Use of the laparoscopic-endoscopic approach, the so-called "rendezvous" technique, in cholecystocholedocholithiasis: a valid method in cases with patient-related risk factors for post-ERCP pancreatitis.

BACKGROUND: Several studies have shown the efficacy and effectiveness of the combined endoscopic-laparoscopic "rendezvous" technique for treatment of gallbladder and bile duct stones without complications, particularly pancreatitis. The so-called rendezvous technique consists of laparoscopic cholecystectomy standards with intraoperative cholangiography followed by endoscopic sphincterotomy (EST). The sphincterotome is driven across the papilla through a guidewire inserted by the transcystic route. This method allows easier and faster cannulation, thus avoiding papillary edema and pancreatic trauma. The aim of this study was to evaluate whether this method is effective in eliminating ductal stones and to verify whether the risk of postprocedure pancreatitis is diminished. METHODS: From January 2002 to September 2004, we enrolled 256 patients with cholecystocholedolithiasis detected by transabdominal ultrasound and magnetic resonance cholangiopancreatography. One hundred and twenty of these had one or more patient-related risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, so they were randomized into two groups of 60 patients. In group A, the patients were treated in a single step with videolaparoscopic cholecystectomy, intraoperative cholangiography, and EST during the surgical procedure with the rendezvous technique. In group B, preoperative ERCP and EST were performed by using a traditional method of bile duct cannulation. RESULTS: No cases of post-ERCP pancreatitis were observed in group A, whereas six cases of acute post-ERCP pancreatitis occurred in group B (five mild and one moderate) (p = 0.0274). No procedure-related mortality was recorded. CONCLUSION: In cholecysthocholedocholithiasis, the combined laparoscopic-endoscopic approach prevents post-ERCP pancreatitis in cases with patient-related risk factors for this complication.

Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial.

BACKGROUND: Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more. AIM: To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors. METHODS: A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 microg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (< 8 mm). RESULTS: A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant. CONCLUSION: Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.

Long-term prophylactic administration of octreotide reduces the rise in serum amylase after endoscopic procedures on Vater's papilla.

The pancreas commonly reacts to endoscopic papillosphincterotomy (EST) with a rise in serum amylase, and acute pancreatitis may also develop. The long-acting somatostatin analogue octreotide has recently been proposed for prevention of colangiopancreatography (ERCP)/EST-induced pancreatic reaction. Therefore, we tested the prophylactic effects of a subcutaneous 3-day administration of octreotide to 60 consecutive patients undergoing ERCP and EST. They were randomly allocated to receive either 200 micrograms octreotide t.i.d. for 3 days (30 cases) or placebo (control group, 30 cases) before the procedure. On the day of the examination, serum amylase levels were determined at baseline and 2, 4, 8, and 24 h thereafter. In the patients as a whole, the increases were statistically significant at 4 h (p < 0.01) and 8 h (p < 0.01). Epigastric pain occurred in 2 patients in the octreotide group and in 13 control subjects (p < 0.001). Even in some patients who had had previous episodes of relapsing pancreatitis, the rise in serum amylase was significantly lower in the octreotide group than in the control group at 4 h (p < 0.01), 8 h (p = 0.05), and 24 h (p = 0.05). Our data suggest that 3 days of prophylactic treatment with octreotide is effective for reducing the rise in serum amylase after EST/ERCP and could be proposed for patients with relapsing pancreatitis and other risk conditions before the Vater's papilla manipulation.

Gastric stromal tumour: a rare neoplasm presenting with gastrointestinal bleeding.

We report the case of a 67-year-old male patient who presented with melaena and acute anaemia. Upper digestive tract endoscopy and computed tomography of the abdomen showed a centrally ulcerated, broad-based, polypoid projection of 4 cm in the gastric antral wall. Although endoscopic biopsies were negative for neoplastic changes, the patient underwent distal gastrectomy with Billroth-I reconstruction. Histological and immunohistochemical studies on the surgical resection specimen revealed a gastrointestinal stromal tumour (GIST) of combined smooth muscle and neural type, with no evidence of mitotic activity but of uncertain biological behaviour. After serological detection, Helicobacter pylori eradication was recommended to prevent bacterial damage of the gastric remnant.

Incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis depends upon definition criteria.

BACKGROUND: The reported incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis ranges between 1.3% and 12.8%. This may likely reflect different definitions of pancreatitis and methods of data collection, rather than differences in patient populations, indications and endoscopic expertise. AIMS: The present study evaluated the incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis using different definition criteria and different data collection methods. PATIENTS: The 24-hour clinical and enzymatic course of 1185 procedures was recorded. METHODS: Pancreatic-like pain and hyperamylasaemia were evaluated either 6 to 8 hours or 24 hours after the procedure; computed tomography scan was performed in those patients with 24-hour pancreatic pain associated with hyperamylasaemia more than three times the upper normal limit. Results. Computed tomography scan findings consistent with pancreatitis were observed in 1.9% of cases, only among those patients with 24-hour pancreatic-like pain and hyperamylasaemia over five times the upper normal limit. The 6-8-hour and 24-hour pancreatic-like pain was associated with serum amylase levels at least three times higher in 11.7% and 6.6% and five times higher or more in 7.4% and 5.1%, respectively; 6-8 and 24-hour hyperamylasaemia higher than five times the upper normal limit, irrespective of pancreatic-like pain, was reported in 8.3% and in 6.9% of cases. No patients with serum amylase values lower than three times the upper normal limit had clinical symptoms. CONCLUSIONS: The incidence of post-procedure pancreatitis ranged from 1.9% to 11.7% depending on the definition criteria adopted.

Antiproteasic activity of C1 inhibitor. Therapeutic perspectives.

Kallikrein is a protease involved in the inflammatory process causing acute pancreatitis. Attempts to prevent this process with antiprotease agents have been successful in experimental animal models but disappointing in humans. We studied 40 consecutive patients undergoing endoscopic papillosphincterotomy. This procedure can induce a transient, moderate pancreatic inflammatory reaction, characterized by hyperamylasemia, which in 1-6% of the patients may evolve to acute pancreatitis. To assess the capacity of C1 inhibitor, the main physiological inhibitor of kallikrein, to prevent such complications, we pretreated 20 patients with 3000 U of C1 inhibitor plasma concentrate i.v.; 20 patients served as controls. Serum levels of amylase and functional C1 inhibitor were determined before the procedure and after 2, 4, 8 and 24 hours. Serum levels of amylase in the control group (146 +/- 21 IU) and in the group treated with C1 inhibitor (158 +/- 25 IU) were similar before treatment. Four and 8 hours after the end of the procedure, amylase levels were significantly lower (p < 0.001) in the treated group (231 +/- 46 and 355 +/- 104 IU) than in the control subjects (969 +/- 229 and 923 +/- 207 IU). After 24 hours both groups had normal amylase levels. In treated patients, functional levels of C1 inhibitor increased from 104 +/- 30 to 175 +/- 30% and remained elevated throughout the observation period. These data indicate that C1 inhibitor plasma concentrate can prevent hyperamylasemia following pancreas injury, probably, by inhibiting the kallikrein-mediated inflammatory process. C1 inhibitor might benefit patients at high risk of pancreatitis who undergo endoscopic papillosphincterotomy.

Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis.

BACKGROUND: The frequency of post-ERCP/sphincterotomy pancreatitis is between 1.3% and 7.6% in prospective studies. This range likely reflects differences in definitions of pancreatitis and methods of data collection. METHODS: To identify clinical findings and enzymatic values consistent for clinical pancreatitis at 24 hours, the post-ERCP/sphincterotomy course of 1185 procedures was prospectively recorded. Patients were evaluated for pancreatic-type pain, white blood cell count, and serum amylase before and 24 hours after the procedure; pain and amylase levels were also recorded 6 to 8 hours after the procedure. CT was performed in all patients with pain associated with amylase levels greater than 3 times normal. All patients were evaluated clinically at 48 hours. RESULTS: Pancreatic-type pain never occurred in cases with amylase levels lower than 3 times normal; it was significantly (p < 0.001) associated with amylase levels greater than 5 times normal, either 6 to 8 hours or 24 hours after the procedure. Leukocytosis and CT findings consistent with pancreatitis were observed only in patients (41.7% and 29.5%, respectively) with 24-hour amylase levels greater than 5 times normal. None of the 18 patients with pain at 24 hours and serum amylase lower than 5 times normal had symptoms that persisted at 48 hours. Twenty-five (41.7%) of the 60 patients with pain at 24 hours and amylase higher than 5 times normal had 48-hour pain at 48 hours and hyperamylasemia. CONCLUSIONS: Features consistent with clinical pancreatitis were present only among patients with pancreatic-type pain at 24 hours and amylase levels higher than 5 times normal. Additional follow-up is required for these patients.

In dyspeptic patients without gastric phase III of the migrating motor complex, Helicobacter pylori eradication produces no short-term changes in interdigestive motility pattern.

BACKGROUND: The relationship between Helicobacter pylori infection and interdigestive gastroduodenal motility in functional dyspepsia is still uncertain. Recent data from a large series documented that in dyspeptic patients without gastric phase III of the interdigestive migrating motor complex (MMC), the prevalence of bacterial infection was significantly higher. Since most H. pylori-positive dyspeptic patients have coexisting chronic gastritis, whether or not dyspepsia per se rather than bacterial colonization or chronic inflammation of the gastric mucosa may account for the observed interdigestive motility pattern is unknown. Our aim was to compare the interdigestive gastroduodenal motility pattern and dyspeptic symptoms before and 1 month after bacterial eradication in 20 H. pylori-positive dyspeptic subjects with chronic non-atrophic gastritis and without gastric phase III of the MMC, who were randomly allocated to receive eradication treatment (n = 10) or not (n = 10). METHODS: Upper GI endoscopy with duplicate biopsies in antrum and corpus, 240-min interdigestive gastroduodenal manometric recording and symptoms assessment were performed before and 1 month after the treatments; bacterial eradication was confirmed by 13C-urea breath test. RESULTS: After H. pylori eradication, neither in the incidence of antral and duodenal phase III of MMC nor in the phase II motility index values were any changes observed. Symptomatic improvement was recorded in both groups, with no significant differences between eradicated patients and controls. CONCLUSIONS: In dyspeptic patients with chronic non-atrophic gastritis and without gastric phase III of MMC, H. pylori eradication influences neither the interdigestive motility pattern nor the symptoms in the short-term period.

Interdigestive antro-duodenal motor disorders in functional dyspepsia. Associated chronic gastritis correlates with a further motor impairment.

The interdigestive antro-duodenal motor activity was studied in 12 dyspeptic patients without gastritis (group A), 12 dyspeptic patients with chronic superficial antral gastritis (group B) and 8 healthy controls (group C) by manometric recording of phases of the interdigestive motility cycle (IDMC) prolonged over 240 minutes. A significantly lower incidence of migrating motor complexes (MMCs) starting from the antrum was observed in dyspeptic patients with gastritis vs dyspeptic patients without gastritis (p = 0.02) and in these latter vs controls (p < 0.01). Likewise, the overall number of MMCs was smaller in patients with gastritis vs controls (p = 0.02). Symptomatic evaluation was performed in the two groups of dyspeptic patients, without detecting any differences in frequency and severity of individual and overall complaints. Our results confirm the role of interdigestive antral motor abnormalities in the genesis of dyspeptic syndrome and suggest that the presence of associated chronic superficial gastritis may correlate with a further motor impairment.

Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment.

OBJECTIVE: In about 30% of cases, the etiology of acute recurrent pancreatitis remains unexplained, and the term "idiopathic" is currently used to define such disease. We aimed to evaluate the long-term outcome of patients with idiopathic recurrent pancreatitis who underwent endoscopic cholangiopancreatography (ERCP) followed by either endoscopic biliary (and seldom pancreatic) sphincterotomy or ursodeoxycholic acid (UDCA) treatment, in a prospective follow-up study. METHODS: A total of 40 consecutive patients with intact gallbladder entered the study protocol after a 24-month observation period during which at least two episodes of pancreatitis occurred. All patients underwent diagnostic ERCP, followed by biliary or minor papilla sphincterotomy in cases of documented or suspected bile duct microlithiasis and sludge, type 2 sphincter of Oddi dysfunction, or pancreas divisum with dilated dorsal duct. Patients with no definite anatomical or functional abnormalities received long-term treatment with UDCA. After biliary sphincterotomy, patients with further episodes of pancreatitis underwent main pancreatic duct stenting followed by pancreatic sphincterotomy if the stent had proved to be effective. RESULTS: ERCP found an underlying cause of pancreatitis in 70% of cases. Patients were followed-up for a period ranging from 27 to 73 months. Effective therapeutic ERCP or UDCA oral treatment proved that occult bile stone disease and type 2 or 3 sphincter of Oddi dysfunction (biliary or pancreatic segment) had been etiological factors in 35 of the 40 cases (87.5%) After therapeutic ERCP or UDCA, only three patients still continued to have episodes of pancreatitis. CONCLUSIONS: Diagnostic and therapeutic ERCP and UDCA were effective in 92.5% of our cases, over a long follow-up, indicating that the term "idiopathic" was justified only in a few patients with acute recurrent pancreatitis.

Serum amylase measured four hours after endoscopic sphincterotomy is a reliable predictor of postprocedure pancreatitis.

OBJECTIVE: Acute pancreatitis is a common complication after endoscopic sphincterotomy (ES) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to detect the time when the peak of serum amylase was predictive for pancreatitis or severe hyperamylasemia, to plan a prolonged follow-up in the hospital and for outpatients. METHODS: In a prospective series of 409 consecutive patients undergoing ES, serum amylase activity was measured immediately before the procedure and 2, 4, 8, and 24 h thereafter; the data obtained at 2, 4, and 8 h were compared with those at 24 h and with the outcome. Sensitivity for long-lasting severe hyperamylasemia (more than five times the upper normal limit) and pancreatitis were also defined for all sampling times. RESULTS: At 24 h after ES, amylase was still more than five times the upper normal limit in 26 patients, 19 of whom had mild/moderate acute pancreatitis. There was a significant difference (p < 0.01 at all sampling times) between the 26 patients with 24-h severe hyperamylasemia and those with lower levels. The sensitivity of amylase measurement in detecting pancreatitis or long-lasting severe hyperamylasemia was highest at 8 h. However, the 4-h assessment appears to be a reliable predictor in practice, as more than two-thirds of cases of pancreatitis (all but one with computed tomography-confirmed pancreatitis) occurred among patients whose 4-h amylasemia was higher than five times the upper normal limit. CONCLUSIONS: Serum amylase assessment 4 h after ES minimizes the likelihood of underestimating the risk of postprocedure pancreatitis. It is therefore a reliable, cost-effective follow-up, particularly in outpatients.

Twenty-four-hour serum amylase predicting pancreatic reaction after endoscopic sphincterotomy.

BACKGROUND AND STUDY AIMS: Acute pancreatitis is still the most common complication after endoscopic sphincterotomy (ES) and cholangiopancreatography (ERCP). The aim of this study was to detect the time when the peak of serum amylase was predictive for postprocedure pancreatitis or long-lasting severe hyperamylasemia, in order to plan the follow-up of patients. METHODS: Serum amylase activity was measured in a prospective series of 409 consecutive patients after ES, immediately before ES and two, four, eight and 24 hours thereafter; the two, four and eight-hour data were compared with those at 24 hours and with the outcome. Evaluation was done separately for the 198 cases with pancreatic duct opacification and for the 202 cases at high risk for postprocedure pancreatitis. RESULTS: Twenty-four hours after ES, amylase was still more than five times the upper normal limit in 26 patients, associated with pancreatic-like pain in 19 of them (mild/moderate pancreatitis) and asymptomatic in the remaining seven (long-lasting severe hyperamylasemia). There was a significant difference at all sampling times between the 26 patients with 24-hour severe hyperamylasemia and those with the lower level. Although the sensitivity of amylase measurement in detecting pancreatitis was highest at eight hours, in practice the four-hour assessment appears a reliable predictor. Almost all patients with serum amylase levels more than five times the upper normal limit at four, eight and 24 hours had had pancreatic duct opacification. In contrast, patient-related risk factors for postprocedure pancreatitis did not play a significant role in the present series. CONCLUSIONS: Serum amylase assessment four hours after ES is a reliable, cost-effective follow-up and minimizes the likelihood of underestimating the risk of post-procedure pancreatic reaction. It should be recommended particularly in out-patients and when pancreatic duct opacification has occurred.

Different interdigestive antroduodenal motility patterns in chronic antral gastritis with and without Helicobacter pylori infection.

Fasting antroduodenal motor activity was studied in 15 dyspeptic patients with chronic superficial antral gastritis and Helicobacter pylori infection (group A), 10 dyspeptic patients with chronic superficial antral gastritis without Helicobacter pylori infection (group B), and eight healthy control subjects (group C) by manometric recording of phases of the interdigestive migrating motor complex (MMC) prolonged over 240 min. A significantly lower incidence of activity fronts (phase III of MMC) starting from the antrum was observed in patients with gastritis and Helicobacter pylori infection vs patients without bacterial colonization (P = 0.013) and in these latter vs control subjects (P = 0.013). Likewise, the overall number of activity fronts was smaller in patients with gastritis than in healthy subjects (P = 0.034). Symptomatic evaluation was performed in the two groups of dyspeptic patients, without detecting any differences in frequency and severity of complaints. Our results show a significant reduction in the occurrence of interdigestive antral phase III of MMC in chronic gastritis associated with Helicobacter pylori infection, suggesting a possible relationship between fasting motility and bacterial colonization.

Longterm oral cisapride improves interdigestive antroduodenal motility in dyspeptic patients.

We have evaluated the effect of cisapride on interdigestive antroduodenal motility during a prolonged oral therapy in 20 consecutive dyspeptic subjects. Individuals with less than two migrating motor complexes (MMCs) starting from the antral region in 240 minutes and without evidence of upper gastrointestinal tract diseases were randomly treated with either cisapride (10 cases), or placebo (10 cases) for 15 days. Computerised manometry of antroduodenal region was performed for 240 minutes, in basal conditions and on the 15th day of therapy. Symptomatic evaluation of patients was also performed before and after treatment. After cisapride administration, a significant increase in the incidence of antral migrating motor complexes was noticed (p = 0.022); likewise, the motility index, calculated for phase-2 periods, appeared to be significantly higher both in the antrum and in the duodenum (p less than 0.001). Symptomatic improvement was observed in both groups, with a hardly significant (p = 0.049) reduction of dyspeptic symptoms severity only but not of frequency in cisapride treated patients v controls. We conclude that longterm oral therapy with cisapride improves interdigestive antroduodenal motor activity.

Combined endoscopic and extracorporeal shock-wave treatment in difficult bile duct stones: early and long-term results.

Endoscopic papillosphincterotomy (EPT) has become a well-established therapeutic procedure in the management of common bile duct stones; however, in difficult cases with large stones or anatomic conditions limiting the amplitude of the sphincteric section, the procedure may fail. In these cases, the association with extracorporeal shock-wave lithotripsy (ESWL) has proved to be helpful. Twenty out of 21 patients in whom the endoscopic approach failed because of the presence of large stones in the biliary tree (15 cases) or anatomic conditions (5 cases) underwent ESWL treatment. Stone fragmentation was achieved in 18 of the 20 treated patients (90%), with spontaneous clearing of the fragments in 10 patients after ESWL sessions and in another 2 patients within three months. In 6 cases the residual fragments were extracted by means of endoscopy. The combined procedures were therefore successful in all the 18 cases in which stone fragmentation was obtained. Complications occurred in two cases after ESWL treatment (asymptomatic pancreatic reaction and severe bleeding from the papillary area). Clinical, ultrasound and biochemical evaluations at 6 and 12 months documented a normal condition in all but two treated subjects.

Controlled trial of different dosages of octreotide in the prevention of hyperamylasemia induced by endoscopic papillosphincterotomy.

Pancreatic reaction after endoscopic papillosphincterotomy (EPT) is a common event occurring in about 70% of cases. Acute pancreatitis may also develop in 1%-6% of cases. Previous attempts to prevent this reaction with an inhibitor of exocrine pancreatic secretion such as somatostatin provided conflicting results. The somatostatin long-acting analogue octreotide has recently proposed for the prevention of ERCP/EPT-induced pancreatic reaction. Therefore we tested the prophylactic effect of a subcutaneous administration of octreotide in two different dosages in 60 consecutive patients undergoing EPT for common bile duct stones and benign papillary stenosis. They were given either octreotide 0.2 mg (20 cases), or octreotide 0.1 mg (20 cases), or placebo (20 cases) before the procedure. Serum amylase levels were determined at baseline and 2, 4, 8 and 24 hours thereafter. The differences were statistically significant at 2 hours between subjects pretreated with octreotide 0.2 mg and control subjects (p = 0.01); at 4 and 8 hours after the procedure between both octreotide-treated groups and control subjects (octreotide 0.1 mg: p < 0.05, at 4 and 8 hrs; octreotide 0.2 mg: p = 0.01, at 4 hrs, and p < 0.01, at 8 hrs). In patients with previous episodes of relapsing pancreatitis, the increase in serum amylase was significantly reduced in the octreotide 0.2 mg group vs control group, at 4 hrs (p < 0.05) and 8 hrs (p < 0.05). Our data suggest that octreotide 0.2 mg has a greater prophylactic efficacy than 0.1 mg in reducing pancreatic reaction after EPT.

The correlation in dyspeptic patients of Helicobacter pylori infection with changes in interdigestive gastroduodenal motility patterns but not in gastric emptying.

BACKGROUND: Available data conflict regarding the possible relation between chronic gastritis, Helicobacter pylori (Hp), and gastric motor disorders in nonulcer dyspepsia. The aim of this study, therefore, was (1) to evaluate both gastroduodenal fasting motility and gastric emptying in subjects with functional dyspepsia, with and without gastritis, and (2) to correlate the motility pattern to Hp infection. MATERIALS AND METHODS: Thirty-eight patients were studied, 20 positive for Hp infection (15 with gastritis) and 18 Hp-negative (8 with gastritis). All the subjects underwent 240-minute manometric recording of the interdigestive migrating motor complex, with evaluation of gastric and duodenal motility pattern and scintigraphic study of gastric emptying. RESULTS: Whereas gastric emptying half-time did not differ in the subgroups of dyspeptic patients, a significant reduction of gastric phase IIIs of the migrating motor complex was detected between Hp-positive and Hp-negative subjects, both in overall patients (p < .01) and in patients with gastritis (p < .05). CONCLUSION: Hp infection seems to be related to a reduction of interdigestive gastric activity fronts, though it does not affect gastric emptying. The conflicting data regarding gastric emptying and interdigestive motility in Hp infection could be explained as probably investigating two different functional aspects.

Effectiveness of cisapride in gastric ulcer. Results of a double-blind randomized trial versus ranitidine and versus cisapride plus ranitidine.

Among the factors involved in the pathogenesis of gastric ulcer, the reduced clearing capacity of the stomach seems to play an important role. On this basis, cisapride, which improves gastrointestinal motility, enhances gastric emptying, and prevents duodenogastric reflux, may be effective in the treatment of the gastric ulcer. We randomly allocated 60 consecutive patients, with uncomplicated antral gastric ulcer (diameter 5-25 mm), into three groups of treatment: cisapride 20 mg b.i.d. (C), ranitidine 150 mg b.i.d. (R), cisapride 20 mg b.i.d. + ranitidine 150 mg b.i.d. (C+R). Endoscopic examination with biopsy specimens was performed on admission, after 4 weeks and (if ulcer not healed) after 8 weeks of therapy. Three patients were lost to follow-up (two in C and one in C+R), and three were withdrawn, due to malignant ulcer (one case in R) or to side effects (one case of diarrhea in C, one case of headache in C+R). Healing rates at 4 weeks were 41.1% in C, 52.6% in R, and 50.0% in C+R; at 8 weeks they were 88.2% in C, 89.4% in R, and 94.4% in C+R. Though the lack of a placebo arm makes final considerations difficult, the results were similar in all three groups, with no evident differences. In conclusion, therapy with cisapride appears as effective as H2-blocker alone or combined treatments in healing benign gastric ulcer.

Manometric evaluation of the interdigestive antroduodenal motility in subjects with fasting bile reflux, with and without antral gastritis.

The interdigestive antroduodenal motor activity was studied in 15 patients with bile reflux without gastritis (group A), 17 with bile reflux and chronic antral superficial gastritis (group B) and in nine healthy controls (group C), by manometric recording of phases of the interdigestive motility complex (IDMC) over 240 minutes, or until two consecutive migrating motor complexes (MMCs) had been recorded, whichever the shorter. In the patients with bile reflux the occurrence of MMCs was decreased and median duration of the IDMC was significantly prolonged (group A = 162.5 min; group B = 185.0 min), compared with controls (group C = 92.0 min; p less than 0.01 v groups A and B). There were no differences in motility pattern between patients with and without gastritis, suggesting that motor abnormalities are not caused by gastritis, but may precede its occurrence. Delayed occurrence of motor activity fronts increases duodenogastric reflux, but correlation with gastric mucosal lesions was not shown, suggesting that other mechanisms are involved.