Showing papers in "The Italian journal of gastroenterology in 1995"

Quality of life in inflammatory bowel disease.

Abstract: The usual indices of activity of Inflammatory Bowel Disease fail to evaluate an important aspect of patients' status, their Quality of Life (QOL) A questionnaire dealing with four important aspects of QOL (intestinal and systemic symptoms, emotional and social function) was developed and validated The questionnaire was administered to 72 healthy controls, 57 patients with Ulcerative Colitis and 55 with Crohn's Disease with different disease severity Compared to controls, QOL was impaired not only in the more severe forms of disease, but also in patients in remission In Crohn's Disease, QOL was not closely correlated with the clinical features, thus indicating that the impairment of QOL cannot be inferred from the clinical status and that patients do not adapt with the passing of time The questionnaire allows a more comprehensive definition of the patients' state of health, identifying features which might be underestimated as they fail to emerge from the routine clinical evaluation A tool of this kind could be used alongside the activity index of disease, both in clinical studies and during routine follow-up

High prevalence of hepatitis C virus infection in a small central Italian town: lack of evidence of parenteral exposure.

Abstract: In the spring of 1994, anti-HCV prevalence and associated risk factors were evaluated in 681 subjects representing all age-groups in the general population of a small central Italian town The overall anti- HCV prevalence was 84%, ranging from 37% in the 30-39 age-group to 182% (p 45 years (OR 272), and lowest number of years of schooling (OR 110) while no association was found with any parenteral exposure such as blood transfusion, intravenous drug use, major or minor surgical intervention, use of glass syringes or dental therapy The HBsAg prevalence in this population was 13%, which corresponds to the rate reported in central Italy These findings show a high level of HCV endemicity, with no evidence of parenteral exposure

Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet.

Abstract: Lactose malabsorption may induce abdominal symptoms indistinguishable from those of the irritable bowel syndrome (IBS), however the exact relationship between the two conditions and the optimal differential diagnostic workup are still to be defined. We prospectively studied the prevalence of lactose malabsorption (by means of a hydrogen breath test) and the clinical effect of a long-term lactose-free diet in 230 consecutive patients with a suggested diagnosis of irritable bowel syndrome, no organic disease of the GI tract, and no history of milk intolerance. Lactose malabsorption was diagnosed in 157 patients (68.2%). In 48 (43.6%) of the 110 patients who complied with the diet symptoms subsided, in 43 they were somewhat reduced and in 17 they remained unchanged. Symptoms never fully subsided in lactose malabsorbers non-compliant with the diet or in normal lactose absorbers who adhered to a lactose-free regimen. Partial improvement was observed in 20% of these subjects. No relation was demonstrated between pre-trial symptoms and the outcome of the diet. The occurrence of symptoms during the lactose breath test strongly suggested a favorable response to diet, but did not help in predicting whether symptoms would subside or be reduced. Conversely, their absence during the test was not associated with an acceptable negative predictive value. The high prevalence of lactose malabsorption in the patients under study suggests that in Italy IBS and lactose malabsorption are frequently associated. A test for diagnosing lactose malabsorption should always be included in the diagnostic workup for IBS and a long-term lactose-free regimen recommended if the test is positive.

Abnormal cholesterol biosynthesis in the Smith-Lemli-Opitz syndrome.

Abstract: We measured plasma sterol concentrations in 7 homozygotes with the Smith-Lemli-Opitz syndrome, 5 heterozygotes and rats treated with BM 15.766, the competitive inhibitor of 7-dehydrocholesterol 7-reductase. Low cholesterol associated with markedly elevated 7-dehydrocholesterol concentrations were detected in the plasma of all homozygotes and inhibitor-treated rats. Heterozygotes were clinically normal and, like control subjects, showed only trace amounts of 7-dehydrocholesterol in plasma. We conclude that the Smith-Lemli-Opitz syndrome is due to an inherited defect in 7 dehydrocholesterol 7-reductase which causes the accumulation of 7-dehydrocholesterol and a deficiency of cholesterol in the plasma, a biochemical abnormality that can be reproduced in rats treated with BM 15.766.

Comparison of lactulose and inulin as reference standard for the study of resistant starch fermentation using hydrogen breath test

Abstract: Disaccharide lactulose is commonly used as a standard to quantitate the colonic fermentation of undigested sugars by means of H2 breath measurements. However, its high hydrogen production rate during fermentation may make it inappropriate for mimicking the fermentation of more complex carbohydrates, such as starch. Indigestible carbohydrates with a higher molecular weight might be more suitable than lactulose as a standard in H2 breath studies of starch digestibility. To test this hypothesis, we measured H2 breath in 8 healthy volunteers after a standard meal supplemented with 5 g or 10 g of lactulose or inulin, an indigestible oligosaccharide with an average degree of polymerization 4.5 times higher than that of lactulose. The results were then compared with those obtained after a standard meal containing a known amount (6.1 g) of resistant starch from high-amylose corn starch. Median H2 breath excretion per gram of reference carbohydrate was lower after the 5 g dose of inulin than after the 5 g dose of lactulose (19.1 vs 26.6 ppm x h x g-1; Wilcoxon's rank test p = 0.021) but similar after the two 10 g doses (inulin 22.4; lactulose 23.6; p = 0.234). Median H2 breath excretion per gram of resistant starch was significantly lower than that for both lactulose and inulin (p < 0.02), being 4.7 ppm x h x g-1. In vitro fermentation for 8 hrs with fecal homogenate showed similar mean hydrogen production rates for inulin and lactulose (30.5 vs 27.7 mL/mg fermented carbohydrate), and a significantly lower rate for starch (9.1 mL/mg) (n = 7; ANOVA p = 0.0007).(ABSTRACT TRUNCATED AT 250 WORDS)

Fine-needle biopsy in focal liver lesions: the usefulness of a screening programme and the role of cytology and microhistology.

Abstract: We evaluated the diagnostic usefulness of 244 ultrasound-guided fine-needle biopsies (FNB) in 226 patients with suspected liver malignancies. A malignancy was detected in 166 cases (73%) -145 hepatocellular carcinomas (HCC), 21 metastases; benign lesions were aspirated in 60 cases (27%). The sensitivity of FNB was 93%, with 100% specificity. In the FNB false-negative cirrhotic nodules, a final diagnosis of HCC was reached on repeating the biopsy 1-8 months later. When both cytological and microhistological examinations were performed, the positive correlation between the two techniques was 80%, with a slightly higher sensitivity for microhistology (93%). The malignancies diagnosed were potentially resectable in 26% of cases. We experienced 1 acute complication of FNB and 1 case of needle tract tumour seeding. These results confirm that FNB is useful in diagnosing malignant liver tumours. We believe that US-guided FNB is the first-choice invasive technique for assessing focal benign lesions and malignant tumors in the liver.

Adenocarcinoma and atypical carcinoid: morphological study of a gastric collision-type tumour in the carcinoma-carcinoid spectrum.

Abstract: We report the morphological features of an unusual cardial gastric tumour in a 72 year-old white man. Histologic examination revealed two adjacent, "side by side", but not merged, components: a poorly differentiated one and a typical moderately-differentiated gastric adenocarcinoma. Both components were also found in the metastatic lymph nodes. Histochemical (Grimelius) and immunohistochemical (neuron specific enolase, chromogranin A, synaptophysin) studies revealed the endocrine nature of the poorly differentiated component, which however, was not argentaffin and did not show immunoreactivity for specific endocrine substances. The neoplastic lesion was classified in the carcinoma-carcinoid spectrum as collision-type tumour. Our data suggest the double and independent origin of the two components.

Thyroid involvement in patients with active inflammatory bowel diseases.

Abstract: Previous studies have documented an association between systemic diseases and disorders of the thyroid gland, expressed by an enlargement of the thyroid and by the presence of anti-thyroid antibodies. Chronic inflammatory bowel diseases (IBD, ulcerative colitis and Crohn's disease) may also present a multi-organ involvement, including the biliary tree, joints and uvea. To detect a possible subclinical thyroid involvement, thyroid volume and function were assessed in 31 patients with IBD in active phase and in 50 control subjects. Thyroid volume was calculated by ultrasonography on the basis of the three maximum diameters of the 2 lobes. A blood sample was taken to determine free thyroid hormones, TSH, and anti-thyroid antibodies. In patients with IBD, thyroid volume was increased on average by 35%, and the prevalence of thyroid enlargements (antero-posterior diameter > 20 mm) was 3 times higher (45% vs 16%). Free thyroxine was increased by nearly 50%, but only 10% of patients had anti-thyroid antibodies. Alterations of thyroid volume and function are present in IBD, even in the absence of clinically-detectable thyroid disease. The association of IBD with thyroid disorders, as well as the involvement of various organs, confirms the view that IBD is a systemic disease.

Clinical course of inflammatory bowel disease during treatment with interferon for associated chronic active hepatitis.

Abstract: Seven patients with inactive ulcerative colitis and seven patients with Crohn's disease (5 inactive, 2 mildly active) received interferon treatment for associated chronic active hepatitis. Neither relapse (except in one patient) nor worsening of the clinical course of the inflammatory bowel disease was observed during treatment. According to these results chronic active hepatitis associated with inflammatory bowel disease can be treated with interferon without the risk of deteriorating the course of the inflammatory bowel disease.

Alcoholic liver disease in alcoholic chronic pancreatitis: a prospective study.

Abstract: The prevalence and characteristics of alcoholic liver disease (ALD) in patients with alcohol-induced chronic pancreatitis (AICP) are not well defined. Fifty consecutive patients undergoing surgery for AICP were investigated for evidence of ALD. In addition to preoperative functional and imaging assessment of the liver, all had liver biopsy during surgery. Hepatic biopsy results were as follows: 12 patients had normal liver and 10 minimal aspecific changes; of the remaining 28 patients, 7 had liver cirrhosis, 11 showed features of alcoholic hepatitis, 2 had moderate steatosis, 6 extrahepatic cholestasis, and the remaining 2 had a combination of alcoholic hepatitis and cholestasis. Of the 7 patients with cirrhosis, 3 had oesophageal varices and 2 of these developed ascites in the postoperative period; in the remaining patients with ALD, this disease was subclinical. Patients with ALD consumed significantly (p < 0.005) more alcohol than those without ALD. In patients with cirrhosis, the duration of alcohol consumption (mean 27.6 years, range 18-42 years) was significantly longer (p < 0.05) than in patients without ALD (mean 19.7 years, range 8-36 years). The association of ALD with AICP is much more common than previously believed. The fact that AICP occurs earlier than liver cirrhosis and the fact that many patients stop alcohol consumption after the first attacks of pancreatic pain may explain, at least in part, the apparent rarity with which this association has been indicated by previous studies.

Prevalence of anti-HCV among spouses and offspring of anti-HCV positive subjects: an Italian multicentre study

Abstract: The role of familial environment in the spreading of hepatitis C virus (HCV) infection is not well established. We studied 1670 family members for 578 anti-HCV+ subjects enrolled in 8 centres distributed throughout Italy. The prevalence of anti-HCV positivity was significantly higher in spouses than in offspring (15.6% and 2.1% respectively; p < 0.01), with no difference between northern and central-southern regions of Italy. Anti-HCV positivity was found almost exclusively in adults; among offspring, during the first two decades of life, the prevalence of anti-HCV positivity was significantly lower than in subjects over 20 years old (0.6% vs 3.1%, respectively).

Bile acids as drugs: principles, mechanisms of action and formulations

Abstract: Bile acid therapy is based on the use of bile acid agonists or bile acid antagonists. Bile acid agonists consist of bile acids or their derivatives. They are used for two purposes. The first is to correct a deficiency in bile acids because of defective biosynthesis or intestinal conservation and thereby to restore bile acid function. This rationale may be termed replacement therapy. The second is to alter the composition of circulating bile acids and thereby to modulate cholesterol metabolism and/or decrease the cytotoxicity of the circulating bile acid pool. This rationale may be termed displacement therapy. Administration of chenodeoxycholic (CDCA) and/or ursodeoxycholic (UDCA) decreases biliary secretion of cholesterol leading to secretion of bile that is unsaturated in cholesterol and gradual dissolution of cholesterol gallstones. Administration of UDCA to patients with chronic cholestatic liver disease lowers the proportion of endogenous cytotoxic dihydroxy bile acids in the circulating bile acids, improves liver tests, and delays liver failure. Bile acid antagonists act to decrease intestinal conservation of bile acids either by sequestering bile acids in the intestinal lumen or by inhibiting bile acid transport by the ileal enterocyte. For therapy, CDCA is administered as the protonated acid and is well absorbed. UDCA is also administered as the protonated acid, but absorption is incomplete. Complete absorption can be obtained using the sodium salt of UDCA in a capsule with a pH-sensitive enteric coating. The taurine conjugate of UDCA is administered as the protonated sulfonic acid, and its absorption requires a carrier mechanism; however, it is likely to undergo rapid deconjugation during enterohepatic cycling, liberating UDCA which can be passively absorbed.(ABSTRACT TRUNCATED AT 250 WORDS)

The urea breath test: a non-invasive clinical tool for detecting Helicobacter pylori infection

Abstract: The urea breath test exploits the urease enzyme of Helicobacter pylori. The hydrolysis of labelled urea releases labelled carbon dioxide that is excreted in the breath. Distribution of urea throughout the stomach prevents sampling errors and allows for semiquantitative assessment of the extent of Helicobacter pylori infection. The urea breath test is very specific and sensitive and can be proposed as the method of choice for detecting Helicobacter pylori infection in ulcer patients before and after eradicating treatment as well as in epidemiological studies.

IgG anti-betalactoglobulin (betalactotest) : its usefulness in the diagnosis of cow's milk allergy

Abstract: The aim of this prospective study was to evaluate the distribution of serum values of IgG anti-betalactoglobulin in 3 groups of subjects: a) 218 healthy subjects (138 M, 80 F) with age ranging from 1 month to 6 years; b) 205 patients with cow's milk protein allergy (CMPA) (130 M, 75 F) aged between 1 month and 4 years; c) 96 patients (50 M, 46 F) with symptoms compatible with CMPA, but suffering from other diseases (age range 1 month-6 years). The IgG anti-betalactoglobulin values were obtained using a new commercially available immunoenzymatic method. There was a marked difference in the distribution of IgG antibetalactoglobulin values in the 3 study groups. In healthy controls the value corresponding to the 5th centile was 5%, to the 50th centile 17%, to the 90th centile 48%. In the gastroenterological controls, 5th centile was 5%, 50th centile 15% and 90th centile was 56%. In the patients with CMPA, 5th centile was 27%, 50th centile 101% and 90th was 147%. The distribution of the values was therefore significantly different in the CMPA group from that of the other 2 groups (p < 0.0001). Plotting receiver operating characteristics curves, we have indicated a betalactotest value of 36% as a cut-off with the highest diagnostic accuracy (89% sensitivity, 85% specificity). We suggest that the betalactotest should be used to confirm diagnosis in patients with suspected CMPA; with a cut-off of over 48% we found only one false positive for diagnosis of CMPA in patients presenting other diseases with an identical clinical picture.

Nocturnal gastric acidity pattern in gastro-oesophageal reflux disease with or without oesophagitis.

Abstract: The reasons why few patients with gastro-oesophageal reflux disease develop oesophagitis are not yet clear. One of the factors whose role is still debatable is the gastric acid secretory state. The aim of this study was to evaluate whether differences exist in nocturnal gastric acidity between patients with oesophagitis and refluxers without oesophageal lesions. We studied 65 patients with gastro-oesophageal reflux disease, 37 of whom presented erosive oesophagitis, while 28 had no oesophageal lesions. Thirty-one healthy volunteers were used as controls. In both patients and controls intragastric and intraoesophageal pH were measured continuously using 2 in-dwelling glass electrodes, placed in the gastric corpus and in the oesophagus. Mean intragastric pH was calculated over 3 nocturnal time periods : 11.00 p.m.-07.00 a.m. ; 11.00 p.m.-03.00 a.m. ; 03.00 a.m.-07.00 a.m. Patients with oesophagitis had a lower nocturnal gastric pH (1.6±0.2) than either refluxers without oesophagitis (2.2±0.3) (p=0.05) or controls (2.6±0.4) (p=0.02). The difference occurred entirely in the second part of the night. Furthermore, in the same time period, oesophagitis sufferers had a higher percentage of oesophageal acid exposure at pH<2 (0.7±0.2) than refluxers without oesophagitis (0.2±0.1) (p=0.05), suggesting that gastric findings are of pathogenetic relevance. Patients with reflux oesophagitis have a higher nocturnal intragastric acidity than refluxers without oesophagitis. This difference, confined to the second half of the night, may be due to an altered circadian pattern of gastric acid secretion and may partially explain why only some refluxers develop oesophagitis.

Peripheral neuropathy in liver cirrhosis. A clinical and electrophysiological study.

Abstract: Clinical symptoms and/or signs of peripheral neuropathy were found in 17 of the 19 patients we studied with liver cirrhosis. In 16 of the 19 patients electrophysiological abnormalities were also observed. Mild-moderate alterations involved both motor and sensory fibres, with a higher incidence in the lower rather than upper limbs, and indicated a fibre loss rather than a fibre demyelination. These changes were observed in both alcoholic and non-alcoholic cirrhotics, suggesting a primary role of liver cirrhosis per se. In fact, both the clinical and electrophysiological abnormalities were related to the severity of the liver disease. A careful clinical examination could reveal the presence and extent of neuropathy in most cirrhotic patients.

Gastrointestinal complications of liver transplantation.

Abstract: Liver transplantation (OLTx) has become a common procedure at many centers in Europe and North America. The 1 and 5 year survival of patients receiving liver transplants at most centers is 75-85% and 60-65% respectively. As such, many physicians, in addition to those at transplant centers, will be called upon to see and care for recipients surviving liver transplants. The gastrointestinal tract is a common site of post-transplantation problems. These problems involve all components of the gastrointestinal tract. Many have characteristic, if not unique, presentations and clinical courses. They are reviewed for the physician in clinical practice who does not practice at a transplant center.

Peptic ulcer and duodenal stenosis: Role of Helicobacter pylori infection

Abstract: A 17-year-old boy who developed a symptomatic duodenal ulcer at 10 years of age with melena, and was then treated continuously for 6 years with ranitidine therapy that only partially controlled symptoms and peptic lesions, came to us with vomiting due to duodenal bulb stenosis and active ulcer. Four months of omeprazole (40 mg/die o.m.) did not modify the endoscopic picture. The diagnosis of H. pylori infection and its treatment with triple therapy led to the cure of both duodenal ulcer and bulbar stenosis. Afterwards he remained asymptomatic without any lesions or complications for 18 months. This case illustrates that H. pylori eradication : a) is able to cure refractory duodenal ulcer ; b) resolves severe complications such as duodenal stenosis.

Update on physical state of bile.

Abstract: Because of recent assertions by a group of investigators that structures called lamellae instead of mixed micelles are present in human bile, the nature of biliary cholesterol solubilization and transport (carriage) has again become a matter of dispute. Lamellae are rod- or tubular- shaped banded images observed when biles are negatively stained and dehydrated during electron microscopy; they are believed to be composed principally of biliary phospholipid (which is mostly lecithin) and cholesterol. It is well known that when mixed together in aqueous systems, lecithin and cholesterol, which are otherwise insoluble amphiphilic lipids, swell to form stacked or multilamellar liquid crystals that have regular periodicity because of the bilayer arrangement of the molecules. Provided super-micellar concentrations of cholesterol are present, multilamellar vesicles occur spontaneously in concentrated model biles, and are a frequent occurrence in human gallbladder biles that are beginning to nucleate cholesterol crystals. When multilamellar vesicles are negatively stained and dehydrated, they produce lamellae images by electron microscopy. Coincidentally, images of lamellae are also produced when purely micellar bile, either model or native is treated similarly. In this review we show that these images are an artifact. This artifact is produced by the dehydration process itself and is due to a phase change i.e. a change in molecular packing which is predicted by the appropriate phase diagram. As a consequence, a dehydrated lamellae phase results and the overall effect is an electron microscopic image that is identical to those produced by multilamellar vesicles in supersaturated or lithogenic biles. The major problem in the current physical-chemical literature is that these distinct phenomena have been equated by the proponents of the lamellae hypothesis as originating from identical biliary cholesterol carriers. This belief has, in turn, led them to suggest that lamellae and not mixed micelles are the principal particles responsible for cholesterol carriage in bile. The problem is compounded by another unanticipated experimental artifact involved in the isolation by gel filtration of the so-called lamellae. When chemically analysed, endogenous bile salts are virtually absent from the lamellae fractions but elute in the simple micellar peak. This occurs because the non-lecithin associated bile salt concentration which is mimicked by a foreign bile salt in the eluting buffer, and absolutely essential to preserve micellar and vesicle integrity, exchanges completely with the endogenous bile salts of the mixed micelles. For all of these reasons therefore, we conclude that the lamellae challange to the traditional paradigm of mixed micelles and vesicles for cholesterol carriage in bile is invalid.

Bile salt-membrane interactions and the physico-chemical mechanisms of bile salt toxicity

Abstract: We present evidence that ursodeoxycholate prevents toxicity of more hydrophobic bile salts by inhibiting micellar solubilization of membrane lipids. Using both centrifugal ultrafiltration and gel filtration methods we studied leakage of inulin from vesicles composed of egg phosphatidylcholine and cholesterol. We observed that the addition of tauroursodeoxycholate to taurodeoxycholate reduced leakage of inulin from large unilamelar vesicles compared to that seen with taurodeoxycholate alone. This protective effect was observed only at high membrane cholesterol:phospholipid ratios (> or = 0.5). By gel filtration we found that fractional leakage of inulin from vesicles was identical to fractional phospholipid solubilization, indicating that release of inulin from vesicles results from membrane dissolution rather than from increased permeability of otherwise intact membranes. Addition of tauroursodeoxycholate to taurodeoxycholate was found to suppress the dissolution of phospholipid from cholesterol-rich vesicles. Bile salts were found to absorb to vesicles with an affinity proportional to their relative hydrophobicity, as estimated by reverse phase HPLC. Adsorption affinity decreased progressively with increasing membrane cholesterol content. Different bile salts displaced each other from membranes in proportion to their respective binding, affinities. Tauroursodeoxycholate, which absorbed to membranes with low affinity, displaced taurodeoxycholate from vesicles only weakly. Based on these findings we postulate that bile salts may damage the liver through solubilization of canalicular membrane lipids. Ursodeoxycholate may protect the liver by inhibiting dissolution of the cholesterol-rich canalicular membrane by more hydrophobic endogenous bile salts. Biliary secretion of vesicles rich in phosphatidylcholine may buffer the intermicellar concentration of bile acids at levels below those required to disrupt the cholesterol-rich canalicular membrane; thus biliary vesicle secretion may have evolved as a mechanism to protect the biliary epithelium from injury by luminal bile salts.

Evaluation of cyst fluid analysis in the diagnosis of pancreatic cysts.

Abstract: The pre-operative differential diagnosis of pancreatic cystic lesions is often difficult because of the lack of reliable clinical or radiological criteria. In order to improve the pre-operative recognition of these lesions, we performed cyst fluid analysis for enzymes (amylase and lipase), tumour markers (CEA, CA 19-9, CA 125, CA 72-4), and cytology in 52 pancreatic cysts. The cases included 21 pseudocysts, 12 mucinous cystic neoplasms, 7 ductal carcinomas, 7 benign lesions, and 5 rare malignancies observed from 1989 to 1994. Cyst fluid amylase, lipase, CEA, and CA 19-9 were variable and not discriminant between the groups. CA 125 fluid levels were high in 63% of malignant cysts. CA 72-4 fluid levels were significantly higher in mucinous cystic tumours than in pseudocysts (p < 0.0001), showing 95% specificity in detecting mucinous or malignant cysts. Cytology showed a sensitivity of 61% and a specificity of 100%. CA 72-4 determination raised the sensitivity of cytology to 92% in detecting mucinous or malignant cysts. This study confirms the low sensitivity of cytologic examination and low amylase specificity in distinguishing cystic neoplasms from pseudocysts. Cyst tumour markers assay is useful to improve the sensitivity of cytology, and CA 72-4 shows the best specificity in detecting (pre)malignant neoplasms.

Cholelithiasis in patients with chronic active liver disease: evaluation of risk factors.

Abstract: The aim of this cross-sectional study was to evaluate the prevalence of gallstones in patients with chronic active liver disease in relation to age, sex, family history of gallstones, number of pregnancies, obesity, diabetes mellitus, aetiology of liver disease and presence or not of cirrhosis. We studied 508 patients (411 with liver cirrhosis and 97 with chronic active hepatitis) by ultrasonography. Overall prevalence of gallstones and previous cholecystectomy was 22.6% and 8.5%, respectively. A higher prevalence of gallstones was found in the subjects studied, matched for sex and age, than in the general Italian population. Univariate analysis of data showed that the prevalence of gallstones is higher in females and increases with age in both sexes and with the progression of liver disease to cirrhosis. No significant association was found between gallstones and lithogenic familiarity, obesity, diabetes mellitus, number of pregnancies and alcohol abuse. In multiple logistic regression analysis of data, female sex, increasing age and cirrhosis in the whole series, age in males and cirrhosis in females proved to be the only independent variables associated with gallstones.

Bile acid structure and intestinal absorption in the animal model.

Abstract: A close structure-activity relationship exists between the transport of bile acids (BA) in the liver and intestine; hepatic and intestinal BA transport can be evaluated and compared by using perfused liver and perfused intestine in the rabbit. The passive intestinal absorption is limited to the unconjugated BA, which occurs throughout the small bowel and colon, and is conditioned by the apical membrane lipid composition. A higher diffusion component is found in the terminal ileum compared to the jejunum, and seems to be related to the higher cholesterol-to-phospholipid ratio of the ileal brush border membranes. The active transport system is well characterized and the brush border membrane receptor, cytosolic BA binding proteins and basolateral anion exchange protein have been identified. Recently, the ileal BA transporter has been cloned from the hamster and human ileum and the main cytosolic BA binding protein was cloned from the rat ileum. In the liver, the active transport predominates on the passive diffusion both for conjugated and unconjugated BA. The maximal transport capacity in the liver is tenfold higher than in the intestine, while the Km values are of the same order of magnitude, i.e. in the millimolar range. Neither system operates at its maximum transport rate with prevalent concentrations of BA in portal blood or luminal content.

Case control study of risk factors for hepatitis A: Naples 1990-1991. Hepatitis Collaborating Group.

Abstract: An increased incidence of hepatitis A was observed in Naples from 1990-1991. A hospital-based case-control study was carried out to evaluate the relative importance of various risk factors. A hundred and ninety-eight cases and 238 hospital controls were recruited during the study period. The strongest association was contact with a jaundiced person among children. A correlation was also shown for children and adults with raw shellfish consumption and pre-school nursery attendance or presence in the household of children attending pre-school nurseries. History of travel and intravenous drug use were risk factors for adult subjects. Considering the relative importance of the specific risk factors we found that 38% of the acute hepatitis A cases were attributable to contact with a jaundiced person, 15% to presence in the household of children attending pre-school nurseries and 28% to raw shellfish consumption.

Non-alcoholic steatohepatitis. Report of five cases and review of the literature.

Abstract: We describe three men and two women, aged 18-50, with an occasional finding of increased aspartate and alanine aminotransferase and gamma-glutamyl transpeptidase levels in the absence of any drug treatment and past or current alcohol abuse. Two patients were overweight (body mass index 29 and 32, respectively) and physical examination was normal in all but one case. Tests for hepatitis A, B and C, Epstein-Barr virus, cytomegalovirus, toxoplasma and autoimmune hepatitis were negative and metabolic diseases (Wilson's disease, haemochromatosis, α-I-antitrypsin deficiency) were excluded by specific tests. Ultrasound liver scan revealed massive steatosis in all patients. Liver histology showed diffuse steatosis and parenchymal inflammation in all cases, with concomitant fibrosis and Mallory bodies in three of them. Findings were consistent with non-alcoholic steatohepatitis, a rare condition with potential progression to cirrhosis in a minority of cases. This disease, for which no treatment is currently available, must be considered in all subjects with elevated aminotransferases, in the absence of known causes of liver damage.

Prognostic factors affecting the survival of operated patients with colorectal cancer : significance of delayed hypersensitivity skin reactions and nutritional status

Abstract: We examined whether an immune status measured with a series of delayed hypersensitivity skin reactions was associated with the survival of colorectal cancer patients. Clinical, laboratory and pathological data and various anthropometric parameters were prospectively measured in a series of 100 Greek patients diagnosed with colorectal cancer between 1987-1989 and followed up to mortality until 31 December 1992. The Kaplan-Meier method and Cox's Proportional Hazards Regression Model were used for the survival analysis. Age and stage of the disease were the most powerful predictors of survival. Other factors associated with survival of patients were various indices of nutritional status, tumour marker CEA, erythrocyte sedimentation rate and haematocrit. Immune status was statistically significantly related to survival, with anergic patients having a threefold risk of mortality compared to immunocompetent patients. Mortality risk decreased with the increasing number of positive hypersensitivity reactions (relative risk=0.72 ; 95% confidence intervals 0.52-1.00), after adjustment for age, sex, stage and body mass index. Similar but attenuated results were obtained when analyses were limited to patients without a disseminated disease. These findings indicate that immune status is significantly associated with the stage of the disease ; patients with advanced stages have a lower immune response. The immune response may be an important factor for the survival of cancer patients irrespective of the stage of the disease.

Chemical sclerosing cholangitis after injection of scolicidal solution.

Abstract: Sclerosing cholangitis may be due to developmental immunological, infective, vascular or chemical factors (1). Hydatid cysts of the liver may communicate with the biliary tree. This is the reason why intracystic injection of scolicidal solution before surgery may cause spreading of the solution into the bile ducts. This complication has already been described in literature (2,3). We present a new well-documented case of sclerosing cholangitis after the injection of formaldehyde into a hydatid cyst of the liver to kill it, and give some suggestions how to avoid this complication.

Cholesterol nucleation in bile.

Abstract: Protein factors, primarily glycoproteins, present in native human bile, have been found to modify, e.g. retard/accelerate, the process of de novo monohydra te crystal formation and, by inference, the rate of formation of cholesterol nuclei in such metastable cholesterol supersaturated systems. Neither the process of nucleation itself or how these modifiers work is yet well understood. From the health standpoint an inhibitor type of protein has been found that may help explain why about 50% of the population have biliary cholesterol supersaturation; whereas, only about 10% actually form gallstones. To date, only one inhibitor glycoprotein has been isolated and characterized. Its role thus seems clear. This is in contrast to the situation with so-called promoter glycoproteins which accelerate nucleation and crystal formation. A number of these proteins have now been identified. An understanding of the comparative roles of each of these proteins has not yet been established This is partly because of conflicting results, insufficient potencies or lack of information about physiologic concentrations.