Selection criteria and outcome of patients referred to intestinal transplantation: an European center experience.

Until 1998, intestinal transplantation (SBT) had not been performed in our region of Flanders, Belgium. Potential SBT activity was not known and selection criteria had not been validated. A multidisciplinary SBT program was launched in 1998. We analyzed requests for SBT and outcomes in these patients whether with or without SBT. Listing for SBT was only considered for patients with irreversible short bowel syndrome who had developed life-threatening complications of total parenteral nutrition, but whose general condition was still thought compatible with surgery and immunosuppression. During the study period 1998 to 2004, one third of the requests for SBT (10/31) were deemed suitable. SBT in this group was lifesaving (100% survival) when performed in time. Mortality in this group without SBT was high (67%). Two thirds of the patients (21/31) did not fulfill the SBT inclusion criteria, either because they were "too moribund" to tolerate transplantation or because they were "too well". This preliminary study emphasized the importance of (1) early referral of potential SBT candidates, (2) adherence to strict criteria for listing patients for SBT, and (3) referral of intestinal donors to procurement organizations.

Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma.

PURPOSE: A prospective study of preoperative tumor-node-metastasis staging of patients with esophageal cancer (EC) was designed to compare the accuracy of 18-F-fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) with conventional noninvasive modalities. PATIENTS AND METHODS: Seventy-four patients with carcinomas of the esophagus (n = 43) or gastroesophageal junction (n = 31) were studied. All patients underwent attenuation-corrected FDG-PET imaging, a spiral computed tomography (CT) scan, and an endoscopic ultrasound (EUS). RESULTS: FDG-PET demonstrated increased activity in the primary tumor in 70 of 74 patients (sensitivity: 95%). False-negative PET images were found in four patients with T1 lesions. Thirty-four patients (46%) had stage IV disease. FDG-PET had a higher accuracy for diagnosing stage IV disease compared with the combination of CT and EUS (82% v 64%, respectively; P: =.004). FDG-PET had additional diagnostic value in 16 (22%) of 74 patients by upstaging 11 (15%) and downstaging five (7%) patients. Thirty-nine (53%) of the 74 patients underwent a 2- or 3-field lymphadenectomy in conjunction with primary curative esophagectomy. In these patients, tumoral involvement was found in 21 local and 35 regional or distant lymph nodes (LN). For local LN, the sensitivity of FDG-PET was lower than EUS (33% v 81%, respectively; P: =.027), but the specificity may have been higher (89% v 67%, respectively; P: = not significant [NS]). For the assessment of regional and distant LN involvement, compared with the combined use of CT and EUS, FDG-PET had a higher specificity (90% v 98%, respectively; P: =. 025) and a similar sensitivity (46% v 43%, respectively; P: = NS). CONCLUSION: PET significantly improves the detection of stage IV disease in EC compared with the conventional staging modalities. PET improves diagnostic specificity for LN staging.

Acute infectieuze (niet Clostridium difficile geassocieerde) diarree bij ouderen : Klinische les.

Acute diarrhoea, non-antibiotic associated, is a common problem and a significant cause of morbidity and mortality in old age. In most cases diarrhoea has an infectious etiology. A number of different micro organisms can cause infectious diarrhoea. Most frequent are viral infections with a benign evolution. Rehydration is the only important therapeutic measure. Infections with bacteria are less common, antibiotics should be prescribed only in severe cases, and when there is suspicion of invasive infections by enteropathogenic bacteria.

[Antibiotic associated diarrhea and Clostridium difficile associated diarrhea in the elderly]. / Antibiotica geassocieerde en Clostridium difficile geassocieerde diarree bij ouderen.

Antibiotic associated diarrhea (AAD) is a common complication when antibiotics are used and is frequent in the elderly. It has an impact on the length of hospital stay and increases the comorbidity. Together with the type of antibiotic that is given, the length of antibiotical treatment and the combination of antibiotics is more predictive for the evolution of diarrhea when compared to the total given dose. Mostly AAD is benign, but an infection with C. difficile should always be excluded. C. difficile-enterocolitis is frequent among residents in nursing homes and in hospitalised patients. The clinical presentation varies from asymptomatic colonisation tot severe debilitating disease. A rapid diagnosis can be performed by detection of C. difficile toxin by an enzyme-linked immunoassay. Oral metronidazole and oral vancomycine are equally effective in the therapy. In relapsing infection an extended tapering regimen is sometimes necessary.

[Acute infectious (not Clostridium difficile-associated) diarrhea in the elderly]. / Acute infectieuze (niet Clostridium difficile geassocieerde) diarree bij ouderen.

Acute diarrhoea, non-antibiotic associated, is a common problem and a significant cause of morbidity and mortality in old age. In most cases diarrhoea has an infectious etiology. A number of different micro organisms can cause infectious diarrhoea. Most frequent are viral infections with a benign evolution. Rehydration is the only important therapeutic measure. Infections with bacteria are less common, antibiotics should be prescribed only in severe cases, and when there is suspicion of invasive infections by enteropathogenic bacteria.

Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient.

PURPOSE: Iron deficiency anemia is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract has become standard practice. In contrast, iron deficiency without anemia has hardly been studied, and its causes are less certain. The aim of the present study was to determine the diagnostic value of upper and lower gastrointestinal evaluation in elderly hospitalized patients with iron deficiency, irrespective of the hemoglobin level. PATIENTS AND METHODS: In a prospective study, 151 consecutive elderly patients with iron deficiency (serum ferritin level < 50 microg/L at two separate occasions) were investigated using esophagogastroduodenoscopy with colonoscopy (n = 90) or barium enema (n = 61). RESULTS: A potential upper gastrointestinal tract lesion was found in 47 (49%) of the 96 anemic patients and in 31 (56%) of the 55 nonanemic patients (P = 0.38). Nonanemic patients had a greater prevalence of erosive gastritis or duodenitis. Anemic patients (72%) were more frequently investigated with a colonoscopy than nonanemic patients (38%, P = 0.001), and a lower gastrointestinal lesion was found in 32% of the anemic patients and 16% of the nonanemic patients (P = 0.03). Cancer was the most common lesion in the colon; 11 of the 18 patients were asymptomatic. Site-specific symptoms, fecal occult blood loss, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) were not associated with the detection of gastrointestinal lesions. In 9.5% of the patients with a benign upper gastrointestinal lesion, a synchronous colonic tumor was found. CONCLUSION: Elderly patients with iron deficiency should undergo endoscopic examination, irrespective of the hemoglobin level. The presence of gastrointestinal symptoms, a positive fecal occult blood test, and the use of NSAIDs are of limited value in guiding the diagnostic procedure.

Combined carbon-13-glycine/carbon-14-octanoic acid breath test to monitor gastric emptying rates of liquids and solids.

UNLABELLED: The aim of the present study was to develop a dual-carbon-labeled breath test for simultaneously measuring gastric emptying rates of liquids and solids with significantly less radiation burden to the patient than the radioscintigraphic technique. METHODS: A test meal was used in which the liquid phase was labeled with two markers, i.e., 3.7 MBq of 111In-DTPA and 100 mg of 13C-glycine; the solid phase also was dually labeled with 110 MBq of 99mTc-albumin colloid and 74 kBq of 14C-octanoic acid. Simultaneous radioscintigraphic and breath-test measurements were performed in 27 subjects, 10 normal controls and 17 patients with dyspeptic symptoms. Mathematic analysis of the excretion rate of labeled CO2 allowed the definition of four parameters, i.e., the gastric emptying coefficient, the gastric half-emptying time, the peak excretion time and the lag phase. RESULTS: There was a good to excellent correlation between the gastric emptying coefficient and the scintigraphic half-emptying time (r = 0.74 for liquids and r = 0.88 for solids), between the half-emptying time determined by breath test and the scintigraphic half-emptying time (r = 0.91 for liquids and r = 0.92 for solids), between the peak excretion time and the scintigraphic half-emptying time (r = 0.91 for liquids and r = 0.96 for solids) and between the lag phase of solid emptying determined by both techniques (r = 0.89). CONCLUSION: The dual carbon-labeled breath test is a valid, minimally invasive technique to measure the gastric emptying rate of both liquids and solids.

Effects on bowel motility of misoprostol administered before and after meals.

Prostaglandin analogues, used in the treatment of duodenal and benign gastric ulcer and in the prevention of gastric ulceration caused by non-steroidal anti-inflammatory drugs, are frequently associated with gastrointestinal side effects, particularly diarrhoea and abdominal cramps. We investigated the effects of misoprostol, a prostaglandin E1 derivative, on bowel motility and faecal loss of fat, water and bile acids in relation to its postprandial vs. preprandial administration. Twelve healthy subjects participated in a double-blind crossover study comparing three 5-day courses of therapy with a washout period of 1-2 weeks between courses. Following a Latin Square design, the dosing regimens were (a) 400 micrograms misoprostol b.d. after meals and placebo b.d. before meals; (b) 400 micrograms misoprostol b.d. before meals and placebo b.d. after meals; (c) placebo before and after meals. Orocaecal transit time measured by H2 breath tests following lactulose administration, was shortest during pre-prandial dosing but was also significantly decreased during post-prandial dosing. The overall treatment difference was highly significant (P less than 0.001), and the difference between each pair of treatments was also statistically significant. Whole bowel transit time studied by means of 3H-PEG 4000 determination in stools, was shorter for the two misoprostol regimens but statistical significance was borderline. The number of stools passed per day was similar in the three groups. During both misoprostol dosing periods, stools were less formed and their content of water, fat and bile acids was higher. There was also more urgency, flatulence, abdominal pain and nausea. It is concluded that the gastrointestinal side effects caused by misoprostol are mainly based on an increased orocaecal transit time. The effects are more important when the drug is administered before meals than after meals.

The influence of isolated doses of drugs, feeding and colonic bacterial ureolysis on urea breath test results.

BACKGROUND: Aim of this work was to improve standardization of the 13C-urea breath test (13C-UBT) by evaluating the effect of drug administration, feeding and colonic ureolysis on the UBT results. METHODS: Three different studies were performed. First, a 13C-UBT was performed in 41 Helicobacter pylori infected subjects before and after 1 day of therapy with sucralfate (5 g), colloidal bismuth (600 mg), amoxycillin (2.5 g) or omeprazole (40 mg). Second, a 13C-UBT was performed in 10 H. pylori-positive patients after an overnight fast and repeated 2 h after lunch. Finally, a 13C-UBT was carried out in seven healthy volunteers, with breath sampling prolonged to 6 h to investigate colonic bacterial ureolysis. RESULTS: Even a short course of drugs specific for H. pylori may result in a falsely negative 13C-UBT. Feeding does not interfere with the 13C-UBT in infected subjects. No significant 13C-urea breakdown by colonic bacteria is observed during the 13C-UBT when it is prolonged to 6 h. CONCLUSION: The 13C-urea breath test is a sensitive clinical tool for the non-invasive diagnosis of H. pylori infection. It is unaffected by feeding or colonic ureolysis. However, false negative results are likely even after 1 day of therapy with bactericidal, 'cytoprotective' or antisecretory drugs.

Evidence for impaired assimilation and increased colonic fermentation of protein, related to gastric acid suppression therapy.

BACKGROUND: Although the role of gastric digestion (by acid-dependent pepsins) in overall protein assimilation has never thoroughly been studied, it is generally considered to be limited. Protein that escapes assimilation in the small intestine is intensely fermented by the colonic flora. Phenol and p-cresol are specific bacterial metabolites of tyrosine. AIM: To elucidate the role of gastric digestion of protein by evaluating the influence of acid suppression therapy on overall protein assimilation and fermentation. METHODS: Protein assimilation was studied in 16 healthy subjects under basal conditions and after omeprazole treatment using the combined 14C-octanoic acid/13C-egg white breath test. The degree of protein fermentation was estimated by measuring the urinary output of phenol and p-cresol in 41 healthy volunteers and in 17 patients treated for more than 1 month with omeprazole because of peptic disease. RESULTS: Protein assimilation was significantly impaired after omeprazole treatment. Gastric emptying, conversely, was not affected. The urinary output of phenol and p-cresol was increased in patients treated with omeprazole as compared to untreated controls. CONCLUSION: Gastric acid suppression therapy hampers protein assimilation and may promote protein malabsorption. Gastric digestion is likely to play a substantial role in overall protein assimilation.

Influence of octreotide on the gastric emptying of solids and liquids in normal healthy subjects.

BACKGROUND: The effects of octreotide on small intestinal and gall-bladder motility are well established. However, the influence of octreotide on the gastric emptying rate of both solids and liquids in normal healthy volunteers has never been studied. METHODS: In nine healthy subjects, the gastric emptying rate of liquids and solids was studied in basal condition and 30 min after subcutaneous administration of 50 micrograms of octreotide, using the combined 14C-octanoic acid/13C-glycine breath test. To determine if the results were entirely due to alterations in gastric emptying, 14/13CO2 excretion rates of intraduodenally administered 14C-octanoic acid and 13C-glycine were measured in basal condition and after subcutaneous injection of octreotide. RESULTS: After subcutaneous injection of octreotide, the gastric emptying rate of solids was decreased in all but one subject, while the gastric emptying rate of fluids was decreased in all subjects. Nevertheless, 14/13CO2 excretion rates in the breath after intraduodenally administered 14C-octanoic acid and 13C-glycine, were similar in basal condition and after subcutaneous injection of octreotide. CONCLUSIONS: Subcutaneous injection of a single physiological dose of octreotide induces a marked delay in the gastric emptying of solids and liquids in young healthy volunteers. The combined 14C-octanoic acid/13C-glycine breath test is very well suited to demonstrate this effect, since the absorption and metabolism of octanoic acid and glycine remains unaltered after administration of octreotide.

Gastric emptying in hyperemesis gravidarum and non-dyspeptic pregnancy.

BACKGROUND: Emesis and hyperemesis are significant problems associated with early pregnancy. However, gastric emptying of solids has never been studied during early pregnancy in humans. AIM: To investigate gastric emptying of solids in patients recovering from hyperemesis gravidarum and in non-dyspeptic pregnant women and to compare these results with a group of healthy non-pregnant women. METHODS: Fourteen patients with hyperemesis gravidarum, 10 non-dyspeptic pregnant women and 36 non-pregnant women in the first half of the menstrual cycle underwent a gastric emptying study. Seven non-pregnant women repeated the test in the post-ovulatory period. RESULTS: Gastric emptying of solids was not significantly delayed in non-dyspeptic pregnant women compared with non-pregnant women. The emptying rate tended to be impaired in the post-ovulatory period of the menstrual cycle. Solid emptying was significantly accelerated in patients recovering from hyperemesis gravidarum, correlating well with thyroid function in the latter group. CONCLUSION: Pregnancy in humans is not associated with decreased solid gastric emptying. In subjects recovering from hyperemesis gravidarum, solid emptying is increased, correlating well with thyroid function abnormalities. Nausea and vomiting in hyperemesis are therefore probably not due to upper gastrointestinal disorders.

Effect of glutamine on the intestinal permeability changes induced by indomethacin in humans.

BACKGROUND: Long-term non-steroidal anti-inflammatory drug (NSAID) intake may induce increased intestinal permeability, eventually resulting in enteropathy. Because increased permeability might be related to cell damage resulting from energy depletion, it was hypothesized that glutamine--the major energy source of the intestinal mucosal cell--might prevent permeability changes. METHODS: The 6-h urinary excretion of 51Cr-EDTA after an oral load of 51Cr-EDTA was used in this study as a measure for intestinal permeability. Healthy volunteers underwent a series of permeability tests: (i) basal test; (ii) test following NSAID (indomethacin); (iii) test following NSAID in combination with glutamine and/or misoprostol. RESULTS: The NSAID induced increased permeability in all volunteers. Pre-treatment with glutamine (3x7 g daily, 1 week before NSAID-dosing) did not prevent the NSAID-induced increase in permeability. Multiple doses of glutamine close in time to NSAID-dosing resulted in significantly lower permeability compared to the NSAID without glutamine. Co-administration of misoprostol with the multiple-dose scheme of glutamine resulted in a further reduction in the NSAID-induced increase in permeability. CONCLUSIONS: Glutamine decreases the permeability changes caused by NSAID-dosing when it is administered close in time, and misoprostol has a synergistic effect.

The effects of smoking and indomethacin on small intestinal permeability.

BACKGROUND: Smoking modulates inflammatory bowel disease, protecting from ulcerative colitis on the one hand and worsening the course of Crohn's disease on the other. This influence might occur through changes in intestinal permeability, because permeability is increased in most patients with Crohn's disease. AIM: To study the influence of smoking on small intestinal permeability and its increase induced by indomethacin. METHODS: 50 smokers and 50 nonsmokers underwent a 51Cr-EDTA basal permeability test and the same test after challenge with indomethacin 125 mg p.o. RESULTS: Small intestinal permeability was the same in smokers (median 1.22%; IQR 1.00-1.58) and nonsmokers (1.24%; 0.94-1.66). Basal small intestinal permeability was lower in females (1.09%; 0.87-1.33) than in males (1.48%; 1.18-1.88). Indomethacin challenge increased permeability by 110% (71-141) in smokers, vs. 156% (78-220) in the nonsmokers (P=0.04). CONCLUSION: Smoking reduces the effect of NSAID on small intestinal permeability. It is therefore unlikely that the adverse effect of smoking on Crohn's disease is related to its influence on intestinal permeability.

The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study.

BACKGROUND: By temporarily suppressing the immune response, the anti-tumour necrosis factor agent, infliximab, may increase the risk of peri-operative complications. AIM: To test this hypothesis for intestinal resection in a cohort of 313 Crohn's disease patients treated with infliximab. Forty received one or more infusions prior to intestinal resection (31/40 within 12 weeks). METHODS: The post-operative events of these patients were compared with those of a control group (infliximab naive) of 39 patients adjusted for age, gender and surgical procedure. Early (10 days) and late (3 months) major or minor complications were identified. RESULTS: The incidence of early minor (15.0% vs. 12.8%) and major (12.5% vs. 7.7%) and late minor (2.5% vs. 5.1%) and major (17.5% vs. 12.8%) complications and the mean hospital stay after surgery (10.3 +/- 4.0 days vs. 9.9 +/- 5.5 days) were similar in both groups. A trend towards an increased early infection rate was found in infliximab pre-treated patients (6 vs. 1; P = 0.10), but more patients in this group received corticosteroids and/or immunosuppressives (29 vs. 16 patients; P < 0.05). CONCLUSION: The use of infliximab before intestinal resection does not prolong the hospital stay and does not increase the rate of post-operative complications.

Screening method for the determination of volatiles in biomedical samples by means of an off-line closed-loop trapping system and high-resolution gas chromatography-ion trap detection.

A method is described for the analysis of volatile organic compounds in biological matrices (faeces and urine). The technique is based on off-line preconcentration by means of a closed-loop trapping system followed by high-resolution gas chromatography-ion trap detection (HRGC-ITD) for separation and identification of the compounds. The technique has been validated for pattern recognition in faecal and urine samples from healthy volunteers. It is considered a very promising tool in metabolic research.

Effect of long-term oral glutamine supplements on small intestinal permeability in patients with Crohn's disease.

BACKGROUND: Glutamine is a major fuel and an important nitrogen source for the small intestinal cell. It plays a key role in maintaining mucosal cell integrity and gut barrier function. Increased permeability may be a factor in the pathogenesis of Crohn's disease and may be an interesting parameter in the follow-up of the disease. Therefore, the aim of this study was to examine whether oral glutamine supplements are able to restore an increased intestinal permeability in patients with Crohn's disease. METHODS: The inclusion criteria for the study were Crohn's disease and a disturbed small intestinal permeability for 51Cr-EDTA. Of 38 patients screened, 18 had an increased permeability (6 hours urinary excretion >1.1% of label recovered in urine). Fourteen patients were included in the study and were randomized to receive either oral glutamine (7 g three times per day; n = 7) or placebo (7 g glycine three times per day; n = 7) in addition to their normal treatment during a 4-week period. The study was performed in a double-blind manner. RESULTS: Baseline permeability (mean +/- SD) was 2.32%+/-0.77% dose in the glutamine group and 2.29%+/-0.67% dose in the placebo group. Permeability did not change significantly after glutamine (3.26%+/-2.15% dose) or after placebo (2.27%+/-1.32% dose). There was no significant effect on plasma glutamine, plasma glutamate, plasma ammonium, Crohn's disease activity index, C-reactive protein, or nutritional status. CONCLUSIONS: Oral glutamine supplements, in the dose administered, do not seem to restore impaired permeability in patients with Crohn's disease.

[Vitamin B12 (cobalamin)-deficiency in the elderly]. / Vitamine B12 (cobalamine)-gebrek bij bejaarden.

In order to determine the relevance of low vitamin B12 concentration in elderly persons (greater than 65 years), serum vitamin B12 levels were measured in 292 consecutive patients upon their admission to a geriatric ward. Eighty (27%) of them were anaemic (haemoglobin less than or equal to 7.14 mmol/l). The vitamin B12 concentration was not statistically different between males and females, nor between the anaemic and non-anaemic groups. Twenty-two patients (7.5%) had a low vitamin B12 level; of these, 10 had a haemoglobin concentration higher than 7.14 mmol/l and a mean corpuscular volume lower than 98 fl. In addition, serum vitamin B12 levels were also measured in 178 consecutive anaemic patients hospitalized in the same ward. Seventeen (9.5%) of them had a vitamin B12 deficiency although in 11 the MCV was lower than 98 fl. Hypersegmented polymorphonuclear leukocytes were rarely observed in the peripheral blood smear. Pernicious anaemia could only be diagnosed in 1 patient. Serum vitamin B12 estimation may be necessary to detect vitamin B12 deficiency but a low level requires additional diagnostic investigation.

Montelukast as a treatment modality for eosinophilic gastroenteritis.

Eosinophilic Gastroenteritis (EG) is a rare condition, caused by eosinophilic inflammatory infiltrates in the gastrointestinal tract. It is usually treated successfully with systemic glucocorticoids. Because of frequent relapses, however, there is need for alternatives. We describe a 38-year old man with steroid-dependent EG, who was successfully treated with montelukast, a leukotriene receptor antagonist. It inhibits leukotriene D4, an important cytokine in the inflammatory cascade. Although montelukast could not replace steroid therapy, it acted as a steroid sparing agent in our patient. Review of the literature shows that montelukast is efficient in the treatment of EG in a part of the patients. The low cost, the low number of side effects and its efficiency make it an interesting alternative in relapsing or steroid dependent EG. There is need for multicentric studies regarding the treatment of EG.

Single-centre experience on use of videocapsule endoscopy for obscure gastrointestinal bleeding in 120 consecutive patients.

BACKGROUND AND STUDY AIMS: Capsule endoscopy (CE) has become first choice for evaluation of the small bowel in case of obscure gastrointestinal bleeding (OGIB). The influence of clinical factors on CE diagnostic yield remains controversial and little is known about the exact impact of CE on management and outcome. We aimed to identify the ideal candidates for CE examination in daily practice by reviewing our own data and the available literature. PATIENTS AND METHODS: We retrospectively analyzed data of 120 consecutive patients with OGIB (33 overt - 87 occult) that underwent CE in a single centre. RESULTS: Complete evaluation of the small bowel was achieved in 82.5%, with only one case of capsule retention. The overall diagnostic yield was 47.5% and no difference was noted in the overt versus the occult group. Only the presence of cardiovascular comorbidity was associated with a statistically significant increase in diagnostic yield (p = 0,041). Arterio-venous malformation (AVM) was diagnosed most frequently in 68.4% of positive studies. Specific management alterations were made in 22 patients (18.3%) following CE, mostly guided by a positive result (91%) (p = 0,0001). CONCLUSION: In daily practice it remains very difficult to predict pathology detection rate on CE as well as to estimate the impact on further management and outcome in the individual patient. Diagnostic yield is significantly higher in patients with cardiovascular comorbidity than in those without.