Detection of small bowel tumors by videocapsule endoscopy in patients with acromegaly.

The prevalence of colon polyposis andmalignancies is increased in acromegalic patients as compared to the general population. An epidemiological study suggests a high prevalence also of small bowel (SB) tumors that nowadays may be detected by videocapsule endoscopy (VCE). The aim of the study was to assess the prevalence of SB neoplasms using VCE in acromegalic patients in comparison to control subjects and to correlate it with cancer risk factors and acromegaly-related parameters. Eighteen acromegalic patients (6 males and 12 females, age+/-SD: 54+/-10 yr), 5 cured after surgery (followed by radiotherapy in 3 cases) and 13 on pharmacological treatment were enrolled, and 36 sex- and age-matched non-acromegalic subjects served as a control group. Cancer risk factors, duration of acromegaly, GH and IGF-I levels, IGF binding protein 3 and IGF-II concentrations, metabolic parameters, tumor markers, colonic lesions by total colonoscopy, and SB lesions by VCE were investigated. VCE images suggestive of SB lesions were detected in 5/36 controls [14%, 4 described as gastrointestinal stromal nodular tumors (GIST), and 1 as polyp] and in 5/18 acromegalic patients [28%, 2 GIST and 3 polyps]. In acromegaly, the calculated relative risk for all SB lesions was 1.69 [95%confidence interval (CI): 0.78-3.65], while the relative risk for SB polyps was 2.50 (95% CI: 1.23-5.07). The effective duration of active disease was longer in patients with positive than in those with negative VCE (112+/-89 vs 49+/-40 months, p=0.06). In conclusion, these preliminary results suggest that acromegalic patients might have a high risk of SB polyp development. VCE might be a useful adjunctive diagnostic tool in acromegaly.

Prospective multicenter quality assessment of endotherapy of biliary stones: does center volume matter?

BACKGROUND AND STUDY AIMS: To study the effectiveness of endoscopic treatment for biliary stones in a large case list of patients treated in units with different experience and different workloads in a region of northern Italy. PATIENTS AND METHODS: We prospectively studied 700 patients undergoing endoscopic retrograde cholangiopancreatography or sphincterotomy, in 14 units (> or < 200 examinations/year), for their first treatment of biliary stones. The difficulty of the examinations, the results in terms of clearance of the stones, and the late outcomes (24 months) were recorded. A questionnaire (GHAA-9modified) was administered 24 hours and 30 days after the procedure to measure patient satisfaction. RESULTS: There were six units with a heavy workload and eight with a light schedule. There were 176 (25.1 %) difficult examinations (Schutz grades 3, 4, and 5). Stones were found in 580 (82.9 %) and were cleared in 504 of these patients (86.9 %). No differences were observed in the clearance of stones for the different groups of difficulty and high- and low-volume centers. Over the 24-month follow-up period, 96 patients (13.7 %) complained of recurrent symptoms and 44 (6.3 %) had proof of stones. In all, 603 questionnaires were evaluable and more than 80 % of patients expressed satisfaction. CONCLUSIONS: Our findings confirm the effectiveness of endoscopic treatment of biliary stones. However, the number of patients with symptoms (13.7) after 24 months, with or without persistence of stones, was not insignificant. It is feasible to record patient satisfaction, and in this series patients stated they were satisfied. Criticism mostly concerned pain control and explanations provided before the examination.

Biophysics and clinical practice for regenerative processes in cirrhosis of the liver/of liver cirrhosis assisted by Delta-S Entropy Variation Systems.

AIM: The therapy in question uses an innovative bioengineering device denoted as ''Delta-S DVD Entropy Variation System''. Previous research indicated regression of cirrhosis as evaluated in its morphofunctional and symptomatological aspects. The aim of the study is to confirm and extend previous experimental observations by enhancing hemodynamic evaluation techniques. In order to clarify scar regression, it was decided to include in the endpoints a quantitative evaluation of portal hypertension called HVPG, which is sensitive to the breakdown of hepatic architecture and the influence of regeneration nodules and therefore the advance of cirrhosis. METHODS: The experimental design consists of a self-controlled study carried out on Child A-B cirrhosis patients with portal hypertension (hepatic venous pressure gradient, HVPG > or = 10 mmHg). Five patients were enrolled, 4 HCV positive, one with autoimmune cirrhosis, all showing extensive symptoms. RESULTS: At the end of the treatment all patients showed a reduction in portal hypertension (mean reduction HVPG = 40.2%, P<0.011), together with an improved ultrasound flowmeter pattern and a sharp decrease or disappearance of the symptoms. No adverse effects were reported. Efficacy on autoimmune cirrhosis was unaffected. CONCLUSIONS: By means of a quantitative analysis of portal hypertension and of functional aspects, this study confirms that the Delta-S DVD system can lead to the regression of the scar component of cirrhosis, promote the regeneration of functioning liver tissue with positive effects on hepatic functionality and prevent symptoms and the risk of varicose vein rupture.

The aging gut motility decay: may symbiotics be acting as "implantable" biologic pace-makers?

Motility recording of small and large intestine was performed in old Wistar rats divided into three groups: (a) standard diet, (b) standard diet plus a symbiotic preparation, and (c) standard diet plus a heat-inactivated symbiotic preparation. SCM-III. significantly increased the myoelectric activity of small intestine and colon (p < 0.01 versus [a] and [c]) paralleling "young" values of 4-month-old rats and increased the spike burst frequency in the proximal-distal colon (p < 0.05). SCM-III significantly increased the frequency and duration of spike bursts in the jejunum, transverse-distal colon, and defecation frequency, while decreasing the intervals of migrating motor complex in the colon (p < 0.01) to "young" values with an increased mRNA expression of VIP (p < 0.05). Gut flora manipulation aimed to modulate myoelectric activity can tentatively help reversing age-related motility decay.

Preventive strategy for Candida gut translocation during ischemia-reperfusion injury supervening on protein-calorie malnutrition.

OBJECTIVE: The aim of the present study was to test the hypothesis that protein-calorie malnutrition aggravates the gut translocation of Candida albicans triggered by mesenteric ischemia-reperfusion (IR) injury in an experimental model while testing a natural product containing the antifungal anethole/polygodial mixture (Kolorex). METHODS: MFI strain white mice (n = 90) were randomly allocated to a 4-week dietary regimen: (1) standard pellet diet containing 25% casein; (2) low-protein (2.5%) casein diet; (3) as group 2 plus oral supplementation with 20 microL of a 5% solution of Kolorex during the last 4 days. Twenty rats from each of these groups (termed 1a, 2a and 3a) were orally inoculated with Candida suspension 6 h prior to mesenteric IR injury. Animals of each group but without Candida inoculation (termed 1b, 2b and 3b) served as control. A colon permeability study was carried out as well. Rats were killed prior to the IR injury and 3 h afterwards. Control rats were killed at the same time. RESULTS: Over 60% of the mesenteric lymph nodes and 30% of kidney samples were positive for C. albicans in the low-protein-fed rats after IR injury. Kolorex significantly decreased that rate of positivity and also significantly reduced the concentration of C. albicans per gram of each positive tissue sample examined. Protein-calorie malnourished animals showed a statistically significant increase in colon permeability and this phenomenon further increased after IR injury. The groups of rats treated with Kolorex compound showed a partial, although significant, improvement of this parameter. CONCLUSIONS: These results suggest that Kolorex might exert a competitive effect against with C. albicans colonization. The present study represents the first experimental in vivo investigation of the anethole/polygodial-containing compound under the specific conditions of calorie-protein malnutrition and the results have potential clinical interest.

Experimental acute alcohol pancreatitis-related liver damage and endotoxemia: synbiotics but not metronidazole have a protective effect.

OBJECTIVE: The aim of this study was to test the effect of gut manipulation by either novel synbiotics or by metronidazole on either endotoxemia or the severity of liver damage in the course of acute pancreatitis from alcohol ingestion. METHODS: Sprague-Dawley rats were fed for 1 week through an intragastric tube a liquid diet with either: (i) 1 mL t.i.d. of a mixture of synbiotics (Lactobacillus acidophilus, Lactobacillus helveticus and Bifidobacterium in an enriched medium); (ii) 20 mg/kg t.i.d. metronidazole; or (iii) standard diet. Then, acute pancreatitis was induced by caerulein and when the disease was full-blown, rats were fed an alcohol-rich diet. Synbiotic and metronidazole treatment was given for a further 2 weeks. Transaminase and endotoxemia levels were measured before treatment, after 6 h, after 24 h and 2 weeks later, at the time the rats were killed. Liver samples were obtained for histological analysis. RESULTS: Synbiotics but not metronidazole improved the acute pancreatitis-induced increase in endotoxemia and transaminase levels. The addition of alcohol worsened these variables to a limited extent in the synbiotic-treated group, while metronidazole had a negative effect on liver damage. CONCLUSIONS: Gut flora pretreatment with synbiotics was able to effectively protect against endotoxin/bacterial translocation, as well as liver damage in the course of acute pancreatitis and concomitant heavy alcohol consumption. The beneficial effect of synbiotics on liver histology seems to be correlated with endotoxemia. Metronidazole did not produce such a beneficial effect; in fact, it further worsened liver damage when alcohol was added to the background of ongoing acute pancreatic inflammation.

Single-blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome.

OBJECTIVE: Experimental and clinical studies have shown that a novel symbiotic (known as SCM-III) exerts a beneficial effect on gut translocation and local and systemic inflammatory and microbial metabolic parameters. The present investigation was a preliminary trial on the effectiveness of SCM-III for irritable bowel syndrome (IBS). METHODS: Sixty-eight consecutive adult patients with IBS who were free from lactose malabsorption, abdominal surgery, overt psychiatric disorders and ongoing psychotropic drug therapy or ethanol abuse were studied prospectively and divided into 2 groups that were comparable for age, gender, body size, education and pattern of presenting symptoms. The 2 groups were blindly given for 12 weeks either SCM-III 10 mL t.i.d or the same dosage of heat-inactivated symbiotic. RESULTS: Treatment with SCM-III was 'effective' or 'very effective' in more than 80% of the patients (P < 0.01 vs baseline values and control). Less than 5% reported 'not effective' as the final evaluation compared with over 40% of patients in the control group. After 6 weeks of treatment, a significant improvement of pain and bloating was reported in the treatment group compared with control and baseline values. There was also a benefit for bowel habits, mostly for patients with constipation or alternating bowel habits. No overt clinical or biochemical adverse side-effects were recorded. CONCLUSION: Compared with baseline values and the control group, SCM-III resulted in a significant increase in lactobacilla, eubacteria and bifidobacteria, which suggests that some selected IBS patients could benefit substantially from symbiotics, but the treatment may need to be given on a cyclic schedule because of the temporary modification of the fecal flora.

The aging/precancerous gastric mucosa: a pilot nutraceutical trial.

The aim of this study was to test the effect of antioxidant supplementation on enzymatic abnormalities and free radical-modified DNA adducts associated with premalignant changes in the gastric mucosa of elderly patients with HP-negative atrophic gastritis (CAG). Sixty patients with atrophic gastritis and intestinal metaplasia underwent a nutritional interview and a gastroscopy with multiple biopsy samples in the antrum that were processed for histology and for assaying: alpha-tocopherol, MDA, xanthine oxidase (XO), ornithine decarboxylase (ODC), and 8-OHdG. Patients were randomly allocated into three matched groups and supplemented for 6 months with (1) vitamin E, 300 mg/day; (2) multivitamin, two tablets t.i.d.; and (3) Immun-Age 6 g/day nocte (ORI, Gifu, Japan), a certified fermented papaya preparation with basic science-validated antioxidant/immunomodulant properties. Ten dyspeptic patients served as controls. Histology and biochemistry were blindly repeated at 3 and 6 months. CAG patients showed a significantly (P <.05) increased level of mucosal MDA and XO concentration that were reverted to normal by each supplementation (P <.05). All supplements caused a significant decrease of ODC (P <.01), but Immun-Age yielded the most effective (P < 0.05) and was the only one significantly decreasing 8-OhdG (P < 0.05). These data suggest that antioxidant supplementation, and, namely, Immun-Age, might be potential chemopreventive agents in HP-eradicated CAG patients and especially in the elderly population.

Chemopreventive effect of a probiotic preparation on the development of preneoplastic and neoplastic colonic lesions: an experimental study.

BACKGROUND/AIMS: A number of studies have suggested a key role played by certain resident gut bacteria in the development of large bowel cancer. The aim of the present study was to test the effect of a novel symbiotic preparation, which has been recently shown to beneficially modify gut ecosystem and systemic immunity, on either preneoplastic and neoplastic changes in a colon carcinogenesis model. METHODOLOGY: Sprague-Dawley rats were fed a standard diet for 1 week and then were randomly assigned to three groups. The control diet was given to groups A and B, whereas in group C, the same diet plus 2 mL of a probiotic mixture was given throughout the experiment. Thirty rats (groups B, C) each received a weekly subcutaneous injection of azoxymethane at a dose of 15 mg/kg of body weight for 10 weeks. Group A served as a control group and received a subcutaneous injection of saline for 10 weeks. Forty-five rats were sacrificed at 3-week observation and 60 rats at 20-week observation for assessing metaphase index together with aberrant crypt foci and intestinal immune system markers from one hand and tumor occurrence from the other, respectively. RESULTS: Group A showed a significantly increased metaphase index either in aberrant crypt foci or in "normal appearing" crypts when compared to group A (p < 0.01). Group B rats caused a significant decrease at both sites (p < 0.05). The numbers of lymphocytes derived from the mesenteric lymph nodes in group B rats were significantly decreased (p < 0.01) as compared to either control and to group C. The percentage of CD8 lymphocytes in group C was significantly higher than that in group B. Group C showed a significantly reduced ratio of aberrant crypt foci/colon and of aberrant crypt per colon and per each single focus (p < 0.05). A total of 18 (90%) group B and 10 (50%) group C rats had colon tumors, this difference was significant. The mean number of colon tumors per rat was 2.2 and 1.0 in group B and C, respectively. CONCLUSIONS: Effective probiotics treatment, through mechanisms still to be fully elucidated (decreased fecal pH, specific reduction of carcinogenetic bacterial enzymes, modulation of gut-associated and systemic immune system etc.) has the potential to exert significant antimutagenic properties against colon cancer.

Ethanol-related gastric mucosal damage: evidence of a free radical-mediated mechanism and beneficial effect of oral supplementation with bionormalizer, a novel natural antioxidant.

Twenty-two healthy teetotal volunteers underwent gastroscopy during which biopsy samples from the antrum and body were taken for chemiluminescence assay, routine histology, and for malonyldialdehyde, xanthine oxidase and glutathione determination. Subjects were divided into 2 groups which, in a double-blind fashion, were randomly and orally given either (a) Bionormalizer 9 g at bedtime and 3 h prior examination, or (b) flavored sugar 9 g as placebo. During the second gastroscopy 40 ml of 80% ethanol were sprayed perendoscopically. Gastroscopy with biopsy was repeated 60 min later. As compared to the placebo group, subjects given Bionormalizer showed significantly reduced gastric mucosal damage at endoscopy and the histological level. When considering the placebo group, ethanol administration brought about a significant increase in the luminol-amplified chemiluminescence response in gastric mucosa as compared to the baseline value which was correlated with the histological score. The mean chemiluminescence value in the Bionormalizer group was significantly lower than in the placebo group. Ethanol ingestion brought about a significant increase in xanthine oxidase and malonyldialdehyde together with a decreased glutathione concentration. Bionormalizer significantly prevented such changes. The present data suggest that the natural antioxidant Bionormalizer when given orally promotes an effective protection against ethanol-induced gastric mucosal damage.

Intramuscular beta interferon for chronic hepatitis C: is it worth trying?

BACKGROUND AND AIMS: The intramuscular use of beta interferon has been tested in the treatment of chronic hepatitis C, but it did not prove effective when the schedule was 3 million units three times a week for six months. Since the lack of effectiveness of this treatment might be due to the low bioavailability of beta interferon when administered intramuscularly, we tested a higher dosage of the drug: 6 million units three times a week for twelve months. PATIENTS AND METHODS: Ninety-two patients were randomized to receive, intramuscularly, either 3 or 6 million units of natural human fibroblast beta interferon three times a week for 12 months. RESULTS: The short-term biochemical response was significantly more frequent in the group of patients who received the higher dosage of beta interferon: 21% vs 4.5% (p < 0.05). Nevertheless, a sustained biochemical response was obtained in only one patient (2%), who received the higher dosage of beta interferon. CONCLUSIONS: Since the better short-term response rate was obtained with the higher dosage of beta interferon, a further increase in the dosage might improve the short-term and, possibly, the long-term response to treatment. However, due to the high cost of beta interferon, this high-dose schedule would probably not be cost-effective in the treatment of chronic hepatitis C.

Treatment of chronic hepatitis B (HBeAg-HBV DNA-positive) with lymphoblastoid alpha interferon with or without corticosteroids: short- and long-term follow-up.

Efficacy and safety of therapy with lymphoblastoid interferon-alpha alone or combined with deflazacort has been investigated in 38 HBsAg-HBeAg+ patients with biopsy-proven chronic hepatitis. Group I received 5 MU/m2 interferon thrice a week for 26 weeks; group II took interferon for 26 weeks simultaneously with a 6-week course of deflazacort. Follow-up was 18-72 months (median 42). After 12 months, responses were achieved in 3 (18%) out of 17 patients on interferon alone vs 5 (26%, p > 0.05) out of 19 on combined therapy. Blind histological assessment revealed no improvement in either group or in patients who responded to therapy within the first year of follow-up ("early responders"). "Delayed" responses were observed in 4 (29%) patients who took interferon alone vs 5 (36%, p > 0.05) who took the combined therapy. Serum HBV DNA levels decreased significantly during treatment and remained low up to 24 and 36 months of follow-up in both groups. One early responder developed hepatocellular carcinoma, another had exacerbation of liver disease in long-term follow-up. No non-responders developed liver failure or hepatocellular carcinoma. These results indicate that lymphoblastoid interferon-alpha inhibits HBV replication and corticosteroids have no synergistic effect in treatment of HBsAg-HBeAg+ chronic hepatitis.

Nafamostat mesilate on the course of acute pancreatitis. Protective effect on peritoneal permeability and relation with supervening pulmonary distress.

Three hundred sixty Sprague-Dawley rats were allocated into four groups, according to different content of a 24-h i.v. infusion performed 1 h after intrabiliary injection of enterokinase/sodium taurocholate to induce acute pancreatitis (AP): (1) Saline; (2) 5 micrograms/kg/h nafamostat mesilate (FUT-175); (3) 10 micrograms/kg/h FUT-175; and (4) 25 micrograms/kg/h FUT-175. Peritoneal fluid was removed and exchanged with 1 mL 3.33 M fluorescein-isothiocyanate-conjugated (FITC) dextrans of 4000-40,000 Dalton. Serial blood samples were withdrawn and examined for FITC-dextrans, phospholipase A2 (PLA2), blood gases, amylase, and lipase. As compared to control (55%), FUT-175 brought about a lower (5 micrograms/kg/h: 25%) or no mortality (10 and 25 micrograms/kg/h), and a milder histological and biochemical evidence of AP. Untreated animals with PLA2 values over two times the standard deviation showed a respiratory distress. Further, unlike group 1, FUT-175 doses as low as 5 micrograms/kg prevented the increase in peritoneal permeability to small-size molecules (up to 20,000 Dalton). In a second experiment under the same drug protocol, 1000 U/mL of PLA2 and 2 mL of pancreatitis ascites were instilled ip. Peritoneal permeability to FITC-dextrans up to 30,000 Dalton and to PLA2 significantly increased in the saline group and in the 5 micrograms/kg FUT-175 group. However, 10 micrograms/kg and 25 micrograms/kg FUT-175 doses prevented such phenomenon. In conclusion, FUT-175 proves to be a potent antiprotease molecule with a biochemical activity also against PLA2 in vivo and prevents significant transperitoneal-blood access of pancreatic enzymes.

Duodenal bicarbonate secretion induced by human epidermal growth factor in rats is partially mediated by prostaglandins.

In the present study, the effect of graded intravenous infusions of human epidermal growth factor (hEGF) 0.005, 0.05 and 0.25 micrograms/ml, with or without 4 mg/kg i.p. indomethacin pretreatment, on rat duodenal bicarbonate secretion was investigated. Perfused duodenal loops were prepared in rats which were given intravenous infusions of hEGF with or without indomethacin. Duodenal pH and pCO2 were measured at 5-min intervals for 45 min, and bicarbonate secretion was calculated. Compared to control, each dose of hEGF caused a significant dose/response rise of duodenal bicarbonate secretion. Prostaglandin release was abolished by indomethacin pretreatment. Indomethacin-pretreated rats had a significant reduction of bicarbonate secretion which was still higher than in controls. These results provide evidence that duodenal bicarbonate secretion induced by hEGF is only partly accounted for by a prostaglandin-dependent mechanism.

Nadolol can prevent the first gastrointestinal bleeding in cirrhotics: a prospective, randomized study.

Propranolol has been reported to prevent the risk of hemorrhage in patients who survived episodes of variceal rupture. Since the first bleeding episode can be lethal, we did a prospective, randomized trial to see whether beta-blockers could also prevent the first hemorrhage. Seventy-nine consecutive cirrhotics with large esophageal varices by endoscopy and who had never bled were randomly allocated to one of the following treatments: placebo; ranitidine (300 mg per day), or nadolol (40 to 120 mg per day)--which is not cardio-selective, reduces portal hypertension and does not interfere with renal flow. Since no significant differences between ranitidine and placebo treatment were observed, the two groups were combined as the control group and compared with the nadolol group. After a mean follow-up of 24 months, only 1 of the 30 patients in the nadolol group had bled, while 11 of the 49 patients in the control group had bled. The percentages of patients who had not bled 1 and 2 years after the inclusion were 100 and 94.4% for the nadolol group and 81.2 and 70.2% for the control group (p less than 0.02), respectively. There were no differences in the mortality rate. In conclusion, nadolol significantly protects against the first gastrointestinal bleeding episode in cirrhotics.