30 ng/ml). Serum pepsinogen I level was significantly higher in duodenal ulcer patients (81 +/- 33 ng/ml), in males as compared to females and in smokers as compared to non-smokers (respectively 91 +/- 32 and 67 +/- 26 ng/ml). Higher than normal values were found in one subject affected by the Zollinger-Ellison syndrome, and in patients with severe renal failure. Low and very low levels were found after partial and total gastrectomies and in A type atrophic gastritis. In the case of duodenal ulcer, serum pepsinogen I determination showed a 16 p. 100 sensitivity and a 96 p. 100 specificity, while for atrophic gastritis it showed an 87 p. 100 sensitivity and a 100 p. 100 specificity. It is concluded that, at present, the most important clinical application seems to be its screening value in the detection of atrophic gastritis and consequently its potential use to detect populations at increased risk for gastric cancer.