Localized amyloid tumor in small bowel.

We report a case of localized jejunal amyloidosis occurring in a 74-year-old man who experienced an episode of digestive bleeding while he was receiving oral anticoagulation. It illustrates a rare entity, characterized by an endoscopic aspect of polypoid, pseudotumoral formations. Histologically, submucosal connective tissues, muscularis mucosae, and blood vessel walls are massively infiltrated by amyloid, giving a typical red/green birefringence under polarized light.

Gastric polyps.

Endoscopy allows a better diagnosis and treatment of gastric polyps. Current methodology includes a detailed examination of the stomach after good insufflation, necessary to diagnose small fundic polyps, biopsies of the polyp as well as of the surrounding mucosa (antrum and fundus). Endoscopy allows a preliminary diagnosis based on the number, location and size of the polyps. Resection is not performed at initial endoscopy as it is not necessary for all polyps and may be risky if vascular lesions are confused with polyps. Glandulocystic fundic polyps are the most frequent (50%), are always associated with a normal gastric mucosa and sometimes with omeprazole. Resection and follow-up are not indicated. Hyperplastic polyps represent 25% of gastric polyps, are located everywhere, with a mean size of 1 cm, and sometimes erosions or superficial necrosis. Gastritis is present, Helicobacter pylori is frequent and eradication may cause regression or disappearance of polyps. The small risk of cancer and the risk of bleeding increase with size. Polypectomy and follow-up are thus indicated in most cases. Adenomatous polyps, although similar in appearance to hyperplastic polyps concerning macroscopy and gastritis have a higher risk of cancer in the polyp or in the stomach. Polypectomy and follow-up are thus mandatory.

The 1998 national Belgian consensus meeting on HP-related diseases: an extensive summary. The HP Belgian contact group organized in CHU Brugmann, Brussels.

"HP testing must be regarded as ONE of the important elements of the proper diagnostic work-up of a DISEASE, managed in close cooperation between GP's and specialists": that's the key message of the national consensus meeting held in CHU Brugmann on February 6th and 7th 1998. HP testing (usually by 2 direct methods: RUT-histology) and eradication treatment (ER), in infected patients, are strongly recommended in: 1. Past or current GDU (absolute indication), regardless of activity, complication(s), NSAID intake; 2. Low-grade MALT Lymphomas (Stage IE1) unequivocally diagnosed, managed and followed-up in specialised centers; 3. Post endoscopic resection of EGC. ER is advisable in HP carriers with a family history of gastric cancer. Chronic atrophic-, lymphocytic-, giant folds gastritis and hyperplastic polyps are acceptable indications for ER as well as scheduled long-term NSAID treatment in individuals with known HP status. Systematic ER in HP+ patients with fully investigated NUD is not indicated but could be considered in individual patients. Extra alimentary disorders and auto immune gastritis are no indication and there was no consensus for a "test and treat" policy in patients under 45 yrs old without alarm symptoms. Systematic screening of asymptomatic individuals is not recommended. A correct monitoring of eradication after treatment is recommended, mainly by UBT. In severe or refractory PUD, symptom recurrence and follow-up of EGC and Maltomas, endoscopic follow-up with HP testing is mandatory. The recommended first line treatment course (except known allergy or intolerance) is PPI full dose bid, Clarithromycin 500 mg bid Amoxycillin 1000 mg bid (7 days minimal 10 days maximal). RBC-based schemes must be locally validated and quadruple therapy is proposed when retreatment is needed. Culture, optional after the first treatment failure, is strongly recommended after a second failure. Overall, ER therapies are safe and neither the decreased efficacy of acid-lowering drugs, nor the possible increased risk of peptic oesophagitis are considered as contra-indications to eradicate. ER is cost-effective and cost-beneficial in PUD and adjusted number of pills delivered would cut costs. No clear economic data are currently available for a potential benefit of ER in GC prevention or NUD management. A national monitoring of HP resistance (Macrolides and Imidazoles) must be organized by specialised centers.

Gastric ulcers and Helicobacter heilmannii.

OBJECTIVE: To compare 14 patients with gastric ulcer and Helicobacter heilmannii with other patients with gastric ulcer: age and sex matched patients, patients colonized by Helicobacter pylori and patients on nonsteroidal anti-inflammatory drugs (NSAIDs). SETTING: The endoscopy unit of a university-affiliated hospital. PATIENTS AND METHODS: All patients underwent endoscopy with two antral biopsies and smears from biopsies (touch cytology) in addition to biopsies of ulcers. Most patients had fundic biopsies (n = 10), antral biopsies for culture (n = 7) and/or a urease test (n = 9). Serologic determination of antibodies against H. pylori was obtained in nine patients. RESULTS: Patients with H. heilmannii diagnosed on smears from biopsies (touch cytology) had multiple and antral ulcers in 11 samples, and nodular or irregular lesions in five samples. No patient had a history of peptic ulcer disease. Biopsy revealed mild chronic gastritis in all patients, with features of reactive gastritis in nine. No patient had coexistent infection with H. pylori. Only two of ten patients with follow-up endoscopies had persistent H. heilmannii infection on smear or biopsy. No patient had symptomatic recurrence. Patients with H. pylori infection were older and often had recurrent ulceration. The majority of ulcers associated with NSAIDs occurred in elderly women. CONCLUSIONS: Newly diagnosed gastric ulcers are associated with H. heilmannii infection. Healing is associated with the disappearance of H. heilmannii and the regression of reactive gastritis. Ulcers differ from those associated with H. pylori infection or with the use of NSAIDs, suggesting that H. heilmannii is a possible cause of gastric ulcers.

Helicobacter pylori and gastric cancer. An endoscopic series.

In a series of 92 patients with gastric cancer who had biopsies of the antrum and fundus, we compared the 65 patients with Helicobacter pylori (71%) with the 27 negative patients. No difference was observed for age, gender or histology (intestinal or diffuse). Significant differences concerned location (11% of H. pylori positive patients had a cancer at the cardia or fundus vs 44%), the presence of a normal mucosa (3% vs 30%) and atrophy in the antrum (53% vs 17%). Seven of the ten patients with a normal mucosa had a cancer located at the cardia (p < 0.05) and in nine of the eleven patients younger than fifty, the cancer was of the diffuse type (p < 0.005). Thus, patients with H. pylori and gastric cancer differ from those uninfected. Of future concern is the large increase in cancers of the cardia, a cancer unassociated with H. pylori.

[Stomach ulcers and Helicobacter pylori. Clinical, endoscopic and histological characteristics]. / Ulcères gastriques et Helicobacter pylori. Caractéristiques cliniques, endoscopiques et histologiques.

OBJECTIVES: The aim of the study was to determine in a large group of patients with a gastric ulcer the differences between patients, ulcers and gastric mucosa as related to the presence or absence of Helicobacter pylori (H. pylori). METHODS: This prospective study evaluated 150 patients with a benign gastric ulcer. A patient was considered as H. pylori positive on the basis of a positive culture or the presence of gastritis and another positive diagnostic test for H. pylori (urease test, cytology, histology, serology). RESULTS: One hundred and five patients were positive for H. pylori (70%) whereas 45 patients were not infected (30%). There were significant differences regarding the clinical characteristics of patients, the ulcer and the mucosa. H. pylori positive patients differed in terms of past history of ulcer (63 vs 12%), age (57 vs 50 years), sex (48% males vs 24%) and consumption of non steroidal antiinflammatory drugs (39 vs 75%). H. pylori positive ulcers were more often single (79 vs 53%) and located on the small curvature (76 vs 33%). Chronic gastritis was always present in positive patients, with associated intestinal metaplasia (35 vs 2%) and atrophy (45 vs 9%). Negative patients often had a normal gastric mucosa (53%) or reactive gastritis (27%). CONCLUSION: Seventy percent of gastric ulcer are associated with H. pylori infection, corresponding to the classical ulcer. The majority of H. pylori negative ulcers appears to be associated to non steroidal antiinflammatory drugs.

[Carney's syndrome: 2 new cases]. / Syndrome de Carney: deux nouveaux cas.

The association of gastric leiomyoblastomas, pulmonary chondromas and extra-adrenal paragangliomas has been called "Carney's Triad" since 1977. It is incomplete when only two of these lesions are present. 42 cases has been published. We report observations of two young women with gastric leiomyoblastomas and pulmonary chondromas; one of them also had an adrenocortical adenoma.

Gastrospirillum hominis ("Helicobacter heilmanii"): a cause of gastritis, sometimes transient, better diagnosed by touch cytology?

OBJECTIVE: Besides Helicobacter pylori, another spirillar microorganism, provisionally called Gastrospirillum hominis, has been described in the human stomach in association with gastritis. The aim of this study was to assess the role of cytology in the diagnosis, to assess the gastritis associated with this infection, and to approach its natural history. METHODS: Charts and endoscopic biopsies and smears (touch cytology) from 28 patients with G. hominis seen between 1986 and 1992 were reviewed and compared with biopsies and smears from 28 patients with H. pylori gastritis. RESULTS: G. hominis was seen on smears from all 28 patients but diagnosed in only 15 of the corresponding sets of biopsies. No patient had evidence of H. pylori colonization. All patients had chronic antral gastritis with lymphoplasmocytes, and neutrophils were present in 13 patients. In addition, reactive changes were frequent: foveolar hyperplasia (n = 25), vasodilation (n = 23), lamina propria edema (n = 23), and increased intracytoplasmic mucin (n = 19). In contrast, intestinal metaplasia (n = 3) and glandular atrophy (n = 2) were infrequent, and lymphoid nodules were not seen. In patients with H. pylori, reactive changes were mild, and the lymphoplasmocytic infiltration was more intense (p < 0.005). Eleven patients had at least two endoscopic examinations with biopsies, with persistent colonization in only four. Seven patients cleared the infection with a concomitant regression of gastritis. CONCLUSIONS: G. hominis is more often detected in smears than biopsies. It is seen in association with a peculiar form of gastritis-associating chronic and reactive changes. Colonization may be a transient phenomenon and is never associated with H. pylori.

Are perforated gastroduodenal ulcers related to Helicobacter pylori infection?

The prevalence of Helicobacter pylori gastritis in 36 patients with a perforated ulcer undergoing endoscopy prior to or at least 2 months after perforation was 56%, intermediate between that of age and sex matched healthy blood donors (36%) who had measurement of circulating antibodies to Helicobacter pylori and of ulcer patients without perforation matched for age, sex and ulcer location (86%). In the 20 patients with Helicobacter pylori gastritis, 8 had a history of peptic ulcer and 7 of 9 patients with a follow-up of at least 12 months and no preventive treatment had a symptomatic relapse. The group of patients without infection included 6 young patients (< 40) who did not use non steroidal anti-inflammatory drugs and 10 older patients (> 60): 9 used non steroidal anti-inflammatory drugs and seven had a normal gastric mucosa on biopsy. One patient without Helicobacter pylori had a second perforation, the only relapse in this group. We conclude that patients with perforated ulcers are a heterogeneous group with a recurrent ulcer disease mainly in patients with Helicobacter pylori.

Helicobacter pylori: 200 patients with a follow-up of 5 years. An observation endoscopic study.

OBJECTIVES: As data on the long-term effects of Helicobacter pylori infection are limited, our aim was to review patients seen repeatedly at endoscopy with biopsies for a minimal period of 5 years. METHODS: The records of 200 patients who had at least two endoscopic examinations with antral biopsies and touch cytology (imprints from biopsies) with an interval of at least 60 months between the first and the last endoscopy. Helicobacter pylori diagnosis was based on the smear. RESULTS: At the first endoscopy, 57% had Helicobacter pylori on the smear, 70% had chronic gastritis on biopsy. During a mean follow-up of 70 months, a colonization rate of 3% per year and an eradication rate of 1% per year were observed. Helicobacter pylori status remained unchanged in 89%. During follow-up, duodenal ulcer was diagnosed at endoscopy in 21 patients, with a significantly (p < 0.05) higher frequency in Helicobacter pylori positive patients, in the presence of gastritis and in men. In two patients, the sequence of colonization and later duodenal ulcer was observed. CONCLUSION: Our retrospective observation study based on endoscopy confirms the chronicity of Helicobacter pylori infection and the low incidence of colonization and eradication. Duodenal ulcer occurred more frequently in Helicobacter pylori positive patients.

Touch cytology. A quick, simple, sensitive screening test in the diagnosis of infections of the gastrointestinal mucosa.

To assess the role of touch cytology (imprint from endoscopic biopsy specimens) in the diagnosis of mucosal infections of the gastrointestinal tract, we reviewed all records and specimens of patients seen during a 30-month period. Touch cytology was performed by rolling biopsy specimens on glass slides. After air fixation, a rapid staining method similar to May-Grünwald-Giemsa was used. The following infections and pathogens were diagnosed (in decreasing order of frequency): Helicobacter pylori gastritis (n = 53), Candida albicans esophagitis (n = 40), Giardia lamblia (n = 13), Gastrospirillum hominis (n = 11), and Blastocystis hominis (n = 8). The smear was positive in 45 patients with H pylori, in 35 patients with C albicans, in nine patients with G lamblia, in 11 patients with G hominis, and in eight patients with B hominis. Cytology was the only positive test in eight, nine, four, seven, and eight patients, respectively, and increased thus the diagnostic yield obtained by histologic examination.

Assessment of the new immunological test Hemoblot for detecting occult blood in faeces.

Hemoblot, a new immunological faecal occult blood test, produced by Gamma, Angleur, Belgium, was characterized and compared with another immunological test (HemeSelect, SmithKline Diagnostics, USA) and with a guaiac test (Hemoccult II, SmithKline Diagnostics). The analytical sensitivity of Hemoblot is 0.15 mg haemoglobin/g faeces and the test is specific for human haemoglobin. In addition, 135 symptomatic patients who had to undergo a colonoscopy were tested using the three tests. Two criteria were considered for the analysis: (1) the blood criterion: any pathology likely to cause colorectal or other bleeding; and (2) the precancerous-cancerous criterion: the pathology being either a colorectal polyp > 0.5 cm or a colorectal cancer. Considering both criteria, the sensitivity of Hemoblot was significantly higher than the sensitivity of Hemoccult: 38% and 23%, respectively, for the blood criterion; and 54% and 29% for the precancerous-cancerous criterion. Sensitivity and specificity did not differ statistically between Hemoblot and HemeSelect but Hemoblot was faster and simpler to perform. It could be widely used in mass screening.

Cytologic patterns of reparative processes, true dysplasia and carcinoma of the gastric mucosa.

The cytologic features of dysplasia and carcinoma of the stomach are still poorly defined. In a series of 90 cases, a precise correlation could be made between smears and histologic data. Cytology was sensitive enough to allow characterization of: (1) active repair/regeneration, associated, in a number of cases, with intestinal metaplasia (slight dysplasia); the cellular atypia is minimal; (2) true dysplasia (formerly moderate and severe); this preneoplastic state is characterized by cellular atypia within clusters; and (3) true carcinomas (intestinal or diffuse type); classic criteria for malignancy are present, with a prominent lack of cell cohesiveness, though distinction from dysplasia may be very difficult. The advantages of cytology are the survey of large mucosal areas, investigation of the cardial region, not always accessible to endoscopic biopsy, and exploration of large ulcers. With the adjunct of cytology, the specificity and sensitivity of endoscopy plus histology clearly increase.

[Hypersensitivity interstitial pneumopathy and ulcero-hemorrhagic rectocolitis: role of methotrexate]. / Pneumopathie interstitielle d'hypersensibilité et rectocolite ulcéro-hémorragique: rôle du methotrexate.

The authors report the case of a 46-year-old man with refractory ulcerative colitis treated with methotrexate who was admitted in the hospital for asthenia, fever, cough and dyspnea. Owing to the development of adult respiratory distress syndrome despite broad spectrum antibiotherapy, the patient was transferred to the intensive care unit. A diagnosis of pneumonitis due to methotrexate was made. Patient's condition improved after discontinuation of the drug, mechanical ventilation, and corticosteroids. The increasing use of methotrexate in several gastroenterological diseases warrants further consideration of the potential devastating side effects of this drug, particularly on the lungs. A review of the literature on this topic is provided in the "discussion" section.

[Validation and clinical and epidemiological use of a serologic test recommended in the diagnosis of Helicobacter pylori infection]. / Validation et usage clinique et épidémiologique d'un test sérologique commercialsié dans le diagnostic de l'infection à Helicobacter pylori.

A commercial serologic test using purified antigens of Helicobacter pylori has been evaluated in the diagnosis of this infection. In a series of 250 patients undergoing endoscopy with antral biopsies for cytology, histology and culture, serology was positive in 68 of 71 patients with a positive culture (sensitivity: 96%) and negative in 67 of 69 patients with a normal mucosa and no microorganisms on biopsy (specificity: 97%). In the entire series, serology was positive in 33 patients with no infection on biopsies (13%). In a group of 205 blood donors, we confirmed an increasing prevalence with age, ranging from 13% in subjects less than 30 years old to 38% in subjects more than 60 years old.

[Currents aspects of H2 receptor antagonists in the treatment of ulcers]. / Actualité des antagonistes des récepteurs H2 dans le traitement de l'ulcère.

Inhibition of H2 receptors has been the first fully evaluated treatment of peptic ulcer and remains the most widely used mode of therapy. In this review, we summarize the current data on clinical pharmacology, therapeutic indications and results of the four currently used drugs: cimetidine - ranitidine - pepticidine - nizatidine. Their similarities are stressed. Recent data are underlined. The superiority or necessity of a single evening dose is questioned, as well as the clinical importance of tolerance and rebound. The effect on gastric alcohol dehydrogenase is mentioned pending further work on the clinical importance of this discovery. In the acute treatment, the antisecretory potency is of major importance in duodenal ulcer, the duration of treatment in gastric ulcer. Maintenance treatment prevents complication as well as recurrence. H2 receptor antagonists remain a primary treatment of peptic ulcer.