Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system: a prospective observational study based on the Maastricht guidelines.

AIM: To test the appropriateness of referrals for upper gastrointestinal endoscopy in Campania, Italy, using the criteria of the Maastricht Consensus. PATIENTS: Patients undergoing endoscopy during a 1-week period in 21 Endoscopy Services were considered prospectively. The reasons for endoscopy were dyspeptic symptoms, history of peptic ulcer and assessment after treatment. The age, sex, symptoms, history of peptic ulcer (previous endoscopic or radiographic examinations and treatment), endoscopic diagnosis and H. pylori status were recorded. The indications for endoscopy were evaluated according to the Maastricht guidelines. RESULTS: Two hundred and sixteen of 706 patients presented with reflux symptoms, 430 with dyspeptic symptoms, 38 with alarm symptoms and 22 with atypical symptoms. Endoscopy was normal in 376 cases (53.2%); duodenal ulcer was found in 219, gastric ulcer in 45, oesophagitis in 82 and gastric cancer in six. All patients with cancer were older than 45 years, and four presented with alarm symptoms. In 398 cases (56%), endoscopy was considered not to be indicated: 250 patients with a previous diagnosis of ulcer without a change in symptoms, 38 patients in order to confirm eradication and 110 patients younger than 45 years with dyspepsia without alarm symptoms. CONCLUSIONS: A large number of endoscopic examinations could be avoided by following the guidelines of the Maastricht Consensus. In order to reduce endoscopic workload, strategies for educating physicians should be pursued.

Accuracy of stool antigen test in posteradication assessment of Helicobacter pylori infection.

Our aim was to evaluate the accuracy of HpSA test in the diagnosis of Helicobacter pylori infection after the end of eradication therapy. In all 106 H. pylori-positive patients (55 men and 51 women, mean age 51 years, range 19-82) were treated with a course of eradicating regimen. [13C]Urea breath test (UBT) and HpSA were performed four weeks after stopping the treatment. The diagnostic accuracy of HpSA was evaluated in comparison with the results of [13C]UBT. In 90 patients (85%) H. pylori was eradicated according to [13C]urea breath test. After eradication, sensitivity of HpSA was 87.5%, specificity 95.5%, positive predictive value 77.8%, negative predictive value 97.7%, and diagnostic accuracy 94.3%. HpSA is a valuable test in the posteradication assessment of H. pylori infection.

Accuracy of the stool antigen test in the diagnosis of Helicobacter pylori infection before treatment and in patients on omeprazole therapy.

AIM: To evaluate the Helicobacter pylori stool antigen (HpSA) test in the assessment of H. pylori infection and the effect of omeprazole treatment on its accuracy. METHODS: Study 1: 140 dyspeptic patients were enrolled in the study and defined as H. pylori positive if histology and rapid urease test, or culture alone were positive. HpSA was performed on all patients and 13C-urea breath test (UBT) on 87. Study 2: 75 patients testing positive using both UBT and HpSA, were given omeprazole 20 mg for 2 weeks (Group A) or omeprazole 40 mg for 2 weeks (Group B), or OAC for 1 week (group C). A Helicobacter pylori stool antigen test was performed on all patients on days 3, 5, 7 and 14 during treatment, and also on days 7 and 14 post-treatment in groups A and B. UBT was performed in groups A and B on days 7 and 14 during treatment, and days 7 and 14 post-treatment. RESULTS: 80/140 patients were H. pylori positive. The sensitivity and specificity of HpSA were 93.8 and 90%, similar to UBT (93.9 and 92.1%). Omeprazole significantly reduced both HpSA and UBT values, resulting in a decreased accuracy. Of 25 patients receiving 20 mg omeprazole, HpSA gave 5 and 6 false negatives after 7 and 14 days treatment respectively, while UBT gave 4 and 7 false negatives after 7 and 14 days treatment. Of 25 patients receiving 40 mg omeprazole, HpSA gave 7 and 9 false negatives after 7 and 14 days of treatment, while UBT gave 8 and 9 false negatives after 7 and 14 days of treatment. Two weeks after stopping omeprazole treatment, the HpSA and UBT were positive in all cases. CONCLUSIONS: The Helicobacter pylori stool antigen test is valuable in the assessment of H. pylori infection. Short-term omeprazole treatment decreases the accuracy of both HpSA and UBT in a similar manner.

High prevalence of reflux symptoms in duodenal ulcer patients who develop gastro-oesophageal reflux disease after curing Helicobacter pylori infection.

BACKGROUND: Gastro-oesophageal reflux disease may develop following eradication of Helicobacter pylori. However gastro-oesophageal reflux disease could be preexistent and misdiagnosed since patients often misinterpret gastro-oesophageal reflux disease symptoms or focus their attention on abdominal symptoms. A questionnaire for analysis of gastro-oesophageal reflux disease symptoms has not been used until now. METHODS: A total of 70 patients with duodenal ulcer and Helicobacter pylori gastritis, without oesophagitis and/or typical gastro-oesophageal reflux disease symptoms were studied. All patients received a questionnaire with 5 items focused on abdominal symptoms and 5 on gastro-oesophageal reflux disease symptoms. The two symptom scores were calculated separately. After Helicobacter pylori treatment, follow-up consisted of clinical controls every 3 months for 1 year. Patients were asked to describe their complaints and to answer the questionnaire. If gastro-oesophageal reflux disease symptoms recurred endoscopy was performed. RESULTS: At interview, all patients reported a significant improvement in their abdominal symptoms after eradication; however 23 patients (32.8%: group A) reported the occurrence of gastro-oesophageal reflux disease symptoms, and 5 of them developed oesophagitis; gastrooesophageal reflux disease symptoms did not appear in the remaining 47 patients (group B). Basal gastro-oesophageal reflux disease score was significantly higher in group A than in group B (1.9+/-1.5 vs 0.9+/-0.9, p<0.005), while the abdominal symptoms score was not different. Following eradication, the score for abdominal symptoms decreased significantly (4.2+/-1.5 vs 1+/-0.8, p<0.0001) in the two groups; conversely, the total gastro-oesophageal reflux disease score remained unchanged, improving in 2 patients in group A and 11 in B, and worsening in 5 in group A and in 1 in B. Presence of hiatus hernia and male sex significantly correlated with the development of reflux symptoms. CONCLUSIONS: Patients who present with gastro-oesophageal reflux disease after Helicobacter pylori eradication are likely to already be affected by gastro-oesophageal reflux disease.

Manometric and pH-metric features in gastro-oesophageal reflux disease patients with and without Helicobacter pylori infection.

BACKGROUND: The role of Helicobacter pylori in the pathogenesis and evolution of gastro-oesophageal reflux disease is still debated. AIM: To investigate the impact of Helicobacter pylori infection on the oesophageal function and on intra-gastric and intra-oesophageal pH in patients with gastro-oesophageal reflux. METHODS: Fifty patients with non-complicated-gastro-oesophageal reflux disease classified according to Savary-Miller in: grade O, n=24; grade 1, n=19; grade 2, n=6; grade 3, n=1. Of these patients, 24 were Helicobacter pylori positive and 26 negative. Patients underwent, on two different days, stationary oesophageal manometry and 24-hour gastro-oesophageal pH-metry. RESULTS: No difference was observed between Helicobacter pylori infected and non-infected individuals with regard to lower oesophageal sphincter function, oesophageal peristalsis and gastrooesophageal reflux. These parameters were more impaired in individuals with erosive gastro-oesophageal reflux disease but this result was not dependent on the Helicobacter pylori status. Helicobacter pylori did not influence the pattern of gastric pH; however, considering only individuals with non-erosive gastro-oesophageal reflux disease, gastric pH was significantly higher in infected individuals, who, histologically, also showed a corpus predominant gastritis. CONCLUSIONS: In patients with gastro-oesophageal reflux disease, Helicobacter pylori does not affect the oesophageal motility or the gastro-oesophageal reflux. These parameters are strictly related to the severity of gastro-oesophageal reflux disease as assessed at endoscopy. In patients with non-erosive gastro-oesophageal reflux disease, a corpus predominant Helicobacter pylori gastritis could be responsible for the less severe gastro-oesophageal reflux.

Flumazenil in the treatment of acute hepatic encephalopathy in cirrhotic patients: a double blind randomized placebo controlled study.

AIMS: The aim of this study was to evaluate the effects of flumazenil on hepatic encephalopathy in patients with liver cirrhosis. PATIENTS AND METHODS: . In the double blind randomized, placebo controlled study, 54 patients with hepatic encephalopathy grade III-IV were randomly assigned to receive either flumazenil 2 mg iv (group A) or placebo (group B); conventional treatment with branched-chain amino acid, saline, glucose, and lactulose was administered in both groups. A 24-hour observation period was established. Clinical improvement was defined as a 3 point decrease in the Glasgow coma score at any time within 24 hours. RESULTS: Clinical improvement was obtained in 22/28 patients in group A and in 14/26 in group B (p<0.05); improvement was observed within the first six hours in 21/22 patients in group A and only in 3/14 in group B. Mortality rate was not different between group A and B; however, all 6 non-responders in group A and only 5 out of 12 in group B died within 24 hours. Among patients with post-bleeding encephalopathy, 11 out of 17 in group A and only 2 out of 14 in group B improved (p<0.001). CONCLUSIONS: Flumazenil may exert a beneficial effect in a subset of patients with acute hepatic encephalopathy; encephalopathy associated with bleeding is more likely to respond to flumazenil; responders to the treatment usually improve within the first 6 hours while lack of response usually represents a bad prognostic sign.

[Acquired deficiency of von Willebrand factor (wWF) associated with intestinal angiodysplasia. An unusual clinical case]. / Deficit acquisito di fattore di von Willebrand (FvW) associato ad angiodisplasia intestinale. Una insolita presentazione clinica.

A rare case of acquired von Willebrand's disease associated with intestinal angiodysplasia is described. The case is very interesting because it clinically mimicked an intestinal neoplasm.

Helicobacter pylori infection, pattern of gastritis, and symptoms in erosive and nonerosive gastroesophageal reflux disease.

BACKGROUND: The aim of this study was to evaluate the prevalence of Helicobacter pylori infection and the characteristics of gastritis and symptoms of patients with erosive and nonerosive gastroesophageal reflux disease (GERD). METHODS: We studied 202 consecutive patients with a diagnosis of GERD (symptoms score and endoscopy): group A (n = 110), erosive GERD; group B (n = 92), nonerosive GERD; 200 patients with upper abdominal complaints without abnormalities at endoscopy (functional dyspepsia, group C); and 200 asymptomatic controls tested for H. pylori serum antibody (group D). Antral and body biopsy specimens were taken for histology and the rapid urease test in groups A, B, and C. RESULTS: The prevalence of H. pylori infection was higher in groups B and C (62% and 55%, respectively) than in A and D (36% and 40%) (P < 0.05). In positive patients H. pylori colonization and gastritis grade scores in the gastric body were higher in nonerosive than in erosive GERD and functional dyspepsia (P < 0.05). No differences in H. pylori colonization or gastritis grades were found in the antrum. Fifty-nine patients with nonerosive GERD (64%) and 42 with erosive GERD (38%) showed other dyspeptic symptoms associated with reflux symptoms (P < 0.05). CONCLUSIONS: H. pylori prevalence is higher in patients with nonerosive GERD than in normal subjects and in patients with erosive GERD and similar to that of patients with dyspepsia. Patients with nonerosive GERD often show dyspeptic symptoms and higher H. pylori colonization and inflammation grades in the proximal stomach. Our data support the hypothesis that in GERD H. pylori gastritis may, on the one hand, protect against the development of esophageal erosions and, on the other, contribute to the esophageal hypersensitivity to acid which is a feature of GERD.

Systemic lupus erythematosus and pregnancy.

In this paper the authors underline the importance of SLE in women, above all those who become pregnant. This review also stresses the importance of an early diagnosis and the need to give correct information to pregnant women regarding the possible risks of pregnancy, both to the maternal organism and to the fetus. The authors also describe the main aspects of diagnosis and the management of this particular type of patient. In conclusion, they affirm that pregnancy should not be avoided categorically, but that it should be carefully planned and, once started, must be scrupulously monitored in view of the deterioration of SLE caused by pregnancy.

Summer camps for diabetic children: an experience in Campania, Italy.

To evaluate the effectiveness of summer camps with objective parameters, the authors examined data relative to nine summer camps organized by the Young Diabetics Association in Campania, Italy. The mean duration of camps was 10 days (range, 8-15) and a total of 256 diabetic children with an average age of 10 (range 8-16) participated in them. The medical personnel consisted of three pediatric endocrinologists, one psychologist, two male nurses and two parents who were directors of the Association. A significant improvement in knowledge and self-management of the disease was noted at the end of the camps. A beneficial effect on mean HbA1c level was also observed in the diabetic children who attended the monthly meetings and follow-up checks with their parents after the camp. On the other hand, a worsening of these values was noted in diabetic children who did not participate in them. No increased incidence of hypoglycaemia or ketoacidosis was found during or after camps, in contrast with previous studies. From a psychological viewpoint, the results suggest that summer camps have an important bearing on achieving acceptance of the disease. Sharing personal experiences with actively involved parents who participated in self-management training together with their children, has favourably influenced the results of this experience in Campania.