Efficacy and safety of bowel cleansing solutions for colonoscopy: a prospective observational study.

BACKGROUND: The most critical factor determining the quality of colonoscopy results is the extent of bowel cleansing. AIM: This observational post-marketing study evaluated the efficacy, acceptability and safety of a range of the most commonly used bowel cleansing solutions in routine clinical practice. PATIENTS: Patients undergoing diagnostic, preventive or follow-up colonoscopy were recruited from 7 centres in Italy, Spain and Greece. METHODS: Quality of bowel preparation was assessed on a 5-point scale and included evaluation of visible bowel surface area and the amount and consistency of residual fluid. Patients evaluated ease of use and palatability. RESULTS: A total of 437 patients took part. Klean-Prep, the most commonly used preparation in this evaluation, achieved the highest score for quality of bowel cleansing and was rated as good or excellent in 72.0% of patients. In dosage-compliant patients, Klean-Prep showed better results in comparison to Fleet Phosphosoda (p < 0.05) in the maximum bowel level reached in the intestine during colonoscopy examinations. All of the bowel cleansing solutions were well tolerated. CONCLUSION: The polyethylene glycol-based preparations provided the most adequate cleansing and, of these, Klean-Prep provided the highest "good" or "excellent" level of bowel preparation.

Colloidal properties of aqueous suspensions of acid-treated, multi-walled carbon nanotubes.

Grafting oxygen-containing functional groups onto carbon nanotubes (CNTs) by acid treatment improves their dispersion in aqueous solutions, but there is a lack of quantitative information on the colloidal properties of oxidized CNTs. We have studied the influence that pH and electrolytes have in determining the colloidal stability of oxidized multiwalled carbon nanotubes (O-MWCNTs), prepared by refluxing pristine MWCNTs in nitric acid. The acid-treated MWCNTs contained oxygen predominantly in the form of carboxyl groups. Colloidal suspensions of O-MWCNTs were prepared by low-power sonication and contained negatively charged, individual MWCNTs with an average length of approximately 650 nm. Time-resolved dynamic light scattering revealed that the aggregation rate of O-MWCNTs exhibited both reaction and mass-transport limited regimes in the presence of different electrolytes and as a function of pH. Particle stability profiles constructed from aggregation rate data allowed for the determination of critical coagulation concentrations (CCC), a metric of colloidal stability. The CCC values of O-MWCNTs varied with counterion concentration and valence in a manner consistentwith DLVO theory. Potentiometric measurements of surface charge correlated well with the observed pH-dependent variations in the O-MWCNT's colloidal stability. Electrophoretic mobility was also a diagnostic of particle stability, but only in neutral and acidic conditions.

Management and outcomes of hepatic cirrhosis: Findings from the RING study.

BACKGROUND/AIM: Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology. MATERIAL/METHODS: More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU. RESULTS: Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8). CONCLUSIONS: Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Seasonal patterns of hospital treatment for inflammatory bowel disease in Italy.

AIM: It is still debated whether clinical flare-ups of chronic inflammatory bowel disease follow a seasonal pattern, and the various reports are based on general practitioners' records or hospital discharge charts. There are, however, no specific figures for treatment in hospital gastroenterology units, which serve as a reference point for these disorders. This study was therefore designed to investigate whether there is a seasonal pattern in admissions for inflammatory intestinal disease in Italy, differing from what is generally known about gastrointestinal pathologies, since there are no nation-wide figures on the subject. METHODS: The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 22 centers in Italy. RESULTS: From winter 2000 to autumn 2003, the 22 gastroenterology units participating in the RING project discharged 32,357 patients following ordinary hospital admissions. Of these, 2,856 (8.8%) had a main diagnosis of inflammatory bowel disease: 1,541 Crohn's disease, and 1,315 ulcerative colitis. No seasonal patterns were detected for either category, or when the analysis was done by age, sex and site of disease. CONCLUSIONS: The most serious flare-ups of inflammatory bowel disease, i.e. those requiring routine hospital treatment, do not appear to follow any seasonal pattern, regardless of the site of the disease or the patient's age or sex.

Quality of life for patients with gastroesophageal reflux disease 2 years after laparoscopic fundoplication. Evaluation of the results obtained during the initial experience.

BACKGROUND: Health-related quality of life (HRQL) is significantly affected by gastroesophageal reflux disease (GERD), and its evaluation is emerging as a factor important to select treatment options for GERD. Antireflux laparoscopic surgery improves HRQL. The aim of this study was to compare the preoperative and medium-term postoperative HRQL in patients submitted to laparoscopic fundoplication during the initial experience to verify its possible influence on HRQL outcomes. METHODS: Clinical assessment, endoscopy, and a previously validated HRQL index were performed before and 2 years after surgery in 32 patients who underwent at the beginning of our experience. RESULTS: The esophageal mucosa returned to normal 2 years after laparoscopic fundoplication in 81% of the patients. Heartburn was absent or occasional in 93%, and 65% were free of antisecretory drugs. All postoperative HRQL items were significantly improved (p <0.0001), with the postoperative curve of HRQL scores superposable to those of healthy Italian subjects (Italian normative sample). CONCLUSIONS: The initial phase of learning does not affect the improvement of HRQL observed after laparoscopic antireflux surgery, which is consistent with durable relief of symptoms and endoscopic healing. Evaluation of HRQL should be added to, and probably could replace in most cases, the objective postoperative testing.

[Multidimensional appraisal in patients suffering from chronic idiopathic constipation]. / Valutazione multidimensionale in pazienti affetti da stipsi cronica idiopatica.

A multidimensional appraisal of the patient suffering from chronic idiopatic constipation is used in this study. 16 consecutive patients affected by chronic idiopatic constipation defined by Rome criteria were enrolled. The following assessments were performed: radiological study of colorectal transit time using radiopaque markers, anorectal manometry, proctography, psychiatric appraisal, with the somministration of The Minnesota Multiphasic Personality Inventory 2, Hamilton Rating Scales for Depression, Hamilton Rating Scales for Anxiety, Toronto Alexithymia Scales, quality of life appraisal, by means of Short Form 36. The present study must be considered a pilot-study, lead on a limited champion of 16 cases; the reported data express therefore tendencies. Chronic idiopatic constipation appears to be a disturbance with a strong impact on the patient's quality of life. The study moreover confirms the hypothesis of a multifactorial genesis for chronic idiopatic constipation, in which psychopathological aspects (anxiety, depression and alessitimia in particular) and personality traits play a fundamental role, as much as the physiopathological alterations. Colorectal transit time study and anorectal manometry confirm to be valid instruments for the evaluation of physiopathological characteristics, useful for a classification of patients, particularly with respect to the presence of a normal or slowed colorectal transit and to the relief of pelvic floor dysfunctions. The differences between subgroups based on physiopathological characteristics, with respect to quality of the life and personality traits, expressed as tendency, need a confirm form studies lead on larger champions.

[Laparoscopic fundoplication in gastroesophageal reflux disease: reflexions on a personal caseload]. / Fundoplicatio laparoscopica per malattia da reflusso gastroesofagea (MRGE): riflessioni su una casistica personale.

Ninety-two patients with severe, proton-pump-inhibitor-dependent gastro-oesophageal reflux disease were submitted to surgery and operated on by the same surgeon (SC) over the past 7 years (mean age: 42; range: 23-74 years). Partial fundoplication was performed in 14 patients with impaired oesophageal motility, while 78 total fundoplications were done in the others, 51 without, and 27 with division of the short gastric vessels. The mean follow-up was 29.5 months (range: 1-85 months). Conversion to open surgery was necessary in 6 patients (all in the first 40 cases). Perforation of the gastric fundus and early migration of the stomach into the mediastinum were the two most important complications observed. The mortality was nil. 39% of the patients complained of postoperative dysphagia but only five required endoscopic (4) or surgical (1) treatment. The percentages of dysphagia after partial fundoplication and total fundoplication with or without division of the short gastric vessels were 28%, 37% and 47%, respectively. In 83.7% the patients were satisfied with the clinical results and in 84% of cases medical treatment was avoided after surgery. On the basis of these data, laparoscopic surgery appears to be a good option for gastro-oeophageal reflux disease in selected patients with a poor response to, or dependent on medical treatment. However, the results of surgery may be subject to the limitations of a learning curve, as in all complex laparoscopic procedures.

Focal oxyntic gland atrophy with endocrine cell hyperplasia in Zollinger-Ellison syndrome during omeprazole treatment.

Development of focal gland atrophy of the oxyntic mucosa was found in two patients with the Zollinger-Ellison syndrome undergoing long-term treatment with omeprazole. The atrophic areas revealed florid proliferation of endocrine cells in the form of both intraglandular crescents and micronodular hyperplasia. This proliferation was significantly more pronounced than in the remaining non-atrophic mucosa. The possible relationship of these changes to long-standing pharmacological therapy for gastric acid suppression is discussed.

Glycoprotein hormone alpha subunit in endocrine cells of human oxyntic mucosa. Studies on its relation to neuroendocrine tumors.

Expression of the alpha-subunit of glycoprotein hormones is an acquired feature of the endocrine cells of the oxyntic mucosa in patients with sustained serum levels of gastrin, and may be related to the hyperplasia-carcinoid sequence occurring in these patients. In the present study we have investigated the intragastric cellular localization and the circulating levels of alpha-subunit in a patient with Zollinger-Ellison syndrome. In this patient we have found that: 1) Endocrine cells accounted for 2.29% +/- 1.44% of the total oxyntic mucosal volume (normal value: 0.9% +/- 0.4%), with the ECL cells representing 63.22% +/- 10.9% of the total endocrine cell volume (normal value: 29.8 +/- 8.8%). 2) Cells immunoreactive for the alpha-subunit were found to correspond ultrastructurally to a subpopulation of enterochromaffin-like cells, indistinguishable from similar cells devoid of significant immuno-electron microscopic labeling. 3) Immunoreactive cells included a portion of oxyntic endocrine cells with punctate granules, a feature previously observed only in carcinoid tumors of the oxyntic mucosa. 4) In consecutive sections of freeze-dried vapor-fixed biopsies a fraction of alpha-subunit storing cells was found to co-express histamine. 5) The serum alpha-subunit levels were abnormally elevated and paralleled those of gastrin in a secretin-stimulation test. Analysis of similar curves in two other patients with Zollinger-Ellison syndrome, and five patients with hypergastrinemic atrophic gastritis, all presenting alpha-subunit containing oxyntic endocrine cells, showed significant alpha-subunit elevations only in the patients with ulcerogenic syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative electron microscopy of endocrine cells in oxyntic mucosa of normal human stomach.

An ultrastructural morphometric study of the endocrine cells of the oxyntic mucosa of the stomach in gastric biopsies collected from five male and five female healthy volunteers aged 19-31 was performed. No sex-related differences were disclosed. Endocrine cells accounted for 1.2 +/- 0.4% of the epithelial volume and 0.9 +/- 0.4% of the mucosal volume, i.e., including the lamina propria. After classification of the specific endocrine cell types according to the ultrastructural morphology of secretory granules, the volume densities of ECL, P and D cells (30 +/- 9%, 24 +/- 7%, and 22 +/- 4% of the entire endocrine cell mass, respectively) were higher than those of other endocrine cell types. In particular, EC cells contributed less than 10% and X cells represented a very low proportion of the total cells. Non-granulated profiles of cells which in all other respects appeared to be endocrine were also found with a volume density of 8 +/- 4%. D cells were distinguished by the high fraction of cytoplasm occupied by secretory granules (31 +/- 5%). Subdivision of the whole mucosa into four horizontal segments revealed the endocrine cells to be mostly distributed in the three lower, with virtually no endocrine cells in the superficial segment. The quantitative ultrastructural analysis of the endocrine cell population of the normal human oxyntic mucosa provided by this study may allow a better evaluation of physiological and pharmacological variations of the endocrine cell population.

Expression of glycoprotein hormone alpha-subunit by endocrine cells of the oxyntic mucosa is associated with hypergastrinemia.

Previous studies have shown that hyperplastic endocrine cells of the oxyntic mucosa in patients with atrophic gastritis may express immunoreactivity for the alpha-subunit of human chorionic gonadotropin (alpha-HCG, common to all glycoprotein hormones). Since this endocrine proliferation is regarded as dependent on the trophic effect of the concomitant hypergastrinemia, the relation between immunohistochemical expression of alpha-HCG by oxyntic endocrine cells and serum levels of gastrin were investigated. The study was performed on endoscopic gastric biopsies of the oxyntic mucosa from 49 patients subdivided into the following groups: A) with histologically normal mucosa and normogastrinemia (22 cases), B) with atrophic gastritis and normogastrinemia (12 cases), C) with normal mucosa and hypergastrinemia (Zollinger-Ellison syndrome, retained antrum) (7 cases) and D) with atrophic gastritis and hypergastrinemia (with or without pernicious anemia) (8 cases). The alpha-HCG immunoreactive cells were found in all hypergastrinemic patients (groups C and D), regardless of the concomitant pathological condition of the mucosa. These cells accounted for 7.8% to 44.7% of the number of Grimelius argyrophil cells in consecutive serial sections. In contrast, alpha-HCG-containing cells were exceptional or absent in most normogastrinemic patients. Their number was sizable in only two cases of group A and three cases of group B, where it ranged from 2.5% to 14.8% of the number of argyrophil cells. It was concluded that expression of alpha-HCG is another feature of oxyntic endocrine cells associated with hypergastrinemia in addition to those previously recognized such as development of hyperplasia and/or carcinoid tumors.

Ultrastructural characterization of fundic endocrine cell hyperplasia associated with atrophic gastritis and hypergastrinaemia.

Clinical and experimental evidence indicates that carcinoid tumours of the stomach fundic mucosa represent another example of hormone-dependent neoplasm, gastrin being the hormone involved in tumour induction. In this context hyperplasia of fundic endocrine cells associated with chronic atrophic gastritis (CAG) and hypergastrinaemia is regarded as the most frequent preneoplastic lesion. However, the cell type involved in this hyperplasia has not been clarified. To elucidate this problem fundic endocrine cells were characterized ultrastructurally in 9 patients from which endoscopic gastric biopsies were obtained. ECL cells were the most frequent cell type in 8 cases, in 4 of which they were more numerous than all other cell types taken together. D1 cells were the most frequent type in one case while they were inconspicuous in the other cases. P cells were found with a frequency in each case intermediate between that of ECL cells and that of D1 cells. These results indicate that fundic endocrine cell hyperplasia occurring in hypergastrinaemic CAG is in most cases cytologically similar to that found in other hypergastrinemic conditions, in which the gastrin-dependent ECL cells were already found to prevail. They also explain why fundic carcinoids arising in CAG are mostly composed of ECL cells. The relation between ECL, D1 and P cells, if any, remains obscure.

Argyrophil cell hyperplasia of fundic mucosa in patients with chronic atrophic gastritis.

Eighteen cases of severe hyperplasia of fundic argyrophil cells observed during routine histologic examination of endoscopic gastric biopsy specimens from unselected patients with upper gastro-intestinal symptomatology were investigated. All patients, except one, were female with a mean age of 57 years. Atrophic gastritis of fundic mucosa with severe hypo- or achlorhydria was present in all cases. Hypergastrinaemia (of antral origin) was found in 15 subjects in which circulating gastrin levels were determined. Pernicious anaemia was seen in 1 patient. At light microscopy, the hyperplastic fundic cells were stained by the Grimelius and the Sevier-Munger silver methods and, in approximately 30% of cases, by lead-haematoxylin. In addition, these cells reacted with anti chromogranin antibodies. In 8 of 9 patients studied by electron-microscopy, enterochromaffin-like (ECL) cells were found to be the more frequent cell type. D1 cells prevailed in 1 case and were rare in the others. The frequency of P cells was intermediate between that of ECL cells and that of D1 cells. In conclusion, our observations indicate that: argyrophil cell hyperplasia of atrophic fundic mucosa is prevalently found in women with hypergastrinaemia, and the hyperplastic process involves mostly the ECL type of gastric endocrine cells. It is noteworthy that similar associations have been shown to be present in patients affected by fundic carcinoid tumours and atrophic gastritis.

Clinical and pathological associations of argyrophil cell hyperplasias of the gastric mucosa.

A consecutive series of 357 endoscopic gastric biopsies was investigated after staining of histological sections with the Grimelius silver method. Argyrophil cells were classified according to the type of mucosa (fundic, antropyloric or intestinalized) in which they were located. Cases of argyrophil cell hyperplasia detectable on a qualitative basis were selected and their associations with various gastroduodenal disorders of the patients as well as with functional and pathological findings of the gastric mucosa were investigated. Hyperplasia of fundic argyrophil cells was more frequent in patients with atrophic gastritis of the fundic mucosa and a relatively well preserved antral mucosa as well as in patients with hyperplastic polyps. In contrast, it was infrequent in patients with duodenal ulcer and gastric stump. Hyperplasia of antropyloric argyrophil (non-G) cells was most frequent in patients with gastric peptic ulcer or with hyperplastic polyps as well as in those with atrophic gastritis of the fundic mucosa irrespective of the concomitant condition of antral mucosa. Hyperplasia of metaplastic argyrophil cells was more frequent in intestinal metaplasia of the antral mucosa than in that of fundic mucosa. Moreover, it was more frequent in patients with gastric cancer.