Comparison of magnetic resonance enteroclysis and capsule endoscopy with balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: New modalities are available for visualization of the small bowel in patients with possible obscure gastrointestinal bleeding (OGIB), but their performance requires further comparison. This study compared the diagnostic yield of magnetic resonance enteroclysis (MRE) and capsule endoscopy in patients with OGIB, using balloon-assisted enteroscopy (BAE) as the reference standard. PATIENTS AND METHODS: Consecutive consenting patients who were referred for evaluation of OGIB were prospectively included. Patients underwent MRE followed by capsule endoscopy and BAE. Patients with high grade stenosis at MRE did not undergo capsule endoscopy. The reference standard was BAE findings in visualized small-bowel segments and expert panel consensus for segments not visualized during BAE. RESULTS: Over a period of 26 months, 38 patients were included (20 female [53 %]; mean age 58 years, range 28 - 75 years). Four patients (11 %) did not undergo capsule endoscopy due to high grade small-bowel stenosis at MRE (n = 3; 8 %) or timing issues (n = 1; 3 %). Capsule endoscopy was non-diagnostic in one patient. The reference standard identified abnormal findings in 20 patients (53 %). MRE had sensitivity, specificity, and positive and negative likelihood ratios of 21 %, 100 %, infinity, and 0.79, respectively. The corresponding values for capsule endoscopy were 61 %, 85 %, 4.1, and 0.46. The reference standard and capsule endoscopy did not differ in percent positive findings (P = 0.34), but MRE differed significantly from the reference BAE (P < 0.001). Capsule endoscopy was superior to MRE for detecting abnormalities (P = 0.0015). CONCLUSION: Capsule endoscopy performed better than MRE in the detection of small-bowel abnormality in patients with OGIB. MRE may be considered as an alternative for the initial examination in patients with clinical suspicion of small-bowel stenosis.

Magnetic resonance cholangiopancreaticography as a diagnostic tool for common bile duct stones: a comparison with ERCP and clinical follow-up.

BACKGROUND/AIMS: The diagnostic potential of magnetic resonance cholangiopancreaticography (MRCP) has improved as a result of evolving technique. MRCP has the advantage of negligible morbidity and mortality in contrast to endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate MRCP as a replacement for diagnostic ERCP for the suspicion of common bile duct (CBD) stones. METHODS: From 1998 to 2001, MRCP was performed in 202 patients with a suspicion of CBD stones based on medical history (MH), cholestatic liver function tests (CL), both MH and CL or other reasons. ERCP was performed in all patients where MRCP indicated the presence of CBD stones and in those patients with a persistent strong clinical suspicion for CBD stones despite a negative MRCP. RESULTS: In 25 patients, MRCP suggested CBD stones which were proven with ERCP in 24 patients. Despite a negative MRCP, 27 patients had a subsequent ERCP. None of these patients appeared to have CBD stones. In this group, MRCP resulted in 100% sensitivity and 96% specificity in detecting CBD stones. Follow-up of all patients revealed 5 more patients with persistent clinical suspicion or cholestatic liver function values. Assuming CBD stones in these patients, MRCP had a sensitivity of 83 % and a specificity of 99% for this diagnosis. CONCLUSION: In the case of CBD stone suspicion, MRCP should be the diagnostic procedure of choice.

[Magnetic resonance cholangiopancreatography: sensitive and specific diagnostic method for suspected choledolithiasis]. / Magnetische-resonantiecholangiopancreatografie: sensitieve en specifieke onderzoeksmethode bij vermoeden van choledocholithiasis.

OBJECTIVE: To evaluate the role of magnetic resonance pancreaticography (MRCP) in the diagnostic process of common bile duct stones. DESIGN: Retrospective. METHOD: All 27 MRCPs performed in the period December 1997-December 1998 in the Deventer Hospital, the Netherlands, were evaluated using chart examination. The group comprised 11 males and 16 females with an average age of 57 years (SD 3.2) with anamnestic or biochemical cholestasis. If at MRCP stones were diagnosed, endoscopic retrograde cholangiopancreaticography (ERCP) was performed. If MRCP was without abnormalities, no further diagnostic procedures were performed. The findings at MRCP were compared with those at ERCP and with the clinical course. The MRCP examinations were performed on a 1.5 Tesla MR unit. RESULTS: In 16 patients MRCP was performed before laparoscopic cholecystectomy and in 5 there after. In 5 MRCP was performed to rule out a biliary cause of acute pancreatitis and in 1 patient because of an elevated alkaline phophatase after laparotomy for an abdominal stab injury. There was one false-positive MRCP result and no false-negative ones. Accordingly, the sensitivity of MRCP for choledocholithiasis was 100% and the specificity 95%.

Increase of Helicobacter pylori-associated corpus gastritis during acid suppressive therapy: implications for long-term safety.

OBJECTIVES: Helicobacter pylori causes chronic active gastritis with predominant localization in the gastric antrum. This predisposes to development of mucosal atrophy, intestinal metaplasia, and eventually, gastric cancer. The effects of acid suppression on H. pylori infection and associated gastritis are unclear. However rapid development of atrophic gastritis has been consistently observed in a number of studies during low acid output. We therefore studied the histological features of antrum and corpus of the stomach before and during acid suppressive therapy. METHODS: Fifty patients with either reflux esophagitis (n = 21), benign gastric ulcer (six patients), gastric erosions (three patients), or duodenal ulcer (20 patients) were treated for 8 wk with omeprazole 40 mg o.d. Esophagogastroduodenoscopy was performed pre-entry and at 8 wk. Biopsy specimens were sampled from the antrum and corpus for histology and cultures. RESULTS: Seventeen H. pylori-negative patients had no histological signs of active gastritis, before or after therapy. Thirty-three H. pylori-positive patients showed predominant colonization and associated inflammation in the antrum before therapy. After therapy, however, the infection predominantly affected the corpus. The inflammation and bacterial colonization in the antrum significantly decreased, leading to negative antral cultures in 61% (20 of 33 patients). In contrast, the inflammation of the corpus mucosa significantly increased despite stable bacterial counts. CONCLUSIONS: We conclude 1) that H. pylori testing in patients on profound acid suppressive therapy should be performed on combined corpus and antral specimens, and 2) that omeprazole therapy leads to a strong increase in corpus gastritis, which may explain the observed development of corpus atrophy in a substantial number of patients after several years of continuous acid suppressive treatment. Therefore, we suggest that patients in need of long-term acid suppressive therapy should receive bacterial eradication therapy if they are H. pylori positive.

Nephroptosis: a considerable cause of renovascular hypertension.

Four females were admitted with hypertension. Other causes of hypertension were excluded on clinical grounds. Digital substraction angiography performed in 3 patients revealed no stenosis of the renal arteries. The 99mTc-Mag3 renogram showed diminished perfusion and excretion on the affected side. Right-sided nephropexy was performed in all 4 cases via lumbotomy after which all 4 patients became normotensive. We conclude that nephroptosis is a considerable cause of renovascular hypertension and deserves particular attention in cases of possible renovascular hypertension when angiography shows no stenosis. We also conclude that renography is the preferred diagnostic method in the diagnosis of renovascular hypertension due to nephroptosis.

Renal trapping of In-111 troponolate labeled platelets in thrombotic thrombocytopenic purpura.

A patient with active thrombotic thrombocytopenic purpura underwent examination with In-111 troponolate labeled autologous platelets. A mean platelet survival of 1.2 days was found, comparable to formerly described studies using other methods. Furthermore, remarkable renal uptake of radioactivity consistent with abnormal platelet trapping was demonstrated. In the absence of any other signs of renal involvement, the conclusion was reached that the platelet scan is a sensitive and direct method for showing renal involvement in thrombotic thrombocytopenic purpura.

Nontuberculous mycobacterial sternal osteomyelitis in a patient without predisposing condition.

A woman is reported with a ten-year history of nonspecific chest pain. Bone scintigraphy showed increased local uptake, suggesting isolated sternal osteomyelitis. Radiographic investigations were positive 18 months later. Cultures of needle aspirations of the sternal bone marrow isolated Mycobacterium fortuitum as well as Mycobacterium simiae. Due to its indolent nature, nontuberculous mycobacterial disease is easily missed, especially in non-compromised hosts.

Renal function and renal function reserve in insulin-dependent diabetic patients during (near) normoglycaemia.

Twenty-three normoalbuminuric (N) and 7 microalbuminuric (M) insulin-dependent diabetes mellitus (IDDM) patients were studied under (near) normoglycaemic conditions. They were reasonably well controlled during the period preceding the renal function test (HbA1: N = 7.6 +/- 1.3%, N = 8.0 +/- 2.2%; normal less than 6.0%). Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured using the clearances of 125I-thalamate and 131I-hippuran, respectively. The renal reserve filtration capacity (RRFC) was tested by using a combination of a liquid mixed meal and an amino acid infusion. Blood glucose levels were kept as constant as possible throughout the testing procedure, both under baseline (BL) conditions and after stimulation (S). Under such (near) normoglycaemic conditions, no BL GFR values exceeding 150 ml/min/1.73 m2 could be established. Furthermore, a RRFC could be established in all patients. Both groups showed a comparatively larger increase in GFR (N 13.0 +/- 3.8%, M 10.8 +/- 3.6%) than in ERPF (N 4.8 +/- 7.0%, M 2.2 +/- 5.8%; % delta GFR vs. % delta ERPF p less than 0.01), resulting in a higher filtration fraction (FF) during stimulation (N: BL FF 0.25 +/- 0.03 vs. S FF 0.27 +/- 0.03, p less than 0.01; M: BL FF 0.25 +/- 0.01 vs. S FF 0.27 +/- 0.01, p less than 0.05). This suggests afferent vasodilation during stimulation in these (near) normoglycaemic, reasonably well-controlled IDDM patients, a situation comparable to that in non-diabetic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Nizatidine versus ranitidine in the treatment of peptic ulcer disease: report on the Dutch investigation as part of a European multicentre trial.

The efficacy and safety of nizatidine was evaluated in comparison with ranitidine in 230 patients with endoscopically documented gastric (71) or duodenal (159) ulcers. Gastric ulcer patients who satisfied all criteria for inclusion and exclusion were randomly allocated to nizatidine 300 mg nocte, 150 mg b.d. or ranitidine 150 mg b.d., duodenal ulcer patients to nizatidine 300 mg nocte or ranitidine 300 mg nocte. Endoscopic healing was defined as complete epithelialisation of all mucosal lesions. Endoscopy was performed at 4 and, if not healed, at 8 weeks. Healing rates were shown to be comparable for all treatment regimens. In both duodenal ulcer treatment groups, and with both drugs, healing was negatively influenced by ulcer size, ulcer number, smoking habits and a disease duration of 5 years or more. Few side effects were noted. Nizatidine, administered as a 300 mg nocte and as a 150 mg b.d. dose appeared to be a safe H2 antagonist and was as effective as ranitidine in the treatment of duodenal and gastric ulceration.

Amiodarone-induced hyperthyroidism in a patient with Marfan's syndrome and Wolff-Parkinson-White syndrome.

In a 20-year-old patient with Marfan's syndrome and Wolff-Parkinson-White syndrome, effective amiodarone treatment had to be stopped due to serious hyperthyroidism. Diagnosis and therapy of amiodarone-induced dysthyroidism is discussed.

Accuracy or inaccuracy of spleen mass measurements from radionuclide images.

In a retrospective study, scintigraphic spleen size was compared with actual spleen weight. Using the formula W = pi/7 h (h2 + 3ab), the normal weight was calculated too large and splenic enlargement was calculated too small. Other scintigraphic parameters seem to be just as unreliable. We suggest to judge scintigraphic spleen mass as normal and only be enlarged in obvious situations.

In-111 leukocyte scanning and partial functional asplenia in a patient with Sézary syndrome.

Functional asplenia is described in the case report of an 80-year-old woman who was admitted with Sézary syndrome. The spleen could not be visualized by a Tc-99m tin colloid (SnC) liver and spleen scan, but was visualized by a Tc-99m sulfur colloid (SC) scan, suggesting a different mechanism in accumulation of SnC and SC in the spleen. In-111 oxine labeled Sézary cells could be found in the spleen, bone marrow, and lymph nodes.

Rectal administration of 13N-ammonia in cirrhosis of the liver.

13N-ammonia, applied rectally, after absorption and transportation visualises the liver. After release of 13N-aminoacids and 13N-urea by the liver, 13N-activity can be measured over other organs. In patients with porta-systemic shunts, 13N-ammonia will appear in the systemic circulation as well. In 16 controls and 26 patients with cirrhosis, activities were measured for 20 minutes over liver, spleen, heart, lungs and forearm. In all subjects, the liver was visualised within a minute, in some patients with cirrhosis faintly, however. Release by the liver of 13N-ammonia metabolites started within a few minutes. Liver/heart activity ratios proved to be more discriminating between the control- and the cirrhosis group than liver/lung and liver/spleen ratios. In the control group, the 20 minutes' liver/heart ratio was most suitable for determining the normal range. The lower normal level was found to be 2.25. Fourteen of the 26 patients with cirrhosis had a normal, 12 an abnormally low 20 minutes' liver/heart ratio.

Rectal 13N-ammonia test (13N-liver/heart ratio), hepatic sinusoidal pressure and prevailing portal flow direction in cirrhosis of the liver.

The 20 minutes' liver/heart activity ratio after rectal administration of 13N-ammonia was abnormally low (less than 2.25) in 12 of 26 patients with cirrhosis of the liver. An abnormal conventional rectal arterial ammonia test (porta-systemic shunts), an abnormally low urea index (prevailing hepatofugal portal venous flow direction), marked portal hypertension (hepatic sinusoidal pressure greater than or equal to 8 mm Hg), ascites and extreme enlargement of the spleen occurred significantly more often in the patients with an abnormally low 13N-liver/heart ratio than in those with a ratio greater than or equal to 2.25. There was no correlation between the 13N-liver/heart ratio and absence or presence of oesophageal varices. The non-invasive rectal 13N-ammonia test appears to be an easy to perform, informative test in cirrhosis of the liver.

The "urea index" as a marker of portal flow direction in cirrhosis of the liver.

In a control group (n = 50) and in 52 patients with cirrhosis, urea was administered orally and ratios for hepatic venous/arterial increment were determined up to 120 minutes after loading. A complete, hepatofugal diversion of the portal blood flow would result in ratios less than or equal to 1. The best discrimination between controls and cirrhotics was obtained with the 0-15 minute ratio ("urea index") which has a normal lower limit of 1.25. In cirrhosis an urea index less than or equal to 1.2 is correlated with an abnormal ammonia test and with the presence of marked portal hypertension (hepatic sinusoidal pressure greater than or equal to 8 mmHg, N: 0-3 mmHg). Ascites occurs more often in patients with cirrhosis and a low index. Regardless of the urea index value, ascites in cirrhosis is associated with an hepatic sinusoidal pressure greater than or equal to 8 mmHg. The urea index procedure may easily be conducted together with the measurement of hepatic sinusoidal pressure.