Patients with established gastro-esophageal reflux disease might benefit from Helicobacter pylori eradication.

BACKGROUND: The aim of this study was to investigate the effect of Helicobacter pylori (H. pylori) eradication in selected H. pylori-positive patients with a primary diagnosis of gastro-esophageal reflux disease (GERD) by using the 3-h postprandial esophageal pH monitoring. METHODS: We recruited patients with erosive esophagitis at endoscopy and H. pylori infection at histology, successfully cured following eradication therapy; the selected H. pylori-positive patients had weekly reflux symptoms for at least six months and endoscopically established Grade A or B esophagitis. Twenty-nine eligible patients were initially subjected to esophageal manometry and ambulatory 3-h postprandial esophageal pH monitoring. All patients received H. pylori triple eradication therapy accompanied by successful H. pylori eradication. After successful eradication of H. pylori (confirmed by 13C urea breath test), a second manometry and 3-h postprandial esophageal pH monitoring were introduced to assess the results of eradication therapy, after a 3-month post-treatment period. RESULTS: All 29 selected H. pylori-positive patients became negative due to successful H. pylori eradication, evaluated by 13C urea breath test after a 4-week post-treatment period. Post-eradication, 62.1% patients showed similar manometric pattern at baseline; 17.2% showed improvement; 17.2% normalization; and 3.4% deterioration of the manometric patterns. The DeMeester symptom scoring in the 3-h postprandial ambulatory esophageal pH monitoring was improved after eradication of H. pylori (median 47.47 vs. 22.00, Wilcoxon's singed rank; P=0.016). On comparing the pH monitoring studies for each patient at baseline and post-eradication period, 82.8% patients showed improvement and 17.2% deterioration of the DeMeester score. CONCLUSION: By using 3-h postprandial esophageal pH monitoring, this study showed, for the first time, that H. pylori eradication may positively influence GERD symptoms. Large-scale controlled relative studies are warranted to confirm these findings.

Chromogranin A as a biomarker of disease activity and biologic therapy in inflammatory bowel disease: a prospective observational study.

OBJECTIVE: To access the correlation of Chromogranin A (CgA) with inflammatory bowel disease (IBD) activity and responsiveness to medical therapy. MATERIAL AND METHODS: A prospective observational study was conducted in 56 patients with moderate ulcerative colitis (UC) or Crohn's disease (CD) (UC, n = 29, CD, n = 27), 17 patients with irritable bowel syndrome and predominant diarrhea (IBS-D) and 40 healthy volunteers. IBD patients were treated by biologics (infliximab or adalimumab) or conventional agents (aminosalicylates, thiopurines or methotrexate and steroids) and were classified according to their treatment in two groups. Serum CgA was measured at baseline and 4-week posttreatment period. RESULTS: Serum CgA was significantly higher in IBD patients than in those with IBS-D or healthy volunteers (p < 0.01). Furthermore, serum CgA was markedly increased in CD patients than in UC patients (p < 0.01). CgA value was significantly reduced in 'biologic' group (24 IBD patients, UC, n = 15, CD, n = 9) at 4-week posttreatment period (p < 0.01), while 18/24 (72%) patients were already in remission during that time. In contrast, CgA value was significantly increased in the 'conventional' treatment group (32 IBD patients, UC, n = 14, CD, n = 18) between the two visits (p < 0.01), although 22/32 (69%) patients were in remission during the 4-week posttreatment period. CONCLUSION: CgA appears to be a reliable marker of disease activity in IBD patients and especially in those who received biologic therapy. IBS-D patients presented normal CgA values.

Development of primary malignant melanoma during treatment with a TNF-α antagonist for severe Crohn's disease: a case report and review of the hypothetical association between TNF-α blockers and cancer.

It is recognized that immunosuppression may lead to reduced immune surveillance and tumor formation. Because of the immunosuppressive properties of tumor necrosis factor (TNF)-alpha (TNF-α) antagonists, it is plausible that these biologics may increase the risk of the occurrence of malignancies or the reactivation of latent malignancies. TNF-α antagonists have gained momentum in the field of dermatology for treating rheumatoid arthritis and psoriasis, and they have revolutionized the treatment of other inflammatory autoimmune diseases such as refractory Crohn's disease. However, there is accumulating evidence that TNF-α inhibitors slightly increase the risk of cancer, including malignant melanoma (MM). The authors herein report the case of a 54-year-old female patient who developed a primary MM during treatment with adalimumab for severe Crohn's disease resistant to successive medical therapies. The patient had been receiving this TNF-α blocker therapy for 3 years before the occurrence of MM. After wide surgical excision of the lesion and staging (based on Breslow thickness and Clark level), evaluation with a whole-body computed tomography scan was negative for metastatic disease. The long duration of the adalimumab therapy and the patient's lack of a predisposition to skin cancer suggest an association between anti-TNF-α drugs and melanocytic proliferation. The authors also review the literature on the potential association between anti-TNF regimens and the occurrence of malignancies such as melanocytic proliferations. There is a substantial hypothetical link between anti-TNF-α regimens such as adalimumab and the potential for cancers such as melanoma. However, the risk of malignancy with biological therapy remains to be established, and most of the relevant studies have lacked the statistical power and randomization required for large clinical trials. Further long-term controlled clinical trials and registries are required to investigate this potentially serious association.

Inflammatory bowel disease: Greek patients' perspective on quality of life, information on the disease, work productivity and family support.

BACKGROUND: The aim of this study was to identify inflammatory bowel disease (IBD) patients' perspectives regarding everyday life issues. METHODS: From October 2010 till April 2011, 1,181 IBD patients completed an anonymous questionnaire through the internet (827 cases) or at the outpatient clinic of the participating centers (354 cases), aiming to identify: a) the impact of disease on social life, emotional status and work productivity; b) the source of disease information; and c) the level of support from family members and friends. RESULTS: Fifty-five percent of the patients reported that IBD interferes with their social life, while 65% felt stressed, 60% depressed and 19% tired because of it. Disease information (physician/ internet) was reported only by 31%, while 26% admitted not discussing their therapy with their gastroenterologist. Forty percent felt that the health service they receive is not satisfactory, with 76% desiring more gastroenterologists, 67% more outpatient clinics, 49% more dieticians and 42% more psychologists specialized in IBD. IBD interfered with working capacity in 40% of the participants, while 57% needed time off of work (ranging from 1-20 days per year). One of three patients (32%) has not informed his work environment about the disease; however, 88% had the support of their family and friends for coping with it. CONCLUSIONS: Greek IBD patients claim that health-related social life, emotional status and work productivity are severely affected by their disease, whereas they complain about lack of information regarding the therapy. These unmet demands call for immediate action by healthcare providers and society.

Does prophylactic administration of somatostatin decrease the rates of complications after pancreatic resection?: A clinical and electron microscopy study.

OBJECTIVES: The postoperative morbidity after pancreatectomy remains high. The role of somatostatin and its analogs in reducing complications after pancreatic resection is controversial. The aim of the study was to evaluate the ability of somatostatin to influence pancreatic cell's function with consequence the decrease of postoperative complications. METHODS: Between January 2006 and December 2009, 67 patients for which pancreatectomy was indicated were randomized into 2 groups. At surgery, biopsies of the pancreas were taken to be studied by electron microscopy and analyzed for ultrastructural morphometry. RESULTS: The total mortality was 4.4% (n = 3/67; 2 patients from the control group and 1 patient from the treatment group). The overall morbidity was 35.8% (n = 24/67). Eighteen patients in the control group (n = 18/32; 56.25%) and 6 patients in the treatment group (n = 6/35; 17.14%) developed postoperative complications (2-tailed Fisher exact test; P = 0.001). The most common complication was the presence of fistula (n = 6/67; 8.95%). CONCLUSIONS: Perioperative administration of intravenous somatostatin at rates applied in this study was able to inhibit the exocrine pancreatic function. This finding supports the prophylactic effect of somatostatin on the early postoperative complications of pancreatic surgery shown in this study.

Non-Hodgkin lymphoma and GIST: molecular pathways and clinical expressions.

We report the case of a 64-year-old woman with a gastrointestinal stromal tumor and a diffuse large cell lymphoma. For this case, we conducted a literature review in an attempt to correlate these two neoplasms on a molecular basis. Diffuse large cell lymphoma is a subtype of non-Hodgkin lymphomas. The etiologic factor of these lymphomas is considered to be the mutations or allelic losses of the TP53 tumor suppressor gene and the overexpression of the bcl-2 oncogene. Gastrointestinal stromal tumors are mesenchymal tumors, which are typically defined by the expression of c-KIT (CD117) and CD34 genes in the tumor cells. Although there are references to dispersants in the literature about patients with both non-Hodgkin lymphoma and gastrointestinal stromal tumors, there is no common molecular pathway between these two diseases. In conclusion, there is no indication that these two neoplasms are relevant on a molecular basis.

Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis.

Umbilical endometrioma is a rare condition, with an estimated incidence of 0.5%-1% in all patients with endometrial ectopia. Spontaneous abdominal wall endometriosis is an even rarer and more unusual condition with unclear pathogenetic mechanisms. A 44-year-old parous woman presented with an umbilical skin lesion, and no history of bleeding from the umbilical mass or swelling in the umbilical area. The initial clinical diagnosis was granuloma, and excision was planned. Pathology examination revealed endometrial glands with mucinous-type metaplasia surrounded by a disintegrating mantle of endometrial stroma. Clinical examination and magnetic resonance imaging did not reveal pelvic endometriosis lesions, and given that the umbilical endometrioma was totally excised, no further treatment with hormonal therapy was proposed for the patient. Three years after excision, she was free of disease and no recurrence has been observed. Complete excision and histology is highly recommended for obtaining a definitive diagnosis and optimal treatment in spontaneous abdominal wall endometriosis.

Benign post-radiation rectal stricture treated with endoscopic balloon dilation and intralesional triamcinolone injection.

Post-radiation stricture is a rare complication after pelvis irradiation, but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction. Endoscopy has gained an important role in chronic radiation proctitis with several therapeutic options for management of intestinal strictures. The treatment of rectal strictures has been limited to surgery with high morbidity and mortality. Therefore, a less invasive therapeutic approach for benign rectal strictures, endoscopic balloon dilation with or without intralesional steroid injection, has become a common treatment modality. We present a case of benign post-radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection. A 70-year-old woman presented to the emergency room complaining for 2 weeks of diarrhea and meteorism, 11 years after radiation of the pelvis due to adenocarcinoma of the uterus. Colonoscopy revealed a stricture at the rectum and multiple endoscopic biopsies were obtained from the stricture. The stricture was treated with endoscopic balloon dilation and intralesional triamcinolone injection. The procedure appears to have a high success rate and a very low complication rate. Histologic examination of the biopsies revealed non-specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation. All biopsies were negative for malignancy. The patient is stricture-free 12 months post-treatment.

Tuberculosis in the peritoneum: not too rare after all.

Peritoneal tuberculosis is rare with increased incidence rates in recent years. The absence of characteristic clinical features of the disease often makes its diagnosis difficult and elusive. We present the case of 61-year-old female with peritoneal tuberculosis. The patient suffered from abdominal pain for a period of 5 months prior to admission. The diagnosis was established on the basis of findings from an abdominal computed tomography scan, a chest radiograph and histopathological analysis of the laparoscopic resection of the two masses. The patient was discharged from hospital receiving a fourfold antituberculous treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. A high index of suspicion and a combination of radiologic, endoscopic, microbiologic and histopathological examination achieves diagnostic accuracy and prevents clinical mismanagement.

Is Post-ERCP Pancreatitis a Genetically Predisposed Complication?

Background/Objectives. Pancreatitis remains the most common complication of ERCP. History of post-ERCP pancreatitis is an independent risk factor for a new episode, suggesting a genetic background. The N34S mutation in serine protease inhibitor Kazal type 1 (SPINK 1) gene may downregulate the threshold for the development of pancreatitis. The aim of the present study is to evaluate the presence of this mutation among patients with post-ERCP pancreatitis. Methods. During a period of four years, thirty patients with post-ERCP pancreatitis entered the study. Patients and procedural data were collected, focusing on risk factors for pancreatitis. Blood samples were taken for genetic testing for the presence of N34S mutation in SPINK 1 gene. After DNA extraction, we used an allele-specific polymerase chain reaction as an initial screening method for the N34S mutation, and in order to confirm the results and to determine the hetero- and homozygosity genotype status, we used a restriction fragment length polymorphism (RFLP) method. Results. None of the thirty patients was found to carry the N34S mutation, with both of the applied methods. Patients had an average of two of the known risk factors. Conclusion. SPINK1 N34S mutation does not seem to play a role in post-ERCP pancreatitis, but larger studies needed to confirm our results.

Abdominal wall endometrioma mimicking an incarcerated hernia: a case report.

The case of a tender, isolated abdominal wall tumor within a Pfannenstiel incision due to a seeding deposit of endometrial tissue secondary to a previous obstetric operation (caesarean section) in a 39-year-old female without previously reported pelvic endometriosis is presented. The lesion clinically mimicked the appearance of an incarcerated incisional hernia at the outer corner of the healed Pfannenstiel incision. The preoperative differential diagnosis also included that of a locally forming post-operative tender granuloma and the remote possibility of an incisional endometrioma (although no link to menstruation could be made). Local malignancy was not taken as a serious possibility. Definitive diagnosis of the excised lesion was made at histology. The pre-operative diagnostic dilemma is presented, along with a short review of the literature.

Adalimumab - an effective and promising treatment for patients with fistulizing Crohn's disease: a case series.

INTRODUCTION: Crohn's disease is a chronic inflammatory bowel disease of unknown etiology which may affect any part of the bowel. Fistulas are a common and often serious complication of Crohn's disease. The treatment for fistulizing Crohn's disease can be medical, surgical or a combination of the two. Recently, adalimumab, a fully human anti-tumor necrosis factor monoclonal antibody, has been suggested as a safe and effective treatment for the induction and maintenance of remission in adult patients with moderate to severe Crohn's disease, who are refractory to conventional therapy or intolerant to infliximab. However, large studies focusing on evaluating the efficacy of adalimumab in fistulizing Crohn's disease have not yet been published. CASE PRESENTATION: We report the cases of three patients, of European Caucasian ethnicity and Greek nationality, with active luminal and fistulizing Crohn's disease. All of the cases were treated successfully with adalimumab. Patient 1 (a 44-year-old man) and patient 2 (an 18-year-old woman) developed early post-surgical enterocutaneous fistulas, while patient 3 (a 20-year-old woman) had peri-anal fistulizing Crohn's disease. Adalimumab treatment (160 mg subcutaneously at week zero, 80 mg at week two, and 40 mg every other week) was used for three different indications: (1) after the failure of other conservative medical treatments for Crohn's disease (patient 1); (2) as a monotherapy in treating a naive patient (patient 2); (3) after an intolerance to infliximab (patient 3). A remission of the active luminal and fistulizing disease was achieved soon after the initiation of adalimumab and sustained thereafter with maintenance doses. No further surgical intervention was required and no adverse effects were observed in any of the cases. CONCLUSIONS: Fistulizing Crohn's disease remains a challenge in clinical practice. Adalimumab seems to be an effective, well-tolerated and safe treatment option for the induction and maintenance of remission in patients with moderate to severe peri-anal fistulizing Crohn's disease. Furthermore, adalimumab seems to be a promising treatment option for patients with moderate to severe fistulizing Crohn's disease with enterocutaneous fistulas. However, this clinical observation needs to be investigated in further clinical trials.