Macroscopic small bowel mucosal injury caused by chronic nonsteroidal anti-inflammatory drugs (NSAID) use as assessed by capsule endoscopy.

OBJECTIVE: To evaluate the type, frequency, and severity of macroscopic small bowel mucosal injury after chronic NSAID intake as assessed by capsule endoscopy (CE), as well as to correlate the severity of gastroduodenal and intestinal damage in these patients. MATERIAL AND METHODS: A prospective, endoscopist-blind, controlled trial. Sixteen patients (14F/2M; age: 57.06 +/- 10.16 yrs) with osteoarthritis (OA) on chronic therapy with NSAIDs underwent CE and upper gastrointestinal endoscopy (UGE). Seventeen patients with OA (9F/2M; age: 57.47 +/- 9.82 yrs) who did not take NSAIDs were included as a control group. A scale ranging from 0 to 2 (0 = no lesions, 1-minor = red spots or petechiae, denuded areas and/or 1-5 mucosal breaks; 2-major = > 5 mucosal breaks and/or strictures, or hemorrhage) was designed to assess the severity of small bowel mucosal injuries. RESULTS: CE found intestinal lesions in 75% (12/16) of patients in the study group and in 11.76% (2/17) of controls (p < 0.01). Seven out of 16 NSAID consumers (43.75%) and none in the control group (0%) had a major small bowel mucosal injury (p < 0.01). The percentages of patients with grade 1 and 2 gastroduodenopathy in the study group, as assessed by UGE, were 37.14 and 23.81%, respectively. There was no significant difference in the rate of major enteropathy between patients with none or minor gastroduodenal injury, and those with major gastroduodenopathy (43.75 vs. 40%; p = N.S.). CONCLUSIONS: Chronic NSAID intake is associated with a high rate of small bowel mucosal injuries. Our data have failed to demonstrate a relationship between the severity of gastroduodenal and intestinal injury.

Diagnosis of paediatric anaplastic large-cell lymphoma: a historical perspective from a single institution.

INTRODUCTION: Anaplastic large-cell lymphoma (ALCL) is an infrequent childhood malignancy whose diagnosis and treatment have largely evolved since its initial description in 1985. PATIENTS AND METHODS: We retrospectively reviewed our experience in the field, and report here a single institution experience focusing on diagnostic and therapeutic milestones achieved as novel tools have been developed. This is a series of 9 children diagnosed from 1987 to 2007. RESULTS: Our first patient was diagnosed shortly alter this entity was described based on morphology and Ki-1 positivity, while the diagnostic work-up for the last two children included accurate molecular diagnosis for ALK-NPM rearrangement. Despite a wide variety of multimodal therapies used over time, only one patient died of toxicity during progression and another child relapsed and survived alter an autograft. After 156 months of median follow-up (range 4-245), 8 out of 9 children are alive, free of disease. CONCLUSIONS: Our series exemplifies the long journey travelled from the definition of a new entity only 20 years ago to the molecular characterization not only with diagnostic but also therapeutic purposes. Besides this, significant efforts are being made to recruit all European patients into a multinational collaborative trial in order to start drawing major evidence-based conclusions.

Diagnosis of paediatric anaplastic large-cell lymphoma: a historical perspective from a single institution

INTRODUCTION: Anaplastic large-cell lymphoma (ALCL) is an infrequent childhood malignancy whose diagnosis and treatment have largely evolved since its initial description in 1985. PATIENTS AND METHODS: We retrospectively reviewed our experience in the field, and report here a single institution experience focusing on diagnostic and therapeutic milestones achieved as novel tools have been developed. This is a series of 9 children diagnosed from 1987 to 2007. RESULTS: Our first patient was diagnosed shortly alter this entity was described based on morphology and Ki-1 positivity, while the diagnostic work-up for the last two children included accurate molecular diagnosis for ALK-NPM rearrangement. Despite a wide variety of multimodal therapies used over time, only one patient died of toxicity during progression and another child relapsed and survived alter an autograft. After 156 months of median follow-up (range 4-245), 8 out of 9 children are alive, free of disease. CONCLUSIONS: Our series exemplifies the long journey travelled from the definition of a new entity only 20 years ago to the molecular characterization not only with diagnostic but also therapeutic purposes. Besides this, significant efforts are being made to recruit all European patients into a multinational collaborative trial in order to start drawing major evidence-based conclusions (AU)

[Is capsule endoscopy useful in children with chronic abdominal pain?]. / Es útil la cápsula endoscópica en niños con dolor abdominal crónico?

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms.

Incidence and factors influencing on Helicobacter pylori infection recurrence.

OBJECTIVES: a) To determine the rate of H. pylori reinfection after successful eradication in a 4-year follow-up study; and b) To evaluate the contribution of different factors in the infection relapse. PATIENTS AND METHODS: A total of 208 patients (age range 18-81 years; average 50 years; 87 women) who had been successfully treated for H. pylori infection were included. Annually, urea breath test was assessed to determine H. pylori status after eradication. Age, sex, rural/urban environment, smoking habit, treatment regimens against H. pylori and urea breath test values were evaluated. RESULTS: reinfection occurred in 9,6% of patients observed, 6,7% (14/208) in the first year, 1,9% (4/208) in the second year, 1% (2/208) in the third and 0% in the forth. Risk factors for infection recurrence were younger age and higher values of urea breath test in the multivariante analysis. CONCLUSIONS: annual reinfection rate was 2,4 pacients-year. Younger patients and higher values of urea breath test were factors associated with a higher rate of reinfection relapse. Annually, urea breath test should be performed to detect reinfection in order to avoid ulcer complications.

Role of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding.

The recent emergence of capsule endoscopy has entailed a relevant diagnostic imaging advance for gastrointestinal conditions, especially those involving the small bowel. Gastrointestinal haemorrhage of obscure origin is probably the most widely accepted indication for this new technique, and promising results have been reported from series extant to date. In view of data available on this new modality, and looking forward to having wide, well designed studies fr corroboration, this paper suggests a tentative algorithm for the management of this patient group.

Ranitidine bismuth citrate in the treatment of Helicobacter pylori infection.

OBJECTIVE: Examine the effectiveness of treatments that include ranitidine bismuth citrate (RBC) for Helicobacter pylori infection. DESIGN: Prospective and randomised study. PATIENTS AND METHOD: 137 patients were included (62 women, 75 males, average age 46.9 +/- 13) diagnosed with peptic ulcer and infection by Helicobacter pylori. None had received treatment previously. 67 patients were treated with RBC 400 mg bd and clarithromycin 500 mg bd for 14 days, and 70 patients with RBC 400 mg bd, clarithromycin 500 mg bd and amoxycillin 1 g bd for 7 days. The infection eradication was proven eight weeks after treatment end. The efficacy of treatment was evaluated using the intention-to-treat method. The Chisquare test (chi 2) was used for the statistical analysis of data. RESULTS: Infection in 48 out of 67 patients (71.64%) treated with RBC-clarithromycin for 14 days was eradicated, versus 88.57% (62 out of 70) among those treated with RBC-clarithromycin-amoxycillin for 7 days, with a significant difference between both regimens (p < 0.05). CONCLUSIONS: 7-day treatment with RBC-clarithromycin-amoxycillin has a good eradication rate (88.57%) and represents a valid alternative to regimens including a PPI and two antibiotics, as both regimens have a similar efficacy. Results obtained with the double therapy of RBC-clarithromycin for 14 days were not satisfactory, the rate of eradication being 71.64%. The use of an RBC treatment for Helicobacter pylori infection should always be accompanied by two antibiotics in a triple therapy.

[Endoscopic treatment of pain in patients with chronic pancreatitis]. / Tratamiento endoscópico del dolor en los pacientes con pancreatitis crónica.

INTRODUCTION: Chronic Pancreatitis is a recurrent disease, frequently alcohol intake related and tend to occur in the third and the fourth decades. Stenoses and lithiasis in the main pancreatic duct causes obstruction and subsequently pain. Therefore endoscopic or surgical decompression of main pancreatic duct results in pain relief. SUBJECTS AND METHODS: Review our experience in the endoscopic management in patients suffering from chronic pancreatitis. 42 patients underwent ERCP for management of their chronic pancreatitis. Therapeutic options were sphincterotomy alone, prostheses and "do nothing". Follow-up was made by phone call and outpatient office visits. Mean follow-up was 47.8 (27.2) months. RESULTS: 22 patients underwent therapeutic ERCP. In 8 patients we performed sphincterotomy and in 14 patients, a sphincterotomy and prostheses intubation. 8 patients are asymptomatic after a mean follow-up of 10.8 (11.6) months. 2 of them, underwent sphincterotomy and six of them, underwent sphincterotomy and prostheses intubation. CONCLUSION: Therapeutic ERCP is a tool that relieves pain in a fifth of patients suffering from chronic pancreatitis.

[McArdle disease: report of four brothers with myophosphorylase deficiency]. / Enfermedad de McArdle: descripción de cuatro hermanos con déficit de miofosforilasa.

Myophosphorylase deficiency, or McArdle disease, is an uncommon entity. The gene for human myophosphorylase has been cloned and is located on chromosome 11, in keeping with the autosomal recessive nature of the disease and there is an excess of male patients. The diagnosis is established by documentation of elevated glycogen content and reduced phosphorylase activity in biopsied muscle tissue. We report four cases with McArdle disease which were 16, 15, 11 and 5 years old. They were brothers, and they came to the hospital because of pain, cramps and myoglobinuria after exercise or infection; in the first case, a male patient, myoglobinuria caused acute renal failure. Three of them showed reduced phosphorylase activity in biopsied muscle tissue. We discuss the different therapeutic possibilities.

Effectiveness of hemorrhoidal treatment by rubber band ligation and infrared photocoagulation.

OBJECTIVES: To demonstrate the effectiveness of the treatment of internal hemorrhoids with rubber band ligation (RBL) and infrared photocoagulation (IRC). PATIENTS AND METHODS: From march 1996 to december 1999, we prospectively studied 358 patients with a total of 817 hemorrhoid groups and a follow-up period of 36 months. Distribution according to gender and age was: 210 men with a mean age of 46 years and 148 women with a mean age 45.8 years. The mean number of hemorrhoids treated per patients was 2.3. All of them had complete a follow-up protocol at 15, 30, 60 and 180 days and at 12, 24 and 36 months. Rubber band ligation was performed with McGown ligator and suction pump, placing the band at the base of the hemorrhoid. For the infrared coagulation we used a Lumatec coagulation system, applying at least four shoots around each hemorrhoid, with an exposition time ranging between 1 and 1.5 seconds. Treatment was considered effective when patients became asymptomatic (relief of pain, bleeding or anal itching) and the obliteration of hemorrhoids after the treatment was confirmed by anal inspection and anoscopy. RESULTS: Two hundred ninety five of 358 patients were treated with RBL (82.4%), this treatment being effective in 98% of the patients after 180 days and very good after 36 months. There were 6/295 relapses at 36 months (2%). All minor and major complications were observed within the first 15 days of treatment: rectal tenesmus in 96/295 patients (32.5%), mild anal pain in 115/295 (38.9%), self-limited and mild bleeding after the detachment of the bands in 30/295 (10%), and febricula in one patient. Sixty three of 358 patients were treated with IRC (17.6%). In this group, relapses were observed in 6/63 patients (9.5%) at 36 months, all of them with grade III hemorrhoids that required additional treatment with RBL. All the complications (inherent to the technique) were observed within the first days: mild anal pain in 40/63 patients (63.4%) and mild bleeding in 1/63 (1.6%). The treatment with RBL or IRC depended on the number of hemorrhoids and the hemorrhoidal grade. No significant differences were found regarding the effectiveness between RBL and IRC for the treatment of grade I-II hemorrhoids, while RBL was more effective for grade III and IV hemorrhoids (p < 0.05). CONCLUSION: RBL and IRC should be considered as a good treatment for all grades of hemorrhoids, due to its effectiveness, its cost-benefit and its small short and long-term morbidity.

Pathogenic implications of interleukin-8 activity and bacterial phenotype in antral gastritis associated with Helicobacter pylori.

OBJECTIVE: Helicobacter pylori (Hp) infection is characterized by an intense inflammatory infiltrate in the gastric mucosa, which is chemoattracted by different cytokines. Interleukin-8 (IL-8) seems to play an important role in the recruitment of circulating neutrophils, and modulation of IL-8 secretion seems to be a strain marker. This study was designed to examine IL-8 concentrations in the gastric mucosa and their relationship with H. pylori phenotype and histologic findings. METHODS: Gastric biopsies were obtained from the antrum and corpus in 106 patients (69 Hp-positive and 37 Hp-negative). IL-8 levels in the gastric mucosa were analyzed by ELISA and Hp phenotype was determined with a western blot test. RESULTS: 75% of H. pylori strains were CagA+ and 54.2% were VacA+. The Houston classification was used for histologic findings. No association between gastric atrophy or intestinal metaplasia and Hp phenotype was found. The highest IL-8 levels were found in CagA+ infected gastric mucosa, but the difference with respect to infection by a VacA+ strain was not statistically significant. IL-8 levels were highest when neutrophils were the predominant cell in the gastric inflammatory infiltrate (p < 0.05). IL-8 levels were higher in patients with atrophic gastritis than in patients with nonatrophic gastritis (p < 0.05). CONCLUSIONS: In patients with H. pylori infection, IL-8 levels are higher than in Hp-negative patients regardless of Hp phenotype. There is an association between IL-8 and a neutrophilic infiltrate. Perpetuation of a chronic infiltrate could lead to more severe lesions such as atrophic gastritis or intestinal metaplasia, as deduced from the IL-8 levels found in these types of lesion.

Clinical relevance of Helicobacter pylori CagA-positive strains: gastroduodenal peptic lesions marker.

OBJECTIVES: peptic ulcer is characterized by its recurrent nature, which necessitates maintenance treatment in most patients. But this natural history can be changed in patients with peptic ulcer associated to Helicobacter pylori, as shown by the low rates of recurrence and decreased hemorrhagic recidivism associated with this infection. Whether CagA or VacA strains are associated with a greater risk of peptic ulcer is controversial. This study was designed to examine endoscopic findings and their relation with H. pylori phenotype (CagA or VacA). METHODS: 106 selected dyspeptic patients underwent upper gastrointestinal tract endoscopic examination between September 1996 and May 1997 [69 with H. pylori (Hp) and 37 without this infection]. Endoscopic findings were classified as gastric ulcer (GU), duodenal ulcer (DU), gastric erosions (GE), duodenitis (Du), chronic gastritis (CG) and normal mucosa (NM). Hp phenotype was analyzed with a western blot test. RESULTS: 75% of H. pylori strains were CagA-positive and 54.2% were VacA-positive. 82.4% of the cases of DU were associated with a CagA+ phenotype, but the association was not statistically significant. Otherwise 100% of gastric ulcers were associated with CagA+ strains (p < 0.005). VacA phenotype was not associated with any particular endoscopic finding. Peptic ulcer (DU or GU) was also associated with the CagA+ phenotype (p < 0.05). CONCLUSIONS: the CagA+ H. pylori phenotype seems to be a peptic lesion marker, but was more frequently related with GU than with DU in our sample of Spanish patients.

Relationship between endoscopic esophagitis and patterns of gastroesophageal reflux in ambulatory pHmetry.

AIM: to evaluate the possible relationship between the various grades of endoscopic esophagitis and the different patterns of reflux determined by 24-hour ambulatory pH-metry. PATIENTS AND METHODS: we selected 80 patients with symptoms of gastroesophageal reflux disease in whom upper digestive tract endoscopy revealed some degree of mucosal lesion. These patients subsequently underwent 24-hour ambulatory pH-metry. The lesions of the mucosa were classified into 4 grades according to the criteria of Savary and Miller. The patterns of reflux were determined by 24-hour pH-metry and classified according to the severity of reflux (slight, moderate or severe, using DeMeester's table) and the type of reflux (in bipedestation, supine or mixed) according to the percentage of time at pH < 4 in bipedestation, in decubitus or in both positions. RESULTS: patients with grades I and II esophagitis showed variable patterns of reflux, although the most frequent seemed to be slight in bipedestation, which we observed in 34% of the patients. Most (76. 2%) of the patients with grades III or IV (p < 0.05) showed a clearly defined pattern of severe type in the supine position or in both positions. CONCLUSIONS: the presence of a reflux pattern of predominantly supine or mixed type in 24-hour pH-metry may help to identify patients at higher risk for developing severe esophagitis or other complications.

[Echoendoscopy: pathological diagnosis using real-time puncture-aspiration]. / Ecoendoscopia: diagnóstico patológico de certeza mediante punción-aspiración en tiempo real.

The aim of this study was to obtain pathologic diagnosis by aspiration punction (AP) by real time lineal echoendoscopy in different lesions suspected to be malignant. AP was performed in 6 cases with a Pentax-Hitachi FG 32UA lineal echoendoscopy. Four pancreatic neoplasms, one plastic linitis and one adenopathy of the celiac trunk were observed. Malignancy was confirmed by clinical evolution or surgery. The sensitivity of malignancy diagnosis was 67%, specificity 100% and diagnostic certainly 87%. No complications were observed. In the authors' preliminary experience, aspiration punction with real time lineal echoendoscopy allowed pathological diagnosis to be performed safely and effectively with relative simplicity.

[Acute pancreatitis due to 5-aminosalicylic acid]. / Pancreatitis aguda por ácido 5-aminosalicílico.

We report a case of a 5-aminosalicylate-induced pancreatitis in a patient with Crohn's disease. These findings suggest that some side effects, traditionally thought to be related to sulphafapyridine, are really due to 5-aminosalicylate. The good prognosis of this rare complication depends on the early withdrawal of the drug. Therefore the degree of the clinical suspicion plays a essential role in the appropriate diagnosis, but a challenge with mesalazine must be carried out in those patients in which other causes of pancreatitis could not be excluded.