Crohn's disease and Takayasu's arteritis: is this association difficult to find out?

Takayasu's arteritis is rarely reported associated with Crohn's disease in the English world literature. A case of Takayasu's arteritis type V in a young female affected by Crohn's disease is presented and the pathophysiology mechanism, and the clinical and diagnostic aspects are underlined. Surgical strategy is discussed.

Plasma chromogranin A in patients with autoimmune chronic atrophic gastritis, enterochromaffin-like cell lesions and gastric carcinoids.

OBJECTIVE: In atrophic body gastritis (ABG) chronic hypergastrinaemia stimulates enterochromaffin-like (ECL) cell proliferation with development of cell hyperplasia, dysplasia and possibly type-1 gastric carcinoids. As circulating chromogranin A (CgA) levels are a marker of neuroendocrine tumours, we evaluated the clinical usefulness of CgA assay in ABG patients to detect those with carcinoids. DESIGN AND METHODS: Plasma CgA levels were measured using a commercial ELISA in 45 healthy volunteers, nine patients with type-1 gastric carcinoids and 43 consecutive ABG patients (21 without and 22 with ECL cell hyperplasia/dysplasia). RESULTS: CgA levels were significantly higher in ABG patients with and without gastric carcinoids than in healthy subjects (P < 0.001). The highest values occurred in patients with carcinoids (median (interquartile range): 58.1 (44.5-65.3) U/l) and with ECL cell hyperplasia/dysplasia (35.5 (31.8-48.65) U/l) but there were no significant differences in CgA among the various subgroups of ABG patients classified according to ECL cell status. Nevertheless, in ABG patients without carcinoids CgA values correlated with the presence and severity of ECL cell lesions (r(s) = 0.428, P < 0.01). The sensitivity and specificity of the CgA assay in identifying patients with carcinoids were 100 and 23% respectively. CONCLUSIONS: CgA plasma levels reflect the histological degree of ECL cell lesions in patients with ABG but the assay specificity is too low to detect among these patients those with gastric carcinoids.

Increased prevalence of celiac disease in patients with dyspepsia.

BACKGROUND: Although 30% to 40% of patients with celiac disease (CD) (which affects 1 in 200 individuals) have dyspeptic symptoms, there is a lack o data concerning the prevalence of CD in patients with dyspepsia. METHODS: In this prospective series, we enrolled all consecutive outpatients undergoing endoscopy of the upper gastrointestinal tract for dyspepsia at our centers between January and June 1998. The exclusion criteria were age younger than 12 years, workup or follow-up of an already known disease of the gastrointestinal tract, suspected CD, malabsorption, and/or iron-deficiency anemia. RESULTS: Of the 3019 patients who were evaluated, 517 (17%) were eligible for the study. Endoscopic findings suggested CD in 5 cases. Celiac disease was histologically diagnosed in 6 patients (5 women and 1 man; mean age, 31.3 years; age range, 20-46 years), 3 of whom had a normal endoscopic pattern and 3 of whom had an endoscopic pattern that was consistent with CD. In the patients with histologically diagnosed CD, antiendomysium antibody positivity supported the diagnosis. The relative risk for CD was 2.32 (95% confidence interval, 1.06-5.07) in comparison with the general population and higher among females (3.22; 95% confidence interval, 1.37-7.56). CONCLUSIONS: The present results indicate that the prevalence of CD in patients with dyspepsia is twice that of the general population. Thus, serological screening for CD should be considered in the early workup of these patients to allow diagnosis and treatment of an eminently treatable disease.

Omeprazole versus famotidine in the short-term treatment of duodenal ulcer disease.

The efficacy and safety of omeprazole, in 241 patients with active recurrent duodenal ulcer from 21 Italian centres, was studied in a multicentre double-blind randomized trial comparing 20 mg omeprazole o.m. or 40 mg famotidine nocte with endoscopic examination, symptom recording, laboratory screening and gastrin assay. In a per protocol analysis, the duodenal ulcer healing rates for omeprazole and famotidine, documented by endoscopy, were 62% (68/109) and 33% (39/117) after 2 weeks of treatment (P less than 0.001), 92% (96/104) and 80% (86/108) cumulative after 4 weeks (P less than 0.05), and 99% (102/103) and 92% (96/104) after 6 weeks (P less than 0.05), respectively. The results of this trial demonstrate that 20 mg omeprazole o.m. is superior to 40 mg famotidine nocte in duodenal ulcer healing.

Plasma pancreatic polypeptide response to secretin.

OBJECTIVE: Intravenously administered secretin stimulates pancreatic polypeptide (PP) release in patients with endocrine enteropancreatic tumors, but data in patients with nontumorous disorders are controversial. Therefore, we aimed to evaluate the plasma PP pattern after secretin administration in healthy subjects and in patients with gastroduodenal diseases investigated for recurrent ulcer disease and/or hypergastrinemia. METHODS: Synthetic secretin was given as an intravenous bolus (2U/kg) in ten patients with Zollinger Ellison syndrome, ten with duodenal ulcer, ten with atropic gastritis and ten healthy volunteers. Blood samples were taken before and at regular intervals for 30min after secretin injection. Plasma PP and gastrin levels were measured by radioimmunoassay. RESULTS: Secretin promptly and significantly (P<0.01) increased PP plasma levels in all groups of subjects without any differences in peak values. There were no significant correlations between PP and gastrin plasma levels. CONCLUSIONS: Secretin at pharmacological doses is a powerful stimulus for PP release.

Clinical, biochemical and histological abnormalities in adult celiac patients on gluten-free diet.

Twenty-six adult patients with histologically confirmed celiac disease on gluten-free diet after apparent disease remission were reexamined at 4-6 months intervals for a mean period of 55.4 months (range 13-137). Eight patients remained clinically well with normal blood tests. Eighteen patients had clinical or biological abnormalities. Eleven patients reported repeated episodes of meteorism and abdominal pain and/or diarrhea which disappeared in 2 after lactose withdrawal. Iron deficiency and macrocytic anemia were sometimes observed in 5 and 4 patients respectively. Altered plasma calcium, phosphorus and alkaline phosphatase and/or bone densitometry findings were detected in 7 patients. Seventeen patients (12 presenting some of the above findings) agreed to a repeat biopsy: 13 of these showed grade II and 4 grade III abnormalities. Although adult celiac patients may show marked improvement during gluten-free diet, minor clinical disturbances and biochemical abnormalities may still be present.

[Problems of diagnostic origin in tumors of the small intestine developing in the smooth muscle. Report on 7 cases]. / Problemi di origine diagnostica nei tumori dell'intestino tenue ad origine dalla muscolatura liscia. Osservazioni su 7 casi.

The smooth muscle tumors of the small intestine are particularly interesting for the difficulty and the delay of their diagnosis. This usually happened for the poor and indefinite symptomatology and the problematic exploration of the organ. Starting up from the observation of 7 patients between 1986 and 1989 the Authors critically examined the literature about this problem to value the diagnostic opportunities of the principal clinical exams, suggesting as resolutive investigation, if indicated, the angiographic selective study of the visceral abdominal arteries.

Treatment of 'cimetidine-resistant' chronic duodenal ulcers with ranitidine or cimetidine: a randomised multicentre study.

Forty patients with endoscopically proven persistent duodenal ulcer who had been treated for six weeks with cimetidine (1 g/day) were randomly allocated to receive a further six weeks' treatment with cimetidine (1 g/day) or ranitidine (300 mg/day). Ulcers healed in 12 of 19 patients given cimetidine (63%) and in 13 of 21 given ranitidine (62%); two patients on cimetidine and two on ranitidine dropped out. In the unhealed ulcer group the ulcer size was reduced in most patients. There was no change in basal acid output, peak acid output, plasma gastrin and pepsinogen I levels after either treatment. Clinical data, gastric function tests, and endoscopic features did not predict ulcer healing. Both treatments were effective in the relief of pain: 72% of patients with unhealed ulcers were asymptomatic at the end of the trial.

Mesenteric lymph node cavitation: a rare hallmark of celiac disease.

The cavitation of mesenteric lymph nodes represents a rare complication of celiac disease (only 30 reported cases) whose pathogenesis remains to be clarified. We here report the case of a 67-year-old woman referred to us because of a malabsorption syndrome lasting for 2 years; massive lymph node enlargement and cavitation were detected by means of ultrasonography and a computed tomography scan. Celiac disease was definitely diagnosed by means of duodenal histology, and a laparotomy was performed to exclude an underlying T-cell lymphoma. The adoption of a gluten-free diet led to a rapid and dramatic improvement in the clinical and histologic picture and normalization of the size of the lymph nodes. Celiac disease should be considered in the differential diagnosis of all patients with mesenteric lymph node cavitation.

Duodenal ulcers preceding cervical tuberculous lymphadenitis.

Lymphadenitis is the most common presentation of extra pulmonary tuberculosis, whereas gastrointestinal localization, particularly duodenal involvement, is rare. We report a case of extra pulmonary tuberculosis with association between cervical lymphadenitis and duodenitis with multiple ulcers, not responsive to treatment with protonic pump inhibitors, in a human immunodeficiency virus-seronegative adult woman of Eritrean origin. Clinical patterns of duodenal TB, diagnostic difficulties and aetiopathogenesis are discussed according to the literature. In this case report it is suggested that tuberculous infection must be considered when duodenal ulcers fail to respond to proton pump inhibitors, especially when the patient comes from an endemic area.

Prevalence of hypertransaminasemia in adult celiac patients and effect of gluten-free diet.

The prevalence of hypertransaminasemia and the effect of gluten-free diet (GFD) were evaluated in 158 consecutive adult celiac patients, 127 women and 31 men, aged 18 to 68 years (mean, 32). At diagnosis, 67 patients (42%) had raised aspartate and/or alanine transaminase levels (AST and ALT; mean, 47 IU/L, range, 30 to 190; and 61 IU/L, range, 25 to 470, respectively), whereas 91 patients had normal liver function tests (LFT). Patients with and without hypertransaminasemia were comparable for epidemiological data, body mass index (18.5 vs. 19.6), and severity of intestinal histological involvement. All patients were given a strict GFD and were followed for 1 to 10 years (median, 4). At 1 year, a highly significant improvement in intestinal histology was observed in both groups (P < .0001). In the 67 patients with raised transaminase levels body mass index (BMI) also increased significantly (from 18.5 to 21.0, P < .001), and transaminase levels normalized in 60 (95%). In the other seven cases liver biopsy showed fatty infiltration in two and chronic active hepatitis (CAH) in the other five, related to chronic infection with hepatitis B virus in three and hepatitis C virus in one, and to autoimmune type in the fifth. We conclude that in adult celiac patients elevated serum transaminases are a frequent finding and normalize in most cases after GFD. When they persist, liver biopsy is mandatory to further investigate hepatic involvement, which is our series was mainly attributable to CAH.

Giant coeloadenoma of the kidney.

A case of giant adenoma of the kidney is described with special regard to the histological and ultrastructural features of the neoplastic cells. The tumoral proliferation consisted mainly of clear and dark epithelial cells among which cells of a third type are occasionally interspersed. A possible origin of this last population from the coelomatic lining is suggested and the hypothesis of a dysontogenetic nature of the neoplasia is purposed.

Reevaluation of duodenal endoscopic markers in the diagnosis of celiac disease.

BACKGROUND: Loss or reduction of duodenal folds, scalloping of Kerkring folds and a micronodular or mosaic duodenal mucosal pattern have been described in celiac disease (CD), endoscopic findings that are considered reliable in the diagnosis of this disorder. However, most data have been obtained in patients with suspected or certain disease. We assessed the accuracy of the above markers in diagnosing CD in patients with nonulcer dyspepsia. METHODS: In this prospective study, in 705 consecutive dyspeptic patients (284 men, 421 women, mean age 51 +/- SD 15.8 years) duodenal biopsies were obtained only in the presence of typical endoscopic markers, whereas in another 517 (207 men, 310 women, mean age 49.9 +/- SD 16 years) duodenal biopsies were done irrespective of macroscopic findings. CD was diagnosed histologically and on the basis of positive antiendomysium antibody. RESULTS: Endoscopic markers were found in 4 patients of the first group but CD was ruled out. In the second group 5 patients had an endoscopic pattern that was consistent and CD was diagnosed in 3, whereas 3 others with normal endoscopic findings were eventually diagnosed as having CD. Endoscopic markers had a sensitivity of 50% and a specificity of 99.6% (95% CI [11.8, 88.2 and 98.6, 99.9], respectively) with positive and negative predictive values of 60% and 99.4%, respectively. CONCLUSION: The accuracy of endoscopic markers in the diagnosis of CD must be reevaluated in relation to the characteristics of the population studied.

Plasma somatostatin levels in patients with chronic idiopathic intestinal pseudo-obstruction.

OBJECTIVES: Somatostatin participates in the control of gut motility. Recently, somatostatin analogs have been proposed as therapeutic agents for chronic intestinal pseudo-obstruction, although the endogenous somatostatin pattern has never been assessed in this syndrome. We aimed to evaluate fasting and postprandial plasma somatostatin levels in patients with chronic idiopathic intestinal pseudo-obstruction (CIIP). METHODS: We studied eight patients with CIIP and 10 healthy volunteers. Blood samples were taken at regular intervals while patients and subjects fasted and during the 3 h after a standard solid/liquid meal (550 kcal) had been eaten. Somatostatin was measured by radioimmunoassay. RESULTS: Fasting somatostatin levels were normal, whereas postprandial peptide responses were markedly impaired or even absent in patients with CIIP. CONCLUSIONS: An impaired postprandial somatostatin response in patients with CIIP seems to be characteristic of this heterogenous disorder. Whether the lack of somatostatin response to a meal identifies patients with severe gut dysmotility for whom treatment with somatostatin analogs would be useful remains to be verified.

Secretin-induced gastrin response in the Zollinger-Ellison syndrome and chronic duodenal ulcer patients before and after cimetidine treatment.

A secretin provocative test was performed in 16 patients with chronic duodenal ulcer and in five patients with the Zollinger-Ellison syndrome. In four chronic duodenal ulcer patients a second secretin test was done during acute iv cimetidine administration. There were only slight variations of gastrin compared with the first test. A third test was done on the same four chronic duodenal ulcer patients after 1 month's po cimetidine treatment (1 g/day); gastrin at 0 time was significantly higher than in the previous two tests (p less than 0.01). Integrated gastrin response after secretin was significantly lower in the third test than in the first (p less than 0.05). In two Zollinger-Ellison syndrome patients treated with 1.0 and 1.4 g/day cimetidine for 3 months, gastrin at 0 time was not markedly increased, whereas compared with the first test gastrin levels were higher at each time after secretin. These data suggest that previous cimetidine treatment does not alter, and may even increase, the diagnostic sensitivity of the secretin test.

Effects of somatostatin infusion in four patients with malignant carcinoid syndrome.

Somatostatin (4 micrograms/min, cyclic form) was infused for 24 h on six occasions in four patients with carcinoid ileal tumor and multiple liver metastases. During infusion, spontaneous flushes and/or diarrhea were markedly reduced with a return to the pretreatment pattern on the next day. Urinary 5-hydroxyindole acetic acid excretion and plasma gastrin were not significantly changed, whereas plasma insulin presented the expected decrease and rebound. These results confirm that carcinoid symptoms are somatostatin-sensitive but do not provide evidence that serotonin or gastrin play a major role in inducing these symptoms.

Patterns of gastrin secretion in patients with nonfunctioning pituitary adenomas.

The presence of gastrin in pituitary tissue as well as gastrin hypersecretion by some pituitary adenomas have been documented using different methodological approaches. In the present study, serum gastrin levels were measured in 93 patients with nonfunctioning pituitary adenoma, i.e. a condition lacking a reliable marker of the disease. Elevated gastrin levels (85-2, 180 ng/l; normal range: 15-80 ng/l) were found in 14/93 patients (15%), the highest values being observed in one patient with MEN I syndrome. In all but MEN I hypergastrinemic patient, a severe gastric hypochlorhydria (Basal Acid Output: 0.04 +/- 0.1 mmol H+/h) unresponsive to pentagastrin (Maximum Acid Output: 0.1 +/- 0.2 mmol H+/h) was seen. Secretin injection caused gastrin to increase in the patient with MEN I and in another hypergastrinemic patient. Antiparietal cells autoantibodies were positive in 3/11 patients. No changes in gastrin concentrations were found after administration of several agents usually employed in the evaluation of pituitary function, except a significant gastrin reduction after octreotide injection. In two hypergastrinemic patients who underwent pituitary adenomectomy, the high gastrin levels did not change after surgery. Finally, gastrin was undetectable in the culture media of 15 pituitary adenomas surgically removed from both normo- and hypergastrinemic patients and immunocytological studies of tumor cells did not show any gastrin staining. In conclusion, although in patients with pituitary adenomas serum gastrin evaluation is indicated in order to document the presence of a MEN I syndrome, the present data show that high gastrin levels cannot be taken as a specific marker of nonfunctioning pituitary adenomas unless the peripheral origin of hypergastrinemia is excluded.

Stainable iron in gastric and duodenal mucosa of primary hemochromatosis patients and alcoholics.

The presence of iron in gastric and duodenal mucosa was investigated with Perl's stain in endoscopic biopsies from 13 patients with overt primary hemochromatosis, 10 chronic heavy alcohol abusers, and 10 patients with nonulcer dyspepsia. In the primary hemochromatosis patients marked iron deposition was found in cells at the base of glands in the gastric body and antrum in nine cases, and in crypt cells and Brunner gland cells of the duodenum in six. Iron was detected in the lamina propria of the stomach in five and duodenum in four cases. A similar distribution of iron overload, usually of lesser degree, was also observed in five alcoholics. Serum ferritin levels and the degree of gastric and/or duodenal iron deposits did not correlate in either hemochromatosis patients or alcoholics. No gastric or duodenal siderosis was observed in nonulcer dyspepsia cases. The absence of gastric and duodenal stainable iron in some hemochromatosis patients and its presence in some alcoholics suggests that the diagnostic value of upper gastrointestinal biopsy in primary hemochromatosis is limited.