Showing papers in "Journal of Clinical Gastroenterology in 2004"

Global epidemiology of hepatitis B virus.

Abstract: The burden of hepatitis B virus (HBV) disease and efforts to control infection will determine the future size of the population requiring treatment of HBV infection. To quantify the current prevalence of HBV infection and to reexamine the epidemiology of HBV infection, a structured review was conducted that focused on available primary literature for over 30 countries worldwide. The prevalence of chronic HBV infection continues to be highly variable, ranging over 10% in some Asian and Western Pacific countries to under 0.5% in the United States and northern European countries. The current global estimate of the number of HBV infected individuals is 350 million. Routes of transmission include vertical (mother to child or generation to generation through close contact and sanitary habits), early life horizontal transmission (through bites, lesions, and sanitary habits), and adult horizontal transmission (through sexual contact, intravenous drug use, and medical procedure exposure) and are evident to varying degrees in every country. Younger age at acquisition of infection continues to be the most important predictor of chronic carriage. However, the choice of serologic markers, temporal influences, and representativeness of the study population limit comparability of HBV seroprevalence results. HBV vaccination programs will decrease the future global burden of HBV infection and evidence of reduced burden is mounting in country-specific populations, but vaccination programs have still not been implemented in all countries, thereby maintaining reservoirs of infection and continued HBV transmission. Regardless of vaccination, large numbers of persons are infected with HBV or will become infected. Preventing the most severe HBV disease consequences in infected individuals, such as cirrhosis and hepatocellular carcinoma, will require appropriate therapeutic agents.

Bacteriotherapy Using Fecal Flora: Toying With Human Motions

Abstract: The intestinal flora may play a key role in the pathogenesis of certain gastrointestinal (GI) diseases. Components of bowel flora such as Lactobacillus acidophilus and Bifidobacterium bifidus have long been used empirically as therapeutic agents for GI disorders. More complex combinations of probiotics for therapeutic bacteriotherapy have also recently become available, however the most elaborate mix of human-derived probiotic bacteria is, by definition, the entire fecal flora. Fecal bacteriotherapy uses the complete normal human flora as a therapeutic probiotic mixture of living organisms. This type of bacteriotherapy has a longstanding history in animal health and has been used sporadically against chronic infections of the bowel, especially as a treatment of last resort for patients with severe Clostridium difficile syndromes including recurrent diarrhea, colitis, and pseudomembranous colitis. Encouraging results have also been observed following infusions of human fecal flora in patients with inflammatory bowel disease, irritable bowel syndrome, and chronic constipation. The therapeutic use of fecal bacteriotherapy is reviewed here and possible mechanisms of action and potential applications explored. Published reports on fecal bacteriotherapy are few in number, and detail the results of small uncontrolled open studies and case reports. Nevertheless, given the promising clinical responses, formal research into fecal bacteriotherapy is now warranted.

The first prebiotics in humans: human milk oligosaccharides.

Abstract: The development of intestinal microflora in newborns is strictly related to the kind of feeding Breast-fed infants, unlike the bottle-fed ones, have an intestinal ecosystem characterized by a strong prevalence of bifidobacteria and lactobacilli Data available so far in the literature show that, among the numerous substances present in human milk, oligosaccharides have a clear prebiotic effect They are quantitatively one of the main components of human milk and are only partially digested in the small intestine, so they reach the colon, where they stimulate selectively the development of bifidogenic flora Such results have been recently proved both by characterization of oligosaccharides in breast-fed infant feces and by the study of intestinal microflora using new techniques of molecular analysis, confirming that human milk oligosaccharides represent the first prebiotics in humans

Probiotics in the treatment of irritable bowel syndrome.

Abstract: Irritable Bowel Syndrome (IBS) may be diagnosed on the presence of symptoms, according to Rome II criteria and some studies have shown that abnormal colonic fermentation may be an important factor in the development of symptoms in some patients with IBS. Since the fermentations of substrates by the intestinal flora may play a key role in the use ofprobiotics in the treatment of IBS, fifty patients (24 males,26 females), mean age 40 years (range = 26-64 years) with IBS, according to Rome II criteria, were enrolled into the study after informed consensus. Patients were randomly assigned to receive either the active preparation containing Lactobacillus Plantarum LPO 1 and Bifidocterium Breve BRO both at a concentration of 5 × 10 9 CFU/ml, or placebo powder containing starch identical to the study product, for 4 weeks. To evaluate treatment efficacy two different scores were considered: Pain score in different abdominal locations after treatment decreased in probiotics group of 38% versus 18% (P < 0.05) of placebo group after 14 days and of 52% versus 11% (P < 0.001) after 28 days. The severity score of characteristic IBD symptoms significantly decreased in probiotic group versus placebo group after 14 days 49.6% versus 9.9% (P < 0.001) and these data were confirmed after 28 days (44.4% versus 8.5%, P < 0.001). In conclusion, short-term therapy with Lactobacillus PlantarumLP0I and Bifidocterium Breve BRO may be considered a promising approach to the therapy for IBS.

Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life.

Abstract: To understand the nature of bowel disturbance in patients with dyssynergia, we prospectively examined demographics, stool patterns, and quality of life by administering a 31-item questionnaire to 120 patients who fulfilled symptomatic and manometric criteria for dyssynergia (Rome II). Data from 118 subjects (M/F = 27/91) was analyzed. Eighty four percent of patients reported excessive straining, and 76% reported feeling of incomplete evacuation; 9.7% had no urge to defecate. Abdominal bloating was reported by 74%. More women than men reported infrequent bowel movements and need to strain excessively (P < 0.05). Forty eight percent of patients, more women (P < 0.05) than men used digital maneuvers to evacuate. Hard stools was reported by 60% of women and 41% of men. Sexual abuse was reported by 22%; 21% were women (P = 0.02). Physical abuse was reported by 32%. Bowel problem adversely affected family life in 33%, sexual life in 56%, work life in 69% and social life in 76% of patients. Most patients with dyssynergia reported an excessive need to strain, feeling of incomplete evacuation and abdominal bloating and one half used digital maneuvers. It significantly affected quality of life, particularly in women.

Bacillus clausii probiotic strains: antimicrobial and immunomodulatory activities.

Abstract: The clinical benefits observed with probiotic use are mainly attributed to the antimicrobial substances produced by probiotic strains and to their immunomodulatory effects. Currently, the best-documented probiotic bacteria used in human therapy are lactic acid bacteria. In contrast, studies aiming to characterize the mechanisms responsible for the probiotic beneficial effects of Bacillus are rare. The current work seeks to contribute to such characterization by evaluating the antimicrobial and immunomodulatory activities of probiotic B. clausii strains. B. clausii strains release antimicrobial substances in the medium. Moreover, the release of these antimicrobial substances was observed during stationary growth phase and coincided with sporulation. These substances were active against Gram-positive bacteria, in particular against Staphylococcus aureus, Enterococcus faecium, and Clostridium difficile. The antimicrobial activity was resistant to subtilisin, proteinase K, and chymotrypsin treatment, whereas it was sensitive to pronase treatment. The evaluation of the immunomodulatory properties of probiotic B. clausii strains was performed in vitro on Swiss and C57 B1/6j murine cells. The authors demonstrate that these strains, in their vegetative forms, are able to induce NOS II synthetase activity, IFN-γ production, and CD4 T-cell proliferation.

Prebiotics in infant formulas.

Abstract: Background: The intestinal flora of breast-fed infants is an important physiologic factor in the function of the gut and in the development of the immune system. The current research is part of a group of studies performed to answer the question whether a bovine milk formula supplemented with a prebiotic mixture from galactooligosaccharides and fructooligosaccharides can stimulate an intestinal flora similar to that of breast-fed infants. Methods: The prebiotic effect of the oligosaccharide mixture was tested in preterm and term infants by measuring fecal flora using plating as well as fluorescent in situ hybridization techniques. The effect of the oligosaccharides on the bacterial metabolism was studied by measuring short-chain fatty acid production in vitro and the short-chain fatty acid pattern in the stools of a group of term infants. Results: The oligosaccharide mixture increases significantly the number of bifidobacteria and reduces the number of pathogens in term as well as in preterm infants when compared with a group of infants fed an unsupplemented formula. Using a concentration of 0.8 g oligosacchrides/100 mL formula, the amount of bifidobacteria is similar to that typical of breast-fed infants. In vitro, the short-chain fatty acids produced by the mixture of oligosaccharides under study were similar to those produced by the human milk oligosaccharides fraction. In clinical trials the pattern of fecal short-chain fatty acids in infants fed the oligosaccharide mixture was similar to that of breast-fed infants but was significantly different from that of a group of infants fed with an unsupplemented formula. Additionally, the fecal pH was significantly higher in the group fed an unsupplemented formula than in the groups fed either breast milk or a supplemented formula. Conclusion: The data obtained indicate that the prebiotic mixture under study is able to stimulate the development of a microbial flora similar to that of breast-fed infants. Several biota, whose growth is enhanced by this prebiotic mixture, represent important factors in the postnatal development of the immune system. On this evidence it can be suggested that prebiotics may play a role as modulators of the postnatal development of the immune system.

Efficacy of tacrolimus in the treatment of steroid refractory autoimmune hepatitis.

Abstract: BackgroundAutoimmune hepatitis (AIH) is an immune mediated chronic liver disease with a prevalence of 17 cases/100,000. Resistance to the standard treatment of AIH (prednisone and azathioprine) occurs in 15% to 20%. There is currently no standard treatment of patients with steroid refractory AIH.Goa

The diagnostic yield of stool pathogen studies during relapses of inflammatory bowel disease.

Abstract: Goals: We sought to determine the yield of stool analysis for bacterial culture, ova and parasites, and Clostridium difficile toxin in suspected relapses of inflammatory bowel disease (IBD). Background: The diagnostic yield of such stool studies has not been examined recently in the United States. Study: The medical records of consecutive IBD patients who underwent stool testing for relapses at our institution between July 1, 2000, and November 25, 2001, were abstracted for demographics, stool test results, recent antibiotic exposure, and hospitalization. Results: Fifty-four patients were evaluated during 62 relapses with 99 stool samples. Twelve stool tests were positive. C. difficile accounted for the majority of positive tests (10/12). Of these, 9 (90%) were associated with antibiotic use in the prior month versus 10 (22%) in the C. difficile-negative group (P < 0.001). Hospitalization, prednisone use, or sulfasalazine use did not differ significantly with C. difficile status. Eight C. difficile-positive patients improved clinically with targeted antibiotic therapy. Two bacterial cultures (4%) were positive for Campylobacter jejuni and Plesiomonas shigelloides. Conclusion: Stool studies yielded a pathogen, mainly C. difficile, in 20% of the relapsing IBD patients. Antibiotic use was significantly associated with a positive C. difficile toxin. Toxin-positive patients improved clinically with targeted antibiotics.

Obesity and non-alcoholic fatty liver disease in chronic hepatitis C

Abstract: BackgroundSuperimposed non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) may affect HCV-related fibrosis. We performed a study to determine the relationship between NAFLD and chronic hepatitis C.MethodsOne hundred and twenty patients with chronic hepatitis C and avai

Factors associated with failure of metronidazole in Clostridium difficile-associated disease.

Abstract: Goal: To identify patients likely to fail metronidazole as initial treatment of C. difficile infection. Background: For moderate to severe Clostridium difficile-associated diarrhea, metronidazole is the drug of choice for treatment. Oral vancomycin is given to patients who fail metronidazole or have intolerable side effects. Study: Retrospective review identified all patients treated for C. difficile-associated diarrhea during hospitalization from January 2000 to September 2001. C. difficile was documented by a positive toxin assay or pseudomembranes on colonoscopy. Metronidazole failure was defined as persistent symptoms of C. difficile-associated diarrhea after 5 days of uninterrupted therapy. Response was defined as improvement in symptoms at day 5 of therapy including reduction of diarrhea to ≤ 2 bowel movements per day. Results: 119 C difficile-associated diarrhea patients were identified, and 99 met inclusion criteria. There were 61 (62%) metronidazole responders and 38 (38%) treatment failures. Albumin <2.5g/l and intensive care unit stay at/prior to diagnosis were the only variables associated with treatment failure. The odds ratios for treatment failure were 11.7 (95% confidence interval: 4.0-31.6) and 4.1 (95% confidence interval: 1.3-12.2), respectively. When considering these 2 variables together (low albumin, intensive care unit care), the area under the receiver operating characteristic curve was 0.80 for predicting treatment failure. Conclusions: Albumin level <2.5g./l and intensive care unit stay were predictors of failure of metronidazole therapy for C. difficile-associated diarrhea. These patients may benefit from oral vancomycin therapy at outset.

Utilization of the intestinal tract as a delivery system for urogenital probiotics.

Abstract: Orally consumed viable bacteria with proposed beneficial health effects, the so-called probiotics, are increasingly used to treat disorders of the gastrointestinal tract. It has been recently suggested that specifically selected lactobacilli could have a therapeutic role in female urogenital tract infections. It has been also suggested that some of these bacteria could be not intravaginally instilled, but also orally delivered. The authors investigate the ability of lactobacilli isolated from the vagina to survive gastrointestinal tract transit, and establish a link between the rate of intestinal survival and vaginal colonization.

Prevalence and Significance of Autoantibodies in Patients With Non-Alcoholic Steatohepatitis

Abstract: GoalsThe aim of this study is to evaluate the prevalence and the clinical and histologic correlates of autoantibodies in patients with nonalcoholic steatohepatitis (NASH).BackgroundAntinuclear antibodies (ANA) and anti-smooth muscle antibodies (ASMA) have been identified in patients with NASH. The s

The natural history of diverticulitis: fact and theory.

Abstract: Epidemiological and anatomic evidence indicates that approximately 60% of humans of westernized societies living into the sixth decade will develop diverticulosis of the colon. The cause remains unknown, but epidemiological studies indicate it is a combination of decreased dietary fiber intake and increased intracolonic pressure. The intraluminal pressure exerted on the wall causes a diverticular outpocketing at any one of the three areas in which vessels enter the wall. In this paper, we advance a hypothesis that fiber deficiency not only leads to diverticula formation but also causes a change in the microecology that results in decreased colon immune response and permits a low-grade chronic inflammatory process that precedes a full-blown acute diverticulitis. Pathophysiologic studies reveal that complications do not occur until there is microperforation through the wall of the diverticulum into the pericolic tissue. The perforation might be small and cause a microabscess, or extend to a phlegmon, or extend to a large abscess formation. Free perforation occurs rarely, but fistulization does occur and most commonly to the bladder. The clinical findings vary. Most often, the clinical picture is one of fever, abdominal pain, a change in bowel habit, and localizing findings associated with leukocytosis. Computerized tomography scanning has become the procedure of choice to evaluate the symptoms since it is of less risk than a barium enema and obtains more information. The differential diagnosis may be difficult but usually can be made with accuracy. Medical treatment is preferred with appropriate antibiotic therapy and variations in fiber intake. When abscess occurs, percutaneous drainage may be tried, but when it is unsuccessful, surgical intervention is necessary. Sudden hemorrhage from a vessel in diverticula may also occur. It is estimated that approximately 20% of all patients that develop diverticula will have either inflammatory or bleeding episodes. In conclusion, fiber deficiency results in diverticular formation and a chronic inflammation that may progress to acute or chronic diverticulitis that can be treated medically but may require surgical intervention.

Result of endoscopic biliary drainage in hilar cholangiocarcinoma.

Abstract: Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post-endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post-biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post-biliary drainage cholangitis (new onset of fever >38.5 degrees C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post-endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).

Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents.

Abstract: Objectives The goal of this study was to evaluate our medium-term results on common bile duct stenting with increasing numbers of stents on strictures due to chronic calcifying pancreatitis Background Common bile duct strictures frequently complicate the course of chronic calcifying pancreatitis The effectiveness of endoscopic stenting to resolve definitely these strictures is still debated Study Twenty-nine patients with common bile duct stricture due to chronic calcifying pancreatitis were stented and followed up Biliary sphincterotomy, dilation of the stricture, and insertion of plastic biliary stents (75-10 F) were performed Patients were scheduled for elective stent changing/restenting at 3-month intervals or any time when it was urgently indicated Our basic intention was to insert the maximum possible number of stents to reach as large diameter as the stricture allowed All stents were removed after the disappearance of common bile duct dilatation or left in place in cases of persisting strictures Results Eighteen patients (60%) had complete radiologic and serologic recovery after a mean of 211 months overall stenting time and had a stent free follow-up period for a mean of 121 months without recurrence of stricture Five patients (16%) still have stents in place after 26 months Three patients (13%) required surgery There were 3 deaths (10%): 1 for unrelated cause and 2 with septic shock of biliary origin Conclusions Most chronic calcifying pancreatitis patients with common bile duct strictures respond to the increasing numbers of endoscopic stents, and remain stent free for medium term periods Less patients (30%) does not benefit of biliary stenting, who are candidates for surgery

The pathology of diverticulosis coli.

Abstract: Left-sided diverticulosis coli is a common condition in western communities, with 30% to 50% of adults over the age of 60 being affected. It predominantly involves the sigmoid colon. The diverticula (pseudodiverticula) are pockets of mucosa bounded by muscularis mucosae and invested with a thin layer of submucosa, that are forced out through weak points in the muscularis propria, the tips ending in the colonic subserosa. The weak points in the muscle coat are the sites of entry of the nutrient vessels of the colonic mucosa. Diverticulosis is attributed to increased colonic intraluminal pressure while straining at stool in individuals who eat low-fiber diets. Muscular hypertrophy, shortening of the bowel, and thickened mucosal folds due to mucosal redundancy are characteristic of this condition. Complications of diverticulosis include bleeding, diverticulitis, peridiverticular abscess, perforation, stricture, and fistula formation. However, most individuals with diverticulosis are asymptomatic, without evidence of complications. Mucosal changes in the diverticula in uncomplicated diverticulosis include an increased lymphoid infiltrate, development of lymphoglandular complexes, mucin depletion, mild cryptitis, architectural distortion, Paneth cell metaplasia, and ulceration. The mucosa of the remainder of the sigmoid colon (ie, the nondiverticular mucosa) is usually normal, but in about 1% of cases it has features that are indistinguishable from ulcerative colitis or from Crohn's disease (segmental colitis associated with diverticular disease, SCAD). Such cases pose a difficult diagnostic challenge as patients with SCAD respond to medical or surgical therapy for diverticular disease, whereas those with ulcerative colitis or Crohn's disease will develop other manifestations of their disease in time and require different treatment. In SCAD, the mucosal changes are confined to the area of diverticulosis; therefore, histologic evaluation of the rectum (which is unaffected by diverticulosis) and more proximal bowel can be helpful in the differential diagnosis.

The overlap of inflammatory bowel disease and diverticular disease.

Abstract: An overlap of inflammatory bowel disease and diverticular disease has long been recognized. Crohn's disease and diverticulitis share clinical and radiologic features but usually differ in histopathologic findings. There is a suggestion, however, that even the characteristic pathology of Crohn's disease can be a secondary reaction to diverticulitis. It is possible, moreover, that the presence of Crohn's disease in association with diverticulosis predisposes to the development of diverticulitis. Finally, an apparently distinct form of segmental colitis associated with sigmoid diverticula has been described further contributing to the overlap of inflammatory bowel disease and diverticular disease.

Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy.

Abstract: Background: Laparoscopic Heller myotomy (HM) has become an increasingly preferred modality to treat achalasia. However, the treatment course after a failed myotomy is controversial with fears that pneumatic dilation (PD) has high perforation risk. Goal: To compare success and safety of graded PD with Rigiflex balloons in achalasia patients without a prior HM (untreated cases) and those with a failed HM. Study: A total of 108 patients were retrospectively evaluated: 96 untreated cases (53 male, 43 female, mean age 51 years) and 12 failed HM (7 male, 5 female, mean age 54 years). Symptoms (dysphagia and regurgitation) and physiologic studies, lower esophageal sphincter pressure (LESP) and timed barium swallow, assessed pre- and post-PD. Success was defined as: 1) symptom improvement to ≤2 to 4 times per week, and 2) ≥80% decrease in 5-minute barium column height from initial timed barium swallow. Results: A total of 139 PDs performed (117 untreated cases, 22 failed HM): 2 perforations in untreated cases and none in failed HM group. Baseline demographics were similar, but failed HM patients had significantly lower LESP and timed barium swallow columns. Despite less LES resistance, failed HM group (symptom and physiologic success: 50% and 10%) did not do as well after PD as compared with untreated cases (symptom and physiologic success: 74% and 52%, respectively). Five failed HM patients had good symptom relief after PD compared with poor responders these patients were older (>50 years) and had LESP >17 mm Hg. Conclusions: PD perforation risk is not higher after HM. Despite lower LES pressure, patients undergoing PD after failed HM do not do as well as untreated cases. Factors predicting better outcome include older age and higher LES pressure.

Collagenous colitis as the presenting feature of biopsy-defined celiac disease.

Abstract: BackgroundPrior case reports have linked celiac disease with collagenous colitis, but serological and retrospective pathologic survey studies of small intestinal biopsies have produced conflicting results.MethodsIn this report, consecutive patients with chronic diarrhea and the initial finding of co

Prebiotics promote good health: the basis, the potential, and the emerging evidence.

Abstract: Background: The prebiotics concept, which was launched in 1995, concerns nondigested and selectively fermented carbohydrate food ingredients. It was thought that their effect in the colon could reduce risk for disease. The prebiotic concept is revisited and possible mechanisms are proposed. The physiologic consequences of prebiotic consumption are evaluated in terms of potential to reduce risk for disease. This is a compilation of several research papers, each of which complied with the World Medical Association Declaration of Helsinki. Methods: For human dietary intervention trials, the aim was to perform double-blind, placebo-controlled, cross-over studies. A parallel design was used only for long-term studies. Most research has been done with β(2-1) fructans, so they are used as an example of prebiotics here. Results: The results are relevant to the fields of gut function, lipid metabolism, mineral absorption, bone formation, immunology, and cancer. Conclusion: It is observed that modification of intestinal flora by inherently selectively fermented prebiotics is central in determining their nutritional properties. They interact positively through the large intestinal surface with various physiologic processes and are thought to improve health status by reducing risk for disease (markers).

Erythromycin in the short- and long-term control of dyspepsia symptoms in patients with gastroparesis.

Abstract: Background: Few prokinetic drugs are available to treat gastroparesis. Data are limited on short-term and long-term efficacy of erythromycin as a prokinetic drug. Goals: Assess efficacy of low-dose erythromycin suspension to treat gastroparesis. Study: Patients with dyspepsia and gastroparesis by gastric emptying study were treated with low-bulk diet and low-dose (50-100 mg 3 times a day and at bedtime) oral erythromycin suspension. Data were collected by retrospective chart review and telephone questionnaire for short- and long-term follow-up, respectively. Results: Of 25 patients, 18 had short-term follow-up, 18 had long-term follow-up, and 14 had both. On short-term follow-up, 15 patients (83%) experienced some or dramatic improvement, while 3 (17%) experienced worsening or no change in symptoms (P 0.005). Mean duration of long-term use was 11 ± 7 months. On long-term follow-up, 12 (67%) patients noticed some or dramatic improvement, while 6 (33%) experienced worsening or no change in symptoms (P = 0.16). Correlation (0.7) between short- and long-term response was significant (P < 0.005). Of the 3 patients with poor short-term response, none did well long term. Of the 11 patients with some or dramatic response in short-term, 7 continued to have some response long term. There was no relation between gastric emptying time and response to erythromycin suspension. Conclusions: Treatment of gastroparesis with low-dose erythromycin and low-bulk diet results in a dramatic short-term improvement in the majority of patients. Short-term response predicts long-term response. This response may not be as great, possibly due to tachyphylaxis.

Hepatic hydrothorax: pathophysiology, diagnosis, and management

Abstract: Hepatic hydrothorax occurs in approximately 5 to 12% of patients with cirrhosis and portal hypertension. Various therapeutic modalities ranging from dietary and pharmacologic interventions to surgical approaches are available for the management of this condition. Treatment must be individualized based on the patient's response to conservative management as well as the severity of the underlying liver disease. Hepatic hydrothorax may be complicated by spontaneous bacterial empyema, which portends a poor prognosis with a mortality rate of up to 20%. All patients with hepatic hydrothorax should be evaluated for possible liver transplantation.

Lymphoproliferative and intestinal malignancies in 214 patients with biopsy-defined celiac disease.

Abstract: Prior studies have suggested that the incidence of some neoplastic disorders, particularly malignant lymphoma, is increased in celiac disease. In the present study, lymphoproliferative and intestinal cancers in 214 consecutive biopsy-defined celiac disease patients, including 148 females (69.2%) and 66 males (30.8%), seen by a single clinician over more than 20 years were tabulated. Of the 214 patients, 151 were diagnosed with celiac disease before age 60 and 63 at or after age 60. In total, 18 malignant lymphomas and 3 small intestinal adenocarcinomas were detected. While the overall incidence of malignant lymphoma was 8.4%, similar to other European centers, the incidence in elderly celiacs in this study was 22.2%. Celiac disease was detected before or even after the diagnoses of lymphoma or small intestinal adenocarcinoma were established. In some, epithelial lymphocytosis was evident in gastric, colonic, or biliary ductal epithelium. In addition, other immune-mediated disorders, dermatitis herpetiformis, and autoimmune thyroid disease were common, suggesting a distinct clinical and pathologic phenotype in celiac disease that may predispose to malignant complications. Finally, except for a single hypopharyngeal carcinoma in a celiac disease patient with a malignant lymphoma, other malignant disorders of esophagus, stomach, and colon were not detected.

Diaphragm disease after use of nonsteroidal anti-inflammatory agents: first report of diagnosis with capsule endoscopy.

Abstract: Diaphragm disease of the small intestine is part of the spectrum of diseases associated with injury to the gastrointestinal tract induced by nonsteroidal anti-inflammatory drugs. Standard endoscopy or contrast studies of the small intestine rarely identify these lesions. The diagnosis usually is established at the time of surgery. We report the case of a 72-year-old woman with obscure gastrointestinal bleeding and intermittent obstruction of the small intestine who had had multiple hospitalizations and extensive testing. The patient had been treated with nonsteroidal anti-inflammatory drugs for osteoarthritis. A radiograph of the small intestine with barium contrast revealed no abnormalities, so capsule endoscopy was performed. Capsule endoscopy showed multiple small intestinal strictures beyond which the capsule could not pass. After the patient experienced continued symptoms suggestive of intermittent partial obstruction of the small intestine, computed tomography showed the capsule within a dilated loop of intestine adjacent to a stricture. After 9 days of conservative medical therapy and worsening symptoms, the patient required an exploratory laparotomy. The capsule was located in a 12-cm segment of intestine with 4 diaphragm-like lesions. Pathologic study found submucosal lesions with features identical to those of neuromuscular and vascular hamartoma (eg, mature, reactive tissue elements of smooth muscle, dense fibrous tissue, and nerve tissue bundles with scattered ganglion cells and vessels). No manifestations of Crohn disease were evident. This case represents the first diagnosis with capsule endoscopy of diaphragm disease of the small intestine with pathologic features of neuromuscular and vascular hamartoma.

Autonomic cardiovascular responses are impaired in women with irritable bowel syndrome.

Abstract: Goals: This study characterizes cardiovascular autonomic function in women with irritable bowel syndrome (IBS), using standardized techniques. Background: Autonomic dysfunction is believed to contribute to abnormal gastrointestinal motility and visceral hypersensitivity in IBS. There is mounting evidence of generalized impairment of autonomic activity in patients with IBS. Study: Thirty women aged 39 years (95% C.l. 25-53 years) diagnosed with IBS, and 30 age-matched healthy women were studied. The ratio of low frequency to high frequency heart rate variability domains (LF: HF ratio) was used to represent cardiac sympathovagal activity, and orthostatic testing and sustained isometric handgrip exercise were used as sympathetic stimuli. Parasympathetic activity was represented by the expiratory to inspiratory R-R interval (E:l) ratio during deep breathing at 6 minutes 1 . Results: LF: HF responses to handgrip exercise (316%, C.l. 134% to 498% vs. 107%, C.l. 15% to 153%, P<0.05) and orthostatic testing (648%, C.l. 520% to 904% vs. 330%, C.l. 140% to 520%; P < 0.05) were higher in IBS patients than controls, and the E:I ratio was significantly lower (1.47, C.l. 1.33-1.61 vs. 1.20, C.l. 1.14-1.26; P<0.01). Conclusions: Autonomic cardiovascular function is impaired in IBS, manifest as attenuated cardio-vagal tone, and relative sympathetic excess during stimulated conditions.

Prevalence and natural history of gastric antral vascular ectasia in patients undergoing orthotopic liver transplantation

Abstract: Goals To describe the prevalence and natural history of gastric antral vascular ectasia (GAVE) in patients with end-stage liver disease undergoing orthotopic liver transplantation (OLT) Background GAVE is a well-recognized cause of gastrointestinal hemorrhage Although 30% of patients with GAVE have liver disease, the prevalence of GAVE in patients with cirrhosis is not known Study We reviewed clinical records of patients who underwent OLT at our institution from February 1, 1998 to June 2003 Demographic and clinical details were recorded with attention to findings during upper endoscopy before and after OLT Results A total of 597 patients underwent OLT, and 345 were evaluated preoperatively with esophagogastroduodenoscopy (EGD) Eight (23%) were found to have GAVE before OLT Three of these eight underwent EGD after OLT, and GAVE was absent in all three None of the patients with GAVE experienced gastrointestinal bleeding postoperatively Conclusions GAVE was present in nearly 1 in 40 patients with end-stage liver disease who underwent EGD before OLT at our institution and appears to resolve after transplant These findings are consistent with a previous report documenting resolution of GAVE after OLT

The usefulness of routine small bowel biopsies in evaluation of iron deficiency anemia.

Abstract: BackgroundIron deficiency anemia (IDA) may be the sole manifestation of celiac disease. The role of routine small bowel biopsies obtained during endoscopy in the evaluation of IDA is unclear. This study assessed the usefulness of routine small bowel biopsies in patients presenting with IDA.StudyEval

Lactoferrin functions: current status and perspectives.

Abstract: Lactoferrin, an iron-binding glycoprotein synthesized by neutrophils and exocrine glands, plays an important role in human innate defense mechanisms against bacteria, fungi, and viruses. First, a bacteriostatic activity of lactoferrin, depending on iron withholding to bacteria, and successively a bactericidal iron-independent effect, related to its binding on bacterial surfaces, was recognized. Many other functions have been ascribed to this cationic protein, including the inhibiting action toward bacterial adhesion and invasion of target host cells. Recent research also reported the lactoferrin influence on bacterial aggregation and biofilm development of Pseudomonas aeruginosa and Streptococcus mutans. The different lactoferrin functions can be justified by different physicochemical properties of the molecule, which include the iron-binding capability, the binding to anionic cell surfaces and molecules, and serine protease activity.

Medical and gastroenterologic management of the post-bariatric surgery patient.

Abstract: Morbid obesity is a serious disease resulting in considerable morbidity. Bariatric surgery is an important treatment modality of morbid obesity. It appears to be safe and effective in reduction of excess weight in carefully selected patients. However, it carries a risk of many short- and long-term complications, some of them unique to bariatric surgery. Knowledge of possible postoperative complications and their management will allow the achievement of the best results. Despite many types of bariatric procedures developed, only a few are currently performed. Since the number of bariatric procedures performed annually increases, primary care physicians and gastroenterologists will be increasingly challenged by post-bariatric surgery patients. Hence, better understanding of the anatomy and adaptive changes in bariatric patients allows for a more efficient evaluation and management of post-bariatric surgery problems. This article reviews common complications in post-bariatric surgery patients and provides guidelines for their evaluation and management.