A Case of Nodular Regenerative Hyperplasia of the Liver Combined with Toxic Hepatitis / 대한소화기학회지

Nodular regenerative hyperplasia (NRH) is an uncommon liver condition characterized by diffuse transformation of the hepatic parenchyma into regenerative nodules without fibrosis. Portal vasculopathy caused by abnormal hepatic venous flow may induce hepatocyte hyperplasia, which forms regenerative nodules. Underlying diseases or certain drugs may also be the cause of NRH. This condition is often underdiagnosed as the patients remain asymptomatic until development of portal hypertension, and histopathologic confirmation by liver biopsy is the only way of making a definite diagnosis. The management mainly involves prevention and treatment of the complications of portal hypertension. The frequency of diagnosis of NRH has increased rapidly in recent years, however, only a few cases have been reported in Korea. Here, we report on a case of NRH of the liver combined with toxic hepatitis.

A case of obstructive jaundice caused by tuberculous lymphadenitis: A literature review

Obstructive jaundice caused by tuberculous lymphadenitis is a rare manifestation of tuberculosis (TB), with 15 cases having been reported in Korea. We experienced a case of obstructive jaundice caused by pericholedochal tuberculous lymphadenitis in a 30-year-old man. The patient's initial serum total bilirubin level was 21.1 mg/dL. Abdominal computed tomography revealed narrowing of the bile duct by a conglomerated soft-tissue mass involving the main portal vein. Abrupt obstruction of the common bile duct was observed on cholangiography. Pathologic analysis of a ultrasonography-guided biopsy sample revealed chronic granulomatous inflammation, and an endoscopic examination revealed esophageal varices and active duodenal ulceration, the pathology of which was chronic noncaseating granulomatous inflammation. Hepaticojejunostomy was performed and pathologic analysis of the conglomerated soft-tissue mass revealed chronic granulomatous inflammation with caseation of the lymph nodes. Tuberculous lymphadenitis should be considered in patients presenting with obstructive jaundice in an endemic area.

Aspectos clínicos e histológicos da úlcera duodenal em crianças e adolescentes / Clinical and histological features of duodenal ulcer in children and adolescents

OBJETIVO: Avaliar as características clínicas e histológicas de crianças e adolescentes com úlcera duodenal. MÉTODOS: Foram avaliadas prospectiva e consecutivamente 43 pacientes com úlcera duodenal ao longo de 6 anos (7,2 pacientes por ano). A avaliação consistiu de questionário clínico de sintomas dispépticos, exame físico e endoscopia digestiva com biópsias gástricas para exame histológico e detecção do Helicobacter pylori. RESULTADOS: A idade no diagnóstico variou de 4 anos e 8 meses a 17 anos e 4 meses (mediana = 12 anos e 4 meses). O sintoma mais freqüente foi dor abdominal (39/43, 90,7 por cento): no epigástrio em 31/39, periumbilical em 7/39 e noturna em 27/39. Outros sintomas freqüentes foram: diminuição do apetite (32/43, 74,4 por cento), vômitos (30/43, 69,8 por cento), plenitude pós-prandial (23/43, 53,5 por cento), perda de peso (22/43, 51,2 por cento) e sensibilidade abdominal (19/43, 44,2 por cento). Hemorragia digestiva alta ocorreu em 19/43 pacientes (44,2 por cento), e anemia em 21/43 (48,8 por cento). H. pylori foi detectado em 41/43 (95,3 por cento), e todos esses pacientes apresentaram gastrite crônica ativa de antro, 92 por cento deles com predomínio do infiltrado linfomononuclear. A erradicação da bactéria ocorreu em 68,3 por cento dos pacientes infectados, mas houve cicatrização da lesão em 100 por cento dos pacientes erradicados e em 89 por cento dos não-erradicados. CONCLUSAO: Ulcera duodenal foi associada à gastrite crônica por H. pylori na grande maioria dos pacientes. Houve grande freqüência de complicações, especialmente hemorragia digestiva alta.

Double pylorus

Double pylorus (DP) or duplication of the pylorus is an uncommon condition that is either congenital or acquired. Acquired double pylorus (DP) results from a peptic ulcer eroding through and creating a fistula between the duodenal bulb and the distal stomach. We report a case of an acquired double pylorus in an adult gentleman that resulted from the erosion of a duodenal and prepyloric ulcer.

Doença de Crohn gastroduodenal-relato de quatro casos e revisao da literatura / Doença de Crohn gastroduodenal - relato de quatro casos e revisao da literatura

BACKGROUND: Crohn's disease can affect all the gastrointestinal tract, but gastroduodenal involvement is rarely seen (0.5 to 13 per cent). OBJECTIVES: Report clinical, radiological and endoscopic findings and treatment of four patients with gastroduodenal Crohn's disease and review the literature. PATIENTS AND METHODS: Four patients (one male of 24 years old three females of 37, 66 and 74 years old) with epigastric pain, weight loss and low grade fever were referred to the University Hospitals of Federal University of Rio de Janeiro and Fluminese Federal University. Two had also mild intermittent diarrhea and arthritis/arthralgia and the third developed pyloric obstruction and received surgical treatment. Anemia was observed in only one (the young female). Barium x-ray studies showed aphthous ulcers in stomach and duodenum with distal ileum lesions and deformity in both. Upper gastrointestinal endoscopy revealed aphthous ulcers in stomach and geographic duodenal ulcers. Polypoid lesions and serpiginous ulcers within gastric antrum were observed in the young female. Colonoscopy was performed in two patients and disclosed an ulcerated ileitis in one and ulcerated pancolitis in other. Histopathology findings of biopsy specimens were inconclusive (granulomas were not found) and other causes of granulomatous disease were ruled out. Corticosteroids and proton pump inhibitors were started and two patients had their disease controlled. The other patient developed pyloric obstruction and had to be operated. CONCLUSIONS: Gastroduodenal Crohn's disease has distinct clinical, therapeutic and prognostic features. Advances in endoscopic methods and recognition of new histopathologic criteria for diagnosis have revealed an incidence higher than previously reported.

Relevance of vacA Genotypes of Helicobacter pylori to cagA Status and Its Clinical Outcome

BACKGROUND: Determination of vacA mosaicism may be important because specific Helicobacter pylori vacA genotype can be used to predict different clinical outcome. The aim of this study was to assess the relationship of vacA genotypes of Helicobacter pylori to cagA status and its development of peptic ulcer diseases in Korean patients. METHODS: Gastric biopsy specimens were obtained from 53 patients with gastric ulcer(GU), 57 with duodenal ulcer (DU) and 26 with chronic gastritis(CG) patients; all patients were infected with Helicobacter pylori. Bacterial mRNAs in the gastric mucosa were amplified by RT-PCR, using synthetic oligonucleotide primers specific for the vacA and the cagA gene. Patients with vacA s1 subtype were further examined to determine whether they had s1a or s1b subtype. RESULTS: There was no correlation in frequency of vacA s1 and/or s1a genotype between CG and either GU or DU, as the vacA s1 and s1a/m1 were present in the majority of strains independent of clinical status(s1 ; 100.0% versus 94.3 % or 93.0 % and s1a/m1 ; 76.9% versus 62.3% or 64.9%, res pectively). Likewise, there was no difference in the prevalence of the cagA gene between CG and either GU or DU patients (92.3% versus 90.6% or 98.2%, respectively). In addition, the cagA-negative status did not predict the presence of vacA s2 genotype. CONCLUSION: These results strongly suggest that either cagA or vacA s1 and/or s1a is not proved to be a useful marker to distinguish disease-specific Helicobacter pylori strains for the development of peptic ulcer diseases in Korean patients.

The comparison of histologic gastritis in patients with duodenal ulcer, chronic gastritis, gastric ulcer and gastric cancer

This study was designed to investigate the differences of histologic gastritis according to the endoscopic diagnosis, and between H. pylori positive and negative gastritis, using the Sydney system. A total of 122 patients (42 duodenal ulcer, 31 chronic gastritis, 35 gastric ulcer and 14 gastric cancer) underwent endoscopy with biopsies from the antrum and body. Among the 122 patients, 104 (85%) were H. pylori positive. H. pylori density of the antrum was significantly higher in duodenal ulcer than in chronic gastritis, gastric ulcer, and gastric cancer. The positivity of intestinal metaplasia was lowest in duodenal ulcer and highest in gastric cancer. H. pylori density as well as grade of activity, inflammation and atrophy were significantly higher in the antrum than in the body in duodenal ulcer, while in chronic gastritis, gastric ulcer and gastric cancer there was no difference of H. pylori density, activity, inflammation and atrophy between the antrum and body. The grade of activity and chronic inflammation were significantly higher in H. pylori positive patients than in H. pylori negative patients in both the antrum and body. In conclusion, the gastritis of duodenal ulcer was mainly localized to the antrum, while the gastritis of chronic gastritis, gastric ulcer or gastric cancer was rather uniform in the antrum and body. H. pylori seemed to be related to the development of chronic inflammation and activity.

Antigenic diversity and serotypes of Helicobacter pylori associated with peptic ulcer diseases

OBJECTIVES: Clinical presentation of Helicobacter pylori (H. pylori) infection has marked variation mainly due to the strain diversity and host susceptibility. Although H. pylori is identified as a major risk factor for gastric and duodenal ulcers, the ulcerogenic or pathogenic strain has not been documented yet. The objective of this study was to investigate antigenic types of the ulcerogenic strain of H. pylori. METHODS: The sera of 64 patients were tested by Western blot using Helicoblot 2.0 for six major anti-H. pylori antibodies, together with CLO test and histological examination of gastric biopsy tissues. Thirty-five, nine and 20 patients had duodenal ulcer, gastric ulcer and chronic active gastritis, respectively. The antigenic types of H. pylori were analyzed in 54 patients with positive H. pylori infection. In this study, H. pylori was divided into four serotypes according to the presence and absence of CagA and VagA: type I; CagA (+) and VacA(+), type Ia: CagA (+) and VacA(-), type Ib: CagA(-) and VacA(+), and type II: CagA(-) and VacA(-). RESULTS: There was no difference in the number of bands for six antigens: 3.2 +/- 1.4, 3.0 +/- 1.2 and 3.1 +/- 1.4 in 35 duodenal ulcer, 7 gastric ulcer and 12 chronic gastritis, respectively. The band with 119 kDa was 90.7%, which was the most common band with the order of 35, 30, 26.5, 89 and 19.5 kDa. Type I, la and Ib were positive in 22.2, 42.6 and 27.8%, respectively, which were significantly higher than type II (p < 0.05). There was no difference in the positive rates of four urease subtypes between the four serotypes.

Lesiones endoscopicas del tracto digestivo superior en pacientes urémicos / Endoscopy lesions of upper gastrointestinal tract in uremics patients

Se estudia la frecuencia de lesiones endoscópicas del tracto digestivo superior en pacientes urémicos en tratamiento con tres modalidades diferentes: hemodialisis(HD), diálisis peritoneal ambulatoria crónica (DPAC) y tratamiento médico (no dialítico). Los tres grupos estudiados totalizaban 27 pacientes, distribuidos de la siguiente forma: 11 pacientes en HD, 9 en DPAC y 7 en tratamiento médico, todos estaban en control médico en los Servicios de Medicina Interna y Nefrología del Hospital "Antonio María Pineda" de la ciudad de Barquisimeto. El estudio, de tipo prospectivo, fue realizado entre los meses de noviembre de 1993 y julio de 1994. La selección de los pacientes fue realizada al azar. Los tres grupos estudiados no diferían de forma significativa en cuanto a edad, sexo, sintomatología digestiva previa, enfermedad concomitante o datos paraclínicos (hemoglobina, hematocrito, úrea, creatinina, calcio, fósforo, sodio y potasio sérico). Todos los pacientes fueron sometidos a endoscopia digestiva superior, encontrándose que las lesiones más frecuentes fueron la úlcera duodenal y la doble lesión gastro-duodenal. El grupo de tratamiento más afectado fue el de hemodiálisis. Del presente estudio puede concluirse que las lesiones gastroduodenales son muy frecuentes en los pacientes urémicos y que la endoscopia digestiva superior debería realizarse de forma periódica y regular a todos los pacientes urémicos, aun a aquellos sin síntomas digestivos previos.

Estudo de lesöes mucosas gástricas associadas às úlceras cloridro-pépticas durante gastrectomias parciais através do uso do vermelho congo / Study of the gastric-mucosal lesions associated to chloridro-peptic ulcer during partial gastrectomy using congo red dye

A identificaçao da secreçao ácida pela mucosa gástrica, através da propriedade metacromática do corante vermelho congo, tem sido utilizada para identificar no corpo gástrico, áreas nao produtoras de ácido, na tentativa de estabelecer a relaçao entre gastrite e úlcera cloridro-péptica duodenal (UCPD). Trinta e três pacientes com UCPD, estenosante ou refratária ao tratamento clínico, foram submetidos à gastrectoinia parcial com reconstruçao a Billroth II. Uma vez aberta a cavidade abdominal, o vermelho congo era infundido no lúmen gástrico e, a secreçao ácida era estimulada através do uso de cloridrato de betazole. Coloraçao metacromática azul era observada no corpo gástrico, exceto em poucas áreas isoladas que eram enviadas para observaçao, juntamente com o restante da peça. Estudo histopatológico revelou que 90,0 por cento (30 dos 33 pacientes) apresentaram gastrite crônica superficial, dos quais 33,36 por cento (l2 dos 30 pacientes) tinham metaplasia intestinal. Observou-se também em 6 pacientes (l8,18 por cento) gastrite crônica atrófica. O uso do corante vermelho congo tem-se mostrado válido na delimitaçao do corpo (cor azul) e do antro (cor vermelha), ajudando a identificar áreas nao descoradas, associadas a UCPD. Estes achados sugerem que a úlcera duodenal ocorre em uma mucosa gástrica previamente inflamada. Os autores acreditam que a refratariedade ao tratamento clínico de seus pacientes, possa ter sido devida a mucosa gástrica alterada, sendo um fator de contribuiçao para o desenvolvimento da UCPD.

Estudio prospectivo de erradicación de helicobacter pylori en ulcerosos duodenales: análisis de biopsias de antro y cuerpo gástrico / Prospective study of helicobacter pylori erradication in duodenal ulcer patients: analysis of antral and gastric body biopsies

Omeprazole may not eradicate helicobacter pylori from the stomach but rather displace it from the antrum to the stomach body. This fact could interfere with colonization studies in patients receiving the drug. The aim of this study was to assess the presence of helicobacter pylori, defined as a positive wrease test, culture or microscopical examination, in antral and gastric body biopsies in patients receiving treatment with omeprazole. Sixty four paired antral and gastric body biopsies obtained at the end of a 28 day course of omeprazole, 62 obtained 4 months later, 40 obtained 8 months later and 23 obtained 12 months later were analized. there was a 92 percent concordance between antral and gastric body biopsies for the presence of helicobacter pylori. However, 9 of the samples obtained at 28 days (14 percent) were negative for H. pylori in the antrum but positive in the gastric body. It is concluded that for early assessment of helicobacter pylori eradication after omeprazole treatment, paired biopsies of antral and gastric body are needed

Serum pepsinogen A and pepsin secretion in duodenal ulcer: helicobacter pylori influence

El pepsinageno sérico A (PGA) y la actividad péptica total (PA) en jugo gástrico, son investigados en 87 pacientes con úlcera duodenal. Los resultados indican un significativo aumento del PGA y PA en relación a controles. Los pacientes con úlcera duodenal, Helicobater Pylori positivo muestran el aumento del PGA no habiendo variaciones en el PA. Este contraste puede deberse a varios factores: dado que los dos parámetros son expresión de actividades celulares distintas y el PA en jugo gástrico es expresión del pepsinógeno total. Se puede concluir que el daño del HP sobre la mucosa duodenal es debido a su acción y no a la alteración de la actividad péptica en jugo gástrico

Histology of the mucosa of gastric antrum and body before and after eradication of Helicobacter pylori

1. Helicobacter pylori status and the histology of the antral and oxyntic mucosa were evaluated in 25 patients with duodenal ulcer treated with a triple schedule of furazolidone, metronidazole and amoxicillin, and in 16 patients treated only with cimetidine. 2. Before treatment, H. pylori was detected in all patients. One month after treatment with the antimicrobial agents, H. pylori was not found in 18 (72.0 per cent ) of 25 patients treated with the triple schedule. In the patients treated with cimetidine (N = 16) the H. pylori tests continued to be positive after treatment. 3. Inflammatory activity and intensity of gastritis were significantly reduced in patients treated with the antimicrobial agents but not in cimetidine-treated patients. Three patients who had negative cultures and improvement of gastritis 1 month after treatment became H. pylori positive again within 2 months, with concomitant reappearance of gastritis. 4. This study provides additional evidence that histological gastritis observed in H. pylori-positive patients with duodenal ulcer is due to the presence of the microorganism

Gastric chief cell mass in duodenal ulcer

A 25 pacientes ulcerosos duodenales y 40 controles sanos se les calculó la massa de células principales y el Pepsinogeno serico I. Se comparó también con la masa celular parietal y la secreción ácida estimulada. La masa celular principal fue expresada por el índice Zinogenico (IZ) obtenido multiplicando al número de células principales por mm2 por el espesor de la capa glandular. Se encontró una significativa disminución del IZ en pacientes com úlcera duodenal que en controles. El agrupamiento según la edad por encima y debajo de 50 anos, confirma que el IZ disminuye significativamente en ulcerosos duodenales en relación a controles. No hay cambios de IZ en ulcerosos duodenales con gastritis fundica superficial en comparación con aquellos con mucosa fundica normal. El pepsinógeno serico II está aumentado en pacientes ulcerosos con gastritis fundica superficial en relación a los que tienen mucosa normal. Se observa hipopesinogenemia en pacientes con hiperparietolismo y normopepsinogenemia en los pacientes con normoparietolismo. Finalmente no se observa correlación entre índice Zinogenico y Pepsinógeno serico I

Ulcera duodenal, metaplasia gástrica y helicobacter pilory

La relación entre H.P. metaplasia gástrica y gastritis antral fue evaluada entre 50 pacientes con úlcera duodenal activa. Todos ellos se sometieron a evaluación endoscópica y biopsia del antro y del duodeno. La investigación del H.P. y de la metaplasia gástrica en las biopsias se realizaron mediante tinción con hematoxilina-eosina. La prevalencia de H.P. fue del 70 por ciento en la muestra estudiada. La presencia de H.P. más metaplasia gástrica en el bulbo se encontró en el 44 por ciento de los casos estudiados. No hubo ni metaplasia gástrica ni H.P. en el bulbo en el 56 por ciento. Estos datos indican que el H.P. es positivo en el bulbo sólo cuando concomitantemente está presente mucosa gástrica metaplasiada en el bulbo. En este caso se entiende facilmente la patogenia del H.P. en el desarrollo de la U.D. No así cuando la bacteria está presente solamente en el antro.

Gastrite crônica associada ao Helicobacter pylori em pacientes com dispepsia näo ulcerosa e com úlcera duodenal / Chronic gastritis associated to Helicobacter pylori in patients with non-ulcerating dyspepsia and with duodenal ulcer

Prevalência da gastrite crônica e da infecçäo da mucosa gástrica por Helicobacter pylori em pacientes com dispepsia näo ulcerosa e com úlcera duodenal. Tipo de estudo, local, pacientes: Foram estudados, prospectivamente, 48 pacientes consecutivos com dispepsia näo ulcerosa (DNU) do tipo dismotilidade e 13 pacientes consecutivos com úlcera duodenal (UD) em atividade, selecionados no ambulatório de Gastrenterologia do Hospital das Clínicas da Universidade Estadual de Campinas (Unicamp). Intervençöes: Em cada um dos pacientes, foram realizadas oito biópsias endoscópicas (quatro do corpo e quatro do antro gástrico), para identificaçäo do H. pylori, utilizando-se três testes: urease, gram e exaqme histopatológico. Medidas e resultados: Nos 48 pacientes com DNU, o teste de urease foi postivo em 89,6% no antro e 81,2% no corpo; o gram foi positivo em 81,2% no antro e em 77,1% no corpo; e o H. pylori foi identificado no exame histopatológico em 79,2% no antro e em 70,8% no corpo gástrico. Na mucosa do antro gástrico de todos os 48 pacientes com DNU, pelo menos um dos três testes empregados foi positivo. Em todos os 13 pacientes com UD, os três testes foram positivos no antro gástrico, todos com gastrite crônica do antro no exame histopatológico. Gastrite crônica do corpo gástrico, com presença do HY. pylori no exame histopatológico, foi encontrada em 10 dos 13 pacientes. O teste de urease foi positivo na mucosa do corpo gástrico em todos os casos de UD. Conclusöes: Os autores acreditam que a alta prevalência dos testes empregados para identificaçäo fo H. pylori nos pacientes com DNU possa ser explicada pelo grupo selecionado de pacientes pertencentes a uma classe socioeconômica menos favorecida. A presença do H. pyloru na mucosa gástrica de todos os pacientes com UD está de acordo com algums trabalhos já publicados