Helicobacter pylori: the Middle East scenario.

A review of Helicobacter pylori in the Middle East is presented. Prevalence studies have been performed in asymptomatic population groups from Algeria, Israel, Saudi Arabia and Turkey. These showed that the prevalence of H. pylori is similar to that of the developing countries of the world with a high level of infection in childhood (40 to 70 percent), which increases with age to 85 to 90 percent. Israel, however, has a low prevalence in children (10 percent), but there is a rapid rise in the second decade of life to 39 percent, reaching 79 percent in those over 60 years old. The prevalence rates were higher in those living in communal settlements (72 percent) than in urban dwellers (65 percent). The infection rates were higher in persons of Mediterranean and Asian origin (89 percent) compared to those of Western European/North American origin (57 percent). The prevalence rate of H. pylori infection in patients undergoing endoscopy for upper gastrointestinal symptoms has now been reported from many Middle Eastern countries, including Egypt, Iran, Israel, Oman, Saudi Arabia, the United Arab Emirates and Yemen. These studies showed that patients with gastritis and peptic ulcer disease had similar rates of infection as reported from Europe, United States and Africa (71 to 92 percent). However, patients with non-ulcer dyspepsia had higher rates of infection (61 to 89 percent). The H. pylori scenario from the prevalence rates, treatment protocols and responses to treatment does not differ very much from other developing areas of the world.

Changes in acid secretion over the years. A 30-year longitudinal study.

We studied the effect of aging on gastric acid secretion in 11 physicians who had augmented histamine tests while at medical school in 1962. One of them had a duodenal ulcer at the time. The augmented histamine test was repeated in 1991 and, in addition, upper gastrointestinal endoscopy was done to exclude peptic ulcer and to obtain biopsies for histologic analysis and assessment of Helicobacter pylori status. The mean basal acid output decreased from 7.3 to 1.9 mEq/hr during the 30-year period of follow-up (p < 0.001), and the mean maximum acid output decreased from 29.9 to 20.3 mEq/hr (p < 0.01). The maximum acid output data showed a profound decrease in 4 of the 11 participants, a lesser decrease in 4, and a minimal increase in the remaining 3. Histologic analysis suggested a greater likelihood of atrophic gastritis, H. pylori infection, or both in participants showing a pronounced decrease in acid secretion with aging.

Two point analysis 15-minute 14C-urea breath test for diagnosing Helicobacter pylori infection.

The value of a two point analysis (double sample) 14C-urea breath test in diagnosing Helicobacter pylori (HP) infection in patients with suspected acid peptic disease has been studied and compared to histology and to a rapid agar plate urease test in 76 patients. Using the histological finding of HP as the gold standard, the 14C-breath test was positive in 59 of the 61 histologically confirmed infected patients and in 3 of the 15 noninfected ones, giving a sensitivity of 97% and specificity of 80%. In 12 patients, a smaller dose of 3 mu Ci 14C-urea was used. The results correlated well with those in whom the higher dose of 10 mu Ci was used. We conclude that a two point 14C-urea breath test with analysis at 5 and 15 min is effective in diagnosing HP infection thus obviating the need for endoscopy and biopsy.

Heterotopic and metaplastic gastric mucosa in the duodenum.

The presence of gastric epithelium or mucosa at any level of the gastrointestinal tract is a well-known phenomenon. In duodenal mucosa, congenital heterotopic gastric mucosa or acquired metaplastic gastric surface epithelium (MGE) may be found. In the present study 325 duodenal biopsies (260 upper gastrointestinal endoscopy and 65 abdominal surgery biopsies) from 297 patients were retrospectively reviewed. Normal duodenal mucosa was present in 119 specimens, duodenitis in 155 and duodenal ulcer in 51. Heterotopic gastric mucosa was present in only one patient with duodenal ulcer, and MGE in 31% of the biopsies with a normal mucosa, in 21.7% with duodenitis and in 82% with duodenal ulcer (P less than 0.01). MGE was present in 120 biopsies of 109 patients--68 men and 41 women, 91% Jews, and 9% Arabs. The hospitalized population of our region comprised 82% Jews and 18% Arabs. Duodenal ulcer was more frequently found in Arab (69%) than in Jewish patients (41%). We conclude that MGE is a common finding, even in the presence of normal duodenal mucosa (30%) and occurs in most (80%) duodenal ulcer cases. The fact that MGE is more frequent in the Jewish population suggests that a genetic factor may be involved.

Serum beta-N-acetyl hexosaminidase and bile acid levels in patients with benign and malignant biliary obstruction.

beta-N-Acetyl hexosaminidase (beta-NAH), a lysosomal enzyme, was measured in the plasma of 15 patients with malignant extrahepatic biliary obstruction, 14 with benign extrahepatic obstruction, and 15 with long-standing benign intrahepatic cholestasis. beta-NAH was correlated with total serum bile acid levels. The correlation was significant (P less than 0.05) for the malignant and benign intrahepatic obstructions but not for the benign extrahepatic obstructions. This is consistent with the idea that circulating high levels of bile acids in patients with long-standing biliary obstruction may cause damage to Kupffer cell membranes and to their receptors for beta-N-acetyl hexosaminidase, impeding the clearance of the enzyme from the circulation resulting in elevated serum levels.

Recurrent acute pancreatitis associated with pancreas divisum.

Described is the case of a 24-yr-old patient in whom recurrent attacks of acute pancreatitis following a cholecystectomy were found to be associated with anomaly of the pancreas--the so-called pancreas divisum. An examination by endoscopic retrograde cholangiopancreatography showed typical findings of a short duct of Wirsung. Cannulation of the secondary duct of Santorini revealed a grossly dilated and strictured duct full of stones. After drainage of the duct by a pancreaticojejunostomy (Puestow procedure), the patient has not had any further episodes of acute pancreatitis during a follow-up period of 4 yr.

Immunoproliferative small-intestinal disease: clinical features and outcome in 30 cases.

Experience with 30 patients with immunoproliferative small intestinal disease followed prospectively between 1971 and 1986 is described. All presented with malabsorption or growth retardation and had similar clinical, biochemical, and radiological features, irrespective of the presence of lymphoma or immunological abnormality. Alpha-chain disease protein was detected in 4 of the 11 patients who had a non-lymphomatous, predominantly plasmacytic infiltration of the small bowel; and in 5 of the 19 cases with diffuse intestinal lymphoma. The importance of exploratory laparotomy to include full-thickness intestinal biopsy in patients who have a benign infiltrate on peroral biopsy is demonstrated by the finding of lymphoma in operative specimens in 9 of 15 patients with mature, lymphoplasmacytic cells, and 5 of 8 patients with atypical, lymphoplasmacytic cells. The majority of patients with fully established benign disease, even those elaborating alpha-chain disease protein, appeared to have a good prognosis. No patient with immunoproliferative small intestinal disease developed immunologically demonstrated alpha-chain disease or frank lymphoma, when this was not found initially at explorative laparotomy.

Pattern-reversal visual evoked potentials in hepatic cirrhosis.

Whole-field pattern-reversal VEPs (VEP) were examined in fifteen patients screened for hepatic cirrhosis. Twelve age- and sex-matched normal individuals and twenty-four psychotic patients on maintenance neuroleptic medication served as controls. There were no differences in latency or amplitude of the major positive component VEP (P100) to binocularly or monocularly presented reversing patterns between hepatic and control groups. Pre-exposure to flicker (the "photostress test") caused no abnormalities of VEP. Only in one patient with hepatic cirrhosis did monocular stimulation in the photostress condition cause a marked delay of P100. It is possible that this was an idiosyncratic response and that visual abnormalities detectable with the VEP technique can be attributed to other factors such as poor attention or accompanying disorders of the visual system.

Serial levels of CA 19-9 and CEA in colonic cancer.

The use of serial carbohydrate antigen (CA) 19-9 assays was assessed by comparison with serial carcino-embryonic antigen (CEA) levels on the plasmas of 53 patients with colorectal carcinoma. The patients had all undergone resection for their primary tumors and in six instances subsequent resections for hepatic metastases. Initial CA 19-9 levels were greater than or equal to 37 U/mL in 22 of the 53 patients (41%) and in 68% of the patients with metastatic disease. Similar trends of serial CA 19-9 and CEA levels were found in 79% of the 53 patients. One patient with initially normal CEA levels had elevated CA 19-9 levels from the start. In ten of the 53 patients (19%), serial CA 19-9 levels remained low despite tumor recurrence or progression, and despite increasing CEA levels above 5 ng/mL. The increasing serial CEA trends predicted recurrence in 88% and increasing CA 19-9 trends in 50% of cases, which was increased to 70% by including trends of CA 19-9 levels below 37 U/mL. Following hepatic lobectomy, both serial CEA and CA 19-9 levels decreased rapidly. Used alone, serial CA 19-9 levels did not appear to be as sensitive as standard CEA in this retrospective study of selected patients.

Plasma cell infiltration of the small intestine, recurrent pulmonary infections, and cellular immunodeficiency (Nezelof's syndrome).

An 18-year follow-up of a young woman who presented at the age of 10 years with a malabsorption syndrome and recurrent chest infections is reported. The serum immunoglobulins, and in particular the IgA, were increased, cell-mediated immunity was impaired but free alpha heavy chains were not detected. A jejunal biopsy showed plasma cell infiltration of the bowel with villous atrophy. Bronchiectasis, recurrent skin infections, and sinusitis were treated with frequent courses of antibiotics and corticosteroids. An initial presumptive diagnosis of cystic fibrosis was excluded by a normal sweat test. Although difficult to classify her exact type of immune deficiency state, the data would appear to conform to the syndrome of cellular immunodeficiency with normal or near normal immunoglobulins and lymphopenia (Nezelof's syndrome).

Plasma cell infiltration of the small bowel: lack of evidence for a non-secretory form of alpha-heavy chain disease.

Eight patients with diffuse plasma cell infiltration of the small bowel who had the clinical features of immunoproliferative small intestinal disease (IPSID), but whose serum was negative for free alpha-heavy chains, were investigated for evidence of a non-secretory form of alpha-chain disease (alpha-CD). Molecular sieving and immunoblotting of serum, immunoperoxidase staining of biopsy specimens, and in vitro protein synthesis studies utilising an immunoprecipitation technique and polyacrylamide gel electrophoresis, failed to detect any new cases of alpha-CD. Four of the eight cases were found to have diffuse intestinal lymphoma. The remaining four patients, who were unsuccessfully investigated for evidence of a significant abnormality in cellular immunity, have not developed detectable alpha-CD protein or lymphoma over a mean of 143 months. Despite continuing exposure to possible environmental stimuli, it is concluded that not all cases of IPSID elaborate detectable alpha-CD protein or evolve to lymphoma.

Endoscopic manometry of the pancreatic duct and sphincter zone in patients with chronic pancreatitis.

A possible mechanism for pain in alcohol-induced chronic pancreatitis is increased pancreatic duct pressure. A study has been done to compare sphincter of Oddi and pancreatic duct pressures in normal controls and patients with alcohol-induced chronic pancreatitis who had recently had pain or who were pain-free. Pressures were measured in the sphincter of Oddi in 10 controls and 33 patients, in the pancreatic duct in six controls and 15 patients, and in the common bile duct in four controls and five patients during station pull-through at the time of an endoscopic retrograde cholangiopancreatogram. There was no significant difference in the mean pressures in the pancreatic duct, sphincter of Oddi (basal and phasic), and frequency of papillary contraction when comparing patients with alcoholic pancreatitis and controls. There was also no difference between patients with or without pain and patients with or without strictures. This study has not confirmed the hypothesis that increased pancreatic duct pressures may be incriminated as a possible mechanism of pain in alcoholic-induced chronic pancreatitis.

[Instrumental dilatation of esophageal and gastric stenoses using Gruntzig's catheter and Celestin's dilator. Preliminary results]. / Dilatation instrumentale des sténoses oesophagiennes et gastriques à l'aide du cathéter de Grüntzig et du dilatateur de Celestin. Résultats préliminaires.

The aim of this study was to present the technique of endoscopic dilatation and the preliminary results obtained with 2 new instruments, the Grüntzig balloon catheter, and the Celestin dilator, in patients with esophageal or gastric strictures. The Grüntzig balloon catheter was used 11 times in 7 patients (6 adults and one child aged 1 1/2 year), for the dilatation of severe or irregular strictures of the esophagus (5 cases), the stomach (1 case) and the pylorus (1 case). Partial (4 cases) or complete relief (2) were observed and allowed subsequent use of the Celestin bougies (2 cases), or the introduction of an esophageal prosthesis (1 case). In the child with caustic stricture of the esophagus, dilatation with the Grüntzig balloon-catheter was complicated twice by perforation. In the second case, the perforation was related to the technique used in dilatation and was treated by conservation measures. Endoscopic dilatations with the Celestin bougies were performed in 27 patients with benign (including 9 peptic strictures) or malignant strictures (14 cases, 7 related to esophageal cancer, and 7 to cancer of the cardia). A total of 74 dilatations were performed, attaining a maximum diameter of 16 or 18 mm in one session, in 21 patients (78 p. 100 of the cases). In the case of peptic stricture, the anatomical result was excellent in 8 patients and the functional result good in 7 of 9 cases. In case of malignant stricture, the result was conditioned by the evolution of the tumor; recurrence of dysphagia called for either repeated dilatations (8 cases) or the introduction of an esophageal prosthesis (5 cases).(ABSTRACT TRUNCATED AT 250 WORDS)