Ranitidine bismuth citrate with either clarithromycin 1 g/day or 1.5 g/day is equally effective in the eradication of H. pylori and healing of duodenal ulcer.

BACKGROUND: No randomized double-blind studies have been performed to compare clarithromycin 1 g/day with higher doses of the macrolide (1.5 g/day) when combined with ranitidine bismuth citrate (RBC). AIM: To compare H. pylori eradication and ulcer healing rates of RBC 400 mg b.d. for 4 weeks combined for the first 2 weeks either with clarithromycin 500 mg b.d. (Group A) or clarithromycin 500 mg t.d.s. (Group B). METHODS: Two hundred and seventy-three patients with H. pylori-positive active duodenal ulcer were included. H. pylori infection was detected by CLO-test and histology on antral and corpus biopsies before and at least 4 weeks after the end of therapy. Eradication was assumed if both CLO-test and histology results were negative for H. pylori. RESULTS: Eradication/healing rates according to intention-to-treat and per protocol analysis were 76/82% and 87/92% for Group A and 78/85% and 88/95% for Group B, respectively (P = N.S.). Adverse events were reported by 7% and 12% of patients in Groups A and B, respectively, and they were generally mild. CONCLUSIONS: RBC in co-prescription with clarithromycin 500 mg b.d. is as effective as RBC plus clarithromycin 500 t.d.s. in eradicating H. pylori and healing duodenal ulcers.

Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.

BACKGROUND: There is a lack of multicenter prospective studies on complications of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We studied 2769 consecutive patients undergoing ERCP at nine centers in the Triveneto region of Italy over a 2-year period. Six centers performed ERCP on less than 200 patients per year (small centers). General and ERCP-specific major complications were predefined. Data were collected at the time of ERCP, before discharge, and in cases of readmission within 30 days. ERCP was defined as therapeutic when endoscopic sphincterotomy (n = 1583), precut (n = 419), or drainage (n = 701) had been carried out, singularly or in combination. RESULTS: One hundred eleven major complications (4.0%) were recorded: moderate-severe pancreatitis 36 (1.3%), cholangitis 24 (0.87%), hemorrhage 21 (0.76%), duodenal perforation 16 (0.58%), others 14 (0.51%). Among 942 diagnostic ERCPs there were 13 major complications (1.38%) and 2 deaths (0.21%), whereas among 1827 therapeutic ERCPs there were 98 major complications (5.4%) and 9 deaths (0.49%). The difference in the incidence of complications between diagnostic and therapeutic ERCPs was statistically significant (p < 0.0001). Small center and precut were recognized as independent risk factors for overall major complications of therapeutic ERCP, whereas the following risk factors were identified in relation to specific complications: (1) pancreatitis: age less than 70 years, pancreatic duct opacification, and nondilated common bile duct; (2) cholangitis: small center, jaundice; (3) hemorrhage: small center; and (4) retroperitoneal duodenal perforation: precut, intramural injection of contrast medium, and Billroth II gastrectomy. CONCLUSIONS: Major complications are mostly associated with therapeutic procedures and low case volume. Present data support a policy of centralization of ERCP in referral centers. A more selected and safer use of precut may be expected to further limit the adverse events of ERCP.

[Importance of the dimensions and histologic nature of polyps of the colon in a comparison between double contrast enema and colonoscopy]. / Importanza delle dimensioni e della natura istologica dei polipi del colon nel confronto tra clisma opaco a doppio contrasto e colonscopia.

In 244 patients the results obtained by double contrast barium enema and endoscopy in the detection of small colonic polyps were compared. The results were evaluated by subdividing the polyps according to size. In order to define the endoscopic false positives percentage, controversial cases were re-examined with a second double contrast barium enema. The authors put forward a few considerations on the suitability of diagnosing small colonic polyps on the basis of their histologic nature.

Nodular hyperplasia of Brunner's glands.

A clinical, endoscopic, and histological study of 206 cases of nodular hyperplasia of Brunner's glands was carried out. Firm nodules with a reddened surface due to hyperplastic Brunner's glands were limited mainly to the first part of the duodenum and affected almost exclusively male patients. Gastric acid secretion after pentagastrin stimulation was significantly increased compared to normal. In most cases, biopsies of the nodule center revealed spreading of Brunner's glands from within the lamina propria to the surface epithelium, whereas in biopsies performed between nodules, Brunner's glands were limited to the deeper part of the mucosa. Thirty-six nodules completely removed by diathermy were composed almost entirely of Brunner's glands. The frequent association with duodenal ulcer, chronic gastric erosions, and cobblestone pattern of the gastric body mucosa, as well as the significant hypersecretory state, suggest that hyperacidity plays a role in the pathogenesis of nodular hyperplasia of Brunner's glands.

Polypoid lesions associated with diverticular disease of the sigmoid colon.

Colonscopy performed in five patients because of narrowing of the sigmoid colon with intramural diverticula revealed several bright red, slightly elevated patches. In three patients, some bright red polypoid structures 1 cm in size and hemispherical in shape were also present. On light microscopy the polyps showed the features of transitional mucosa but revealed a different pattern of mucus secretion.

Chronic erosions of the stomach--a clinical, endoscopic and histological evaluation.

A clinical, endoscopic and histological study was performed in 300 patients with chronic gastric erosions. The male-female ratio was 4:1. The antrum was the preferential site of erosions. Chronic erosions were classified into two categories: "active" (with a dark clot or whitish coat of fibrin) and "inactive" (covered by a normal pink mucosa). All the lesions showed foveolar hyperplasia, partial obliteration of the lamina propria by fibrous and smooth muscle bundles, a greatly thickened muscularis mucosae and an increased number of submucosal thick-walled vessels. In the "active" stage the central umbilicated area was covered by a collection of granulocytes, while in some of the "inactive" erosions the central depression showed the presence of a channel-like structure penetrating into the lamina propria. In two cases the lesion mimicked a gastric adenomyoma. Gastric acid secretion was significantly increased in the tested patients as compared with normal. The similarity of the histological findings with those in ischemic conditions of the gastro-intestinal tract suggests that both hypersecretion and localized ischemia may play a role in the pathogenesis of chronic erosions.

Juvenile and inflammatory polyps of the colon--a histological and histochemical study.

A light microscopy and histochemical study of 24 juvenile and 27 inflammatory polyps showed that both may derive from inflammatory processes. Granulation tissue, secondary to spontaneous local inflammation or due to surgical procedures may subsequently be covered by regenerating epithelium which lines haemorrhagic cavities and mucus lakes to form irregular, elongated and cystic glands, which are characteristic of juvenile polyps. Both juvenile and inflammatory polyps showed cystic, metaplastic and 'transitional-type' glands. The mucin distribution was identical in both types of polyps. All these findings suggest a common origin of the polyps. The presence of 'transitional-type' glands seems to confirm these as a secondary regenerative phenomenon rather than pre-neoplastic, although dysplastic changes in juvenile polyps have been described. It is suggested that both the juvenile and inflammatory polyps may undergo dysplasia only in genetically predisposed subjects. However, this event seems to be very rare.

Squamous papillomas of the esophagus.

Fifteen cases of squamous papilloma of the esophagus were found in 20,000 upper gastrointestinal endoscopies. Squamous papillomas are usually incidental findings; symptoms are related to associated esophageal or gastrointestinal lesions. Chronic irritation from gastric acid reflux may play an etiological role.

Transitional polyps of the colon.

Fourteen polps with the gross appearance of small hyperplastic (metaplastic) polyps, not exceeding five mm in diameter, were removed from the rectum and the sigmoid colon of patients during colonscopy, and from surgical specimens. At light microscopy they were seen to be composed of apparently normal mucosa. In most cases some hyperplastic (metaplastic) and adenomatous polyps were also present. HID-AB stain revealed the polyps to be composed of "transitional" mucosa containing almost exclusively sialomucins, in contrast to normal mucosa, in which sulphomucins predominate. It is suggested that these "transitional" polyps may represent a reservoir of hyperplastic (metaplastic) and adenomatous polps, the different fate depending on different environmental situations.

Heterotopic gastric (fundic) mucosa in the duodenum.

Twenty cases of heterotopic fundic mucosa in the duodenum are reported. The patients had several small polyps ranging from one to three mm tightly grouped to form a plaque in a limited zone of the duodenal bulb. In some cases the polyps were separated from one another. They were round or conical and manifested a frosted-glass appearance with a pale-pink or redded coloration. In two cases a whitish solitary polyp of five mm was located in the 2nd part of the duodenum. Biopsies obtained from the polyps revealed them to be composed of fundal mucosa, thus representing a particular form of heterotopia, other then the steroid-induced type, and that of patients undergoing regular dialysis for uraemia. The different clinical and morphological data in the various forms of fundal heterotopia are discussed.

"The evolution of the solitary ulcer of the rectum"--an endoscopic and histopathological study.

A follow-up study of fourteen out of twenty-seven cases of solitary ulcer syndrome of the rectum was performed at one year's interval from the previous endoscopic and histologic examination. Most of the lesions consistently changed their aspect, resulting in incomplete irregular narrowings, polypoid protrusions or linear ulcers. The symptoms remained unchanged or slightly diminished. A striking difference was found in the histological pattern of the "evolved" ulcer in comparison to the active one, the former showing features of hyperplastic (metaplastic) colonic polyps as well as of the so called "transitional mucosa". It is suggested that chronic ischemia occurring in solitary ulcer of the rectum leads to "transitional mucosa" as an exaggerated regenerative phenomenon, hyperplastic (metaplastic) mucosa representing a later maturative phase. Possibly "transitional" mucosa may undergo dysplastic changes under the influence of environmental factors.

A comparative evaluation of endoscopic retrograde cholangiopancreatography and the secretin-cholecystokinin test in the diagnosis of chronic pancreatitis: a multicentre study in 124 patients.

A comparative evaluation of ERCP and the bicarbonate output 30 min after stimulation of the pancreas with secretin and cholecystokinin-pancreozymin, was carried out in 124 patients, of whom 65 were affected by proven chronic pancreatitis (PCP), and 59 by only suspected chronic pancreatitis (SCP). In PCP patients the false negative results were 14.7% and 21.5%, respectively. In 5 of the PCP patients with false negatives on ERCP and functional test a normal result of both the procedures was found. ERCP and bicarbonate output were found to be abnormal in 12% and 40%, respectively of 59 patients with SCP. In 30 SCP subjects both procedures gave a normal result, and only in two cases were results abnormal. A correct classification of the SCP patients with pathological bicarbonate secretion and normal ERCP seems quite impossible. The diagnostic usefulness of ERCP results is preeminent but the of carrying out both types of investigation together may give complementary information in the evaluation of pancreatic disorders.

Histologic evidence of cytomegalovirus in the duodenal and gastric mucosa of patients with renal allograft.

Endoscopic examination of the upper gastrointestinal tract was performed in 12 patients after renal transplantation and immunosuppressive therapy. Histological examination of the specimens obtained from the duodenal bulb revealed the presence of cytomegalovirus (CMV)-type cells in four cases. In one of these patients several CMV-type cells were scattered in the duodenal mucosa and also affected the antral mucosa. In the other three cases just one or two cells with prominent intranuclear inclusions (CMV) were present in only a few of the multiple sections. No correlation of CMV inclusion with symptoms and with the morphological appearance of the upper gastrointestinal tract has been found. CMV infection seems to be correlated with immunosuppressive therapy.

[Value of transduodenoscopic wirsungography in the diagnosis of pancreatic pseudocysts]. / Valore della wirsungrafia transduodenoscopica nella diagnosi delle pseudocisti pancreatiche.

The radiographic pictures obtained by endoscopic wirsungraphy in a group of 24 patients suffering from pancreatic pseudocysts and subsequently examined intraoperatively by wirsungraphy and cystography are analysed and commented. Pre-operative endoscopic visualisation of the lesion was obtained in 70% of the cases. In 55% of the cases there were co-existing alterations of calibre and trend of the main pancreatic duct, chiefly attributable to chronic basic pancreatitis and to a very small extent to the pseudocystic lesion. The following are discussed: a) the diagnostic value of the endoscopic procedure, which reaches absolute values in the direct visualisation of the sac, with a power of resolution that is difficult to reach with other methods; b) the probable prognostic significance with reference to the not absolutely precluded possibilities of spontaneous regression; c) the notable usefulness of the procedure, combined with intra-operative wirsungraphy and cystography, for anatomo-topographical definition of the lesion and its relations with the ductal system, indispensable for a correct formulation of the surgical tactic.