Evaluation of computerised questionnaires designed for patients referred for gastrointestinal endoscopy.

The aim of this prospective study was to assess the applicability of a computerised medical history system at the open-access endoscopy unit of a University Hospital during routine clinical practice. We studied feasibility, acceptability and reproducibility of computerised questionnaires designed for patients referred for endoscopy of either the upper or lower gastrointestinal (GI) tract, partly in comparison with almost identical paper questionnaires. In the first period of the study 1134 patients were referred of whom 73% answered the paper questionnaire, and during the second period 537 patients were referred of whom 64% answered the computerised questionnaire (P less than 0.001). There was no sex dependency regarding the ability to answer both types of questionnaires. A significant age dependency regarding the ability to answer the paper questionnaires was observed for patients referred for upper and lower GI endoscopy (P less than 0.0001 and P less than 0.0001). Corresponding with this observation, the ability to answer the computerised questionnaires significantly decreased with increasing age for both groups of patients (P less than 0.0001 and P less than 0.0001). The average completion times of both computerised questionnaires, designed for the upper and lower GI tract, were 11 min. The completion times did not depend on sex, but there was a slight positive correlation with age (P less than 0.0001 with multiple R = 0.27 and P = 0.0593 with multiple R = 0.12). Answering our computerised questionnaires was consistently reported to be interesting and easy, and did not last too long according to the respondents. After patients had answered the computerised history system, the insight into their complaints had increased in 40%, and 45% could put their complaints into words more easily. Only 25% of the patients were unable to express all their complaints. A reproducibility of medical history data of 85% was observed between paper and computerised questionnaires. Our computerised questionnaires can provide us with a detailed and uniformly acquired medical history of most patients referred for GI endoscopy. They are well accepted by the patients and can be completed during the normal waiting period. The medical history data obtained with these questionnaires are quite reproducible.

Helicobacter pylori in gastric biopsy specimens. Comparison of culture, modified giemsa stain, and immunohistochemistry. A retrospective study.

Antral biopsy specimens of 302 different endoscopic investigations of 200 patients with non-ulcer dyspepsia were studied for the presence of Helicobacter pylori in order to determine the most sensitive detection method. Part of the biopsy was cultured, and part stained using a modification of the Giemsa stain, and with an immunoperoxidase technique using a polyclonal rabbit anti-H. pylori antiserum. Cross-reactivity of this antiserum with other Campylobacter species was minimal. Material from 244 investigations was studied using all three detection methods. Culture was positive in 44 per cent, Giemsa in 78 per cent, and immunoperoxidase in 89 per cent of these biopsy specimens. Only five positive Giemsa stains with negative immunoperoxidase stain were found, whereas in 32 cases a negative Giemsa stain with a positive immunoperoxidase stain was seen. In the latter cases, the bacterial load was very low. The specimens revealed bacteria only sporadically, always confined to the deep layers of the gastric pits. Culture results correlated significantly with the bacterial load observed in the Giemsa stain. It is concluded that culture of H. pylori is the least sensitive detection method, whereas immunoperoxidase staining is the most sensitive. For daily practice the modified Giemsa stain, however, appears to be sufficient to diagnose the presence of the micro-organism.

Portal hypertension and intrahepatic cholestasis in hepatic amyloidosis.

Despite the fact that hepatic involvement is frequently seen in systemic amyloidosis, major clinical symptoms or impaired hepatic functional capacity are rare. We describe a patient with primary hepatic amyloidosis, severe intrahepatic cholestasis and portal hypertension, a combination previously reported only three times in the literature. In case of an unexplained intrahepatic cholestasis or portal hypertension the possibility of amyloidosis should be considered and a Congo red staining should be performed.

Helicobacter pylori and gastric carcinoma.

A retrospective study was performed on gastric carcinomas to establish the prevalence of Helicobacter pylori infection in gastric epithelium adjacent to the tumour. A total of 105 carcinomas were studied. The overall prevalence of Helicobacter pylori infection was 59%. The prevalence in different age cohorts from patients with gastric carcinoma was compared with that in patients suffering from non-ulcer dyspepsia and, based on serological testing, with that in healthy blood donors. The presence of Helicobacter pylori in cancer patients aged 41-50 and 51-60 was significantly higher than in blood donors. No difference was seen in comparison with non-ulcer dyspepsia patients. The presence of Helicobacter pylori showed an inverse correlation with the extent of intestinal metaplasia. The intestinal type of carcinoma was associated with a higher bacterial load than the diffuse type. These data suggest that the presence of Helicobacter pylori in gastric mucosa could play a role in the pathogenesis of gastric carcinoma, especially in the young age group.

The prevalence of anti-Helicobacter (Campylobacter) pylori antibodies in patients and healthy blood donors.

An enzyme linked immunosorbent assay (ELISA) with a sonicated suspension of Helicobacter (Campylobacter) pylori as antigen was used to detect anti-H. pylori antibodies in 517 patients without dyspepsia or peptic ulcer symptoms and 401 healthy blood donors. The criterion of seropositivity was determined from a receiver operating curve computed with the values of optical densities of 48 sera from dyspeptic patients with proven helicobacter-associated gastritis and 16 sera from dyspeptic patients with normal antral mucosa and no microbiological or histological evidence of H. pylori infection. The 227 (44%) seropositive persons amongst the patient group appeared to be significantly higher than the 142 (35%) sera with antibodies in the blood donors tested (p less than 0.03), even when adjustment was made for increasing age. We conclude that the prevalence of antibodies against H. pylori increases with age and that although antibodies are more prevalent in patients attending a hospital than in healthy blood donors, seropositivity suggestive of current or past infection can be found in one third of a randomly chosen population of blood donors.

Oesophageal varices: prophylactic treatment?

Oesophageal varices: prophylactic treatment? Patients with oesophageal varices as a result of liver cirrhosis are at risk of bleeding from these varices. Because of the high mortality, specially from the first variceal haemorrhage, it would seem justified to pose the question: does prophylactic treatment of oesophageal varices reduce the risk of bleeding and improve life expectancy? A review of the literature shows that until now no mode of prophylactic therapy has succeeded in accomplishing these goals. It is not, therefore, possible at this time to advise the use of prophylactic treatment of oesophageal varices as a routine therapy.

Presence of Helicobacter pylori in patients with non-ulcer dyspepsia revealing normal antral histological characteristics.

Two hundred consecutive patients suffering from non-ulcer dyspepsia were studied for the presence of Helicobacter pylori in antral gastritis and normal antral mucosa, using the combination of culture, modified Giemsa stain and a sensitive immunoperoxidase stain as means of detection. H. pylori gastritis was present in 56% of the cases. The bacterium was present in 75% of cases of normal antral mucosa, however, in low numbers. It is concluded that 87% of patients with non-ulcer dyspepsia are H. polory-positive implying a larger role for the micro-organism as initially thought.

Campylobacter associated gastritis in patients with non-ulcer dyspepsia: a double blind placebo controlled trial with colloidal bismuth subcitrate.

Fifty consecutive patients with non-ulcer dyspepsia and a Campylobacter associated gastritis (CAG) were randomly assigned to treatment with colloidal bismuth subcitrate (CBS) 240 mg twice daily or placebo, according to a double blind study design. After the blind treatment an 'open' treatment with CBS was started in both groups. Twenty six patients treated with CBS showed a significant reduction in colonisation with Campylobacter pylori and a significant improvement in the Whitehead gastritis score. No significant changes were recorded in twenty four patients treated with placebo. After an additional course of CBS no further improvement in gastritis score was noted but there was a further reduction in Campylobacter colonisation. CBS did not greatly alter subjective complaints. Subjective complaints were improved in both treatment groups except for nausea and meteorism that improved more in the CBS treated patients. This finding again questions the clinical significance of gastritis and also casts doubt on the clinical relevance of therapeutical measures aimed at eradication of C pylori.

Sucralphate-technetium scintigraphy in inflammatory bowel disease: experience in 23 patients.

Serial abdominal scanning after the oral administration of sucralphate-99mTc was performed in order to determine the extent of active inflammatory bowel disease in 15 patients with Crohn's disease and in 8 patients with ulcerative colitis. Scintigraphic data were compared with those obtained by endoscopy and radiology in all patients. True positive scans were obtained in 6 (40%) patients with Crohn's disease and in 3 (38%) patients with ulcerative colitis. Overall, sensitivity was higher in colonic disease than that in ileal disease. In 4 (17%) patients, false negative scans were obtained and in the remaining 10 (44%) patients, localisation of the inflammatory bowel disease by the isotope was completely inaccurate. Since sensitivity of the sucralphate-99mTc scintigraphy appears to be low, its widespread use in the screening for inflammatory bowel disease or in assessing the extent of disease involvement cannot be advocated at this moment.

Diagnostic value of an immunoassay to detect anti Campylobacter pylori antibodies in non-ulcer dyspepsia.

An enzyme-linked immunosorbent assay (ELISA) for detection of IgG antibodies against Campylobacter pylori was used to examine sera from 70 patients with non-ulcer dyspepsia. 48 patients had C pylori associated gastritis according to culture or histology; mean optical density (OD) of the ELISA was significantly higher than that for the 22 patients with normal antral mucosa and absence of C pylori. Positive and negative predictive values for campylobacter-associated gastritis were 100% above OD 2.10 and below OD 1.00, respectively. Serology might replace endoscopy in the diagnosis of campylobacter-associated gastritis.

Clinical relevance of lysozyme in the faeces.

To elucidate the value of faecal lysozyme determination in the differential diagnosis of patients with atypical abdominal complaints, stool samples of healthy controls, patients with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) were analysed. Faecal lysozyme concentration in healthy controls ranged from 0 to 6 mg/l with a mean of 3 mg/l. Patients with IBS had similar faecal lysozyme levels. In contrast, faecal lysozyme concentrations in patients with IBD were increased (range 6 to 104 mg/l). The difference between patients with IBS and IBD was highly significant (P less than 0.001). The determination of faecal lysozyme concentration may provide a useful test in the work-up of patients with abdominal complaints. In addition, the faeces lysozyme concentration appeared to be an objective parameter of the inflammatory activity of IBD in 11 patients investigated.

Retrospective study of Campylobacter-like organisms in patients undergoing partial gastrectomy.

One hundred and five stoma biopsy specimens and 108 corpus biopsy specimens from 108 patients who had undergone a partial gastrectomy because of peptic ulcer disease were examined retrospectively for the presence of Campylobacter-like organisms and gastritis. In the corpus biopsy specimens Campylobacter-associated gastritis was found in 55 (71%) of the cases and in 42 (48%) of the stoma biopsy specimens. It is concluded that Campylobacter-like organisms have a role in gastritis after partial gastrectomy, although this role is more prominent in the corpus region. The role of Campylobacter pylori in peptic ulcer disease is not clinically important.

Serum cobalamins and cobalamin-binding proteins during total parenteral nutrition.

Levels of serum cobalamin and both saturated and unsaturated serum cobalamin-binding proteins (transcobalamin II and R-binders) were determined prospectively in 43 patients before and after 2 weeks of total parenteral nutrition (TPN). Nine patients showed subnormal serum levels of cobalamin but none of them had clinical signs of cobalamin deficiency. Serum cobalamin levels significantly declined after 2 weeks of TPN as did both saturated and unsaturated R-binder levels whereas transcobalamin II levels remained constant. Since cobalamin in serum is entirely bound to proteins, of which R-binders comprise 80-90%, the changes in R-binder levels will markedly influence serum cobalamin levels, in fact they adequately explain the short time fluctuations of serum cobalamin levels observed. It is argued that the changes in serum cobalamin levels may reflect a changed distribution of cobalamins over the various body compartments rather than decreased or increased body stores. Moreover, only cobalamin bound to transcobalamin II is delivered to the tissues. Therefore, serum cobalamin levels alone may inadequately reflect cobalamin availability in patients receiving TPN.

Fungal colonization of gastric ulcers.

Retrospectively, samples from 337 newly diagnosed gastric ulcers were studied for the prevalence of fungus using a periodic-acid Schiff-diastase stain. In 64 (19%) gastric ulcers, fungal material was found in the ulcer base. There was no difference in prevalence of fungi between benign gastric ulcers and ulcerating gastric carcinomas. The "fungal" ulcers tended to be larger in diameter and are more often suspected to be malignant than "normal" gastric ulcers. Since no tissue invasion was found and healing tendency after therapy seemed not to be delayed, we conclude that fungus in gastric ulcer is probably a secondary phenomenon, and has little clinical significance.

Campylobacter associated gastritis in patients with non-ulcer dyspepsia.

Gastric biopsy specimens from 109 patients with non-ulcer dyspepsia were retrospectively examined. Sixty one patients had gastritis and there was a strong correlation with the presence of Campylobacter pyloridis. Ninety eight per cent were positive in large numbers for C pyloridis by histological examination or by culture, or both. Of 48 patients with normal histological results, 21 had evidence of C pyloridis by histological examination or culture, or both, but in small numbers. It is concluded that there is a quantitative rather than a qualitative association between C pyloridis and gastritis.

Faecal lysozyme: determination, reference intervals and some data in gastro-intestinal disease.

After diluting faecal samples with a solution of Brij and saline and subsequently ultrafiltrating the faecal mixtures, lysozyme concentration can be reproducibly measured in the obtained faecal fluids, using a turbidimetric method. Measuring faecal lysozyme concentration enables discrimination normal individuals and patients with irritable bowel syndrome between patients with inflammatory bowel disease and colonic cancer. Lysozyme distribution in stools appears to be homogeneous. Faecal lysozyme concentration is stable when samples are stored during at least 1 wk at 6 degrees C. It appears that the lysozyme activity is directly correlated with the clinical status and severity of the disease. Faecal lysozyme may thus serve as an important tool both in diagnosis and in follow-up in the out-patients clinic for gastroenterology.

The influence of guar-gum bread on the regulation of diabetes mellitus type II in elderly patients.

The effect of a high-fibre bread mixed with guar-gum (75 g/kg flour) on serum glucose, connecting peptide (C-peptide), haemoglobin A1 (HbA1), high-density-lipoprotein-cholesterol (HDL-cholesterol) and triglycerides was examined in fourteen elderly patients with diabetes mellitus type II. The mean daily consumption of guar gum was 8.1 g. Gastrointestinal disorders were not observed. Consumption of guar-gum bread resulted in a significant decrease in C-peptide values on the 1st day and blood glucose values after 3 weeks (both measured 90 min after breakfast). C-peptide values remained low, while an unaccountable 'rebound' phenomenon was seen in the blood glucose values 90 min after breakfast at the end of the study. No significant change was seen in respect to HDL-cholesterol and triglycerides. However, a small significant increase in HbA1 was noted.

A patient with primary hyperparathyroidism and an abnormal bone scan.

A patient with primary hyperparathyroidism whose bone scan showed signs of extensive pulmonary and gastric calcifications is described. The patient also had renal insufficiency. A review of the literature and of data of 13 patients with primary hyperparathyroidism who were seen in the Department of Internal Medicine at the University Hospital of Maastricht, led to the conclusion that only in patients with renal insufficiency could ectopic calcifications be expected to occur. Phosphate retention, rather than the hyperphosphaturia that occurs in that particular situation, is cited as the cause.