[The topical therapy of ulcerative colitis. A multicenter study with beclomethasone dipropionate foam]. / Terapia topica della colite ulcerosa. Studio multicentrico con beclometasone dipropionato schiuma.

BACKGROUND AND AIMS: The use of steroids was recently extended to the various forms of ulcerative rectocolitis by the introduction of topical formulations, above all steroids with an hepatic "first pass" devoid of systemic interference. The aim of this study was to evaluate the efficacy and tolerability of Beclomethasone dipropionate (BDP) in a rectal foam formulation, in the treatment of patients suffering from ulcerative colitis. METHODS: The experimental protocol took the form of a 28-day open prospective trial using BDP rectal foam in patients suffering from ulcerative colitis. Endoscopic, histological, clinical and tolerability parameters were evaluated. The centres taking part in the trial collected data for 60 cases out of a total of 80 patients enrolled in the study, of both sexes and aged between 20 and 81 years old, suffering from proctosigmoiditis (46.7%) and ulcerative rectocolitis (53.3%). RESULTS: Endoscopic parameters showed an improvement after 28 days of treatment in 74.5% of patients; a clinical improvement was achieved in 65.2% of cases. In percentage terms of the mean value of all the improved parameters, histological parameters were altered in 56.9% of patients. With regard to tolerability 82% of patients judged the treatment to be good/excellent. CONCLUSIONS: In conclusion, in line with recent reports regarding other pharmaceutical forms of BDP, including the use of rectal foam, these data confirm the efficacy and tolerability of this molecule and emphasise the validity of its use in the treatment of ulcerative colitis and proctosigmoiditis.

Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation.

BACKGROUND AND STUDY AIMS: The choledocho-choledochostomy (CCS) stricture is one of the most frequent complications occurring after liver transplantation. Endoscopic retrograde cholangiography (ERCP) is the most sensitive method used to define the presence and narrowness of the stricture. Endoscopic stenting of the strictured anastomosis could provide an effective alternative to the surgical intervention. PATIENTS AND METHOD: ERCP was performed in 36 of 210 patients with liver transplantation and acute cholestasis or jaundice: in 15 cases biliary anastomotic stricture was found. These patients were endoscopically treated by long-term stenting of the common bile duct (CBD) (1 year) and followed up for more than 12 months after stent removal. RESULTS: In all cases the stenting procedure resolved the biliary obstruction syndrome within 7 days. At the end of the stenting period the CCS was dilated enough to allow adequate bile flow and absence of cholestasis. Moreover, in most patients (10) the anastomosis was kept patient for more than 1 year after stent removal, whereas only two patients had stricture recurrence and needed endoscopic restenting. Four patients dropped out of the study, respectively because of liver rejection (two), acute liver failure (one) and myocardial infarction (one). One patient who developed a stone of the transplanted CBD underwent surgical intervention. CONCLUSIONS: According to our data, the endoscopic stenting of the CBD might be considered as the first choice procedure in the setting of the biliary anastomotic strictures occurring after liver transplantation. It has proved to be safe and effective, avoiding the need for more invasive surgery, which in any case should be considered for nonresponsive patients.

Endoscopic diagnosis of leiomyosarcoma of the esophagus, a rare neoplasm.

We report a case of leiomyosarcoma of the distal third of the esophagus in a 51-year-old woman presenting with a six-month history of severe epigastric pain, disphagia and weight loss. The diagnosis, suspected on endoscopic examination, was preoperatively acheived by biopsy and immunohistological stain. Surgical treatment was undertaken with good results. Differentiation between leiomyosarcoma and more common esophageal neoplasm may be difficult if based on radiographic and endoscopic appearance. Preoperative histological confirmation is therefore mandatory to schedule a wide surgical excision.

The effect of endoscopic sclerotherapy of esophageal varices on the development of gastric varices.

BACKGROUND AND STUDY AIMS: The effect of sclerotherapy of esophageal varices on the development of gastric varices is a controversial question. The aim of the present study was to evaluate prospectively the presence and development of gastric varices as a consequence of esophageal variceal sclerotherapy. PATIENTS AND METHODS: We prospectively studied 227 patients, all of whom had liver cirrhosis at the time of the first bleeding episode due to esophageal varices. All patients were treated with emergency endoscopic sclerotherapy, and further courses of sclerotherapy to eradicate the varices were given at seven-day intervals for three sessions, and then every fifteen days until eradication was complete. At the time of inclusion in the study, patients were divided in two groups: group A, with initial gastric varices, and group B, without any gastric varices initially. RESULTS: Group A included 138 patients (60.8%), in 99 of whom (71.7%) disappearance of the gastric varices was observed. In 63 cases (63.6%) the varices were eliminated during the sclerotherapy treatment, before the eradication of esophageal varices; in 36 cases (36.4%), the gastric varices disappeared after the eradication of the esophageal varices. Group B included 89 patients (32.9%); in 78 of them (87.6%), no appearance of gastric varices was observed, while in 11 (12.4%), gastric varices appeared. CONCLUSION: From these data, it can be concluded that sclerotherapy of esophageal varices cannot be a determinant factor either for the appearance of gastric varices or for their subsequent risk of bleeding.

Non-bleeding visible vessel treatment: perendoscopic injection therapy versus omeprazole infusion.

BACKGROUND: The non-bleeding visible vessel in a peptic ulcer is the highest risk factor for a bleeding recurrence among not actively bleeding lesions. Perendoscopic injection of sclerosing compounds is usually used as prophylaxis against rebleeding. METHODS: Forty-two patients with visible vessels in a peptic ulcer at an emergency endoscopic procedure have been studied: 21 patients underwent prophylactic perendoscopic hemostasis, and 21 patients were infused with omeprazole intravenously. RESULTS: Eight patients (19%), four in each group, had early rebleedings (within 48 h after the enrollment). There was no significant difference between the two types of treatment. At the endoscopic control after 48 h there were significantly more lesions with higher risk of rebleeding (Forrest IIa and IIb) in the group treated with perendoscopic hemostasis. CONCLUSIONS: Our data suggest that omeprazole infusion is a valid alternative to injection treatment of non-bleeding visible vessels.

Endoscopic treatment of anastomotic biliary stenosis in patients with orthotopic liver transplantation.

The choledocho-choledochostomy stricture is one of the most frequent complications occurring after liver transplantation. Today endoscopic retrograde cholangiopancreatography may be considered one of the most common methodologic approaches for the diagnosis; at the same time it provides an effective treatment of the stenosis, avoiding more invasive surgery. Biliary flow through a strictured anastomosis definitely improves after endoscopic stenting which, in most cases, resolves the biliary obstruction syndrome; moreover, the stent could allow restoration of the anatomical and functional integrity of the common bile duct. We have successfully treated eight liver transplanted patients with biliary anastomotic stenosis by endoscopic stenting of the common bile duct or by balloon dilation (one patient). The stents were replaced every 3 to 4 months and then removed after 1 year of follow-up. We observed one patient with acute cholangitis due to the clogging of the prosthetic device.

The use of a long-acting somatostatin analogue (octreotide) for prophylaxis of acute pancreatitis after endoscopic sphincterotomy.

Acute pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). In addition, serum pancreatic enzymes increase without clinical symptoms in about 40-50% of patients undergoing these endoscopic procedures. We evaluated the potential of octreotide, a long-acting somatostatin analogue, to prevent these complications in patients who underwent EST for choledocholithiasis. 151 patients were randomly allocated to two groups (A and B). Group A was given 0.1 mg of octreotide subcutaneously 120 and 30 min before EST and four hours after; group B was given a placebo. Serum amylases (normal range 20-220 IU/l) were measured before premedication and 4, 24, and 48 hours after the end of endoscopy. After EST, the increase in the mean serum amylase was greater in the control group, but the difference was statistically significant only at the 48-hour measurement. There were five cases of acute pancreatitis in each group, with a trend (but not statistically significant) toward less severe pancreatitis in the treated group. In the control group, one patient with acute pancreatitis died. In conclusion, octreotide does not seem to prevent acute post-EST pancreatitis.

A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices.

Hemorrhage from esophageal varices in cirrhotics is a frequent event with high mortality in spite of therapy. Preventive sclerotherapy seems to be beneficial only if the patient's bleeding risk is higher than 40 to 50% a year. A series of 320 patients with esophageal varices without previous bleeding was studied prospectively; the varices were classified according to three widely used endoscopic classifications. During follow-up (6 to 36 months, average 14 months), hemorrhage occurred in 49 patients (15.3%) of whom 30 (61.2%) bled from varices (8.2 and 11.0% at 12 and 24 months, respectively). At the same time intervals, mortality of the entire population studied was 18.0 and 23.8%, respectively, of which one third was directly due to hemorrhage. With all three classifications, the higher the degree of bleeding risk, the greater the actual percentage of hemorrhages recorded; however, it never reached 40% a year. In predicting the bleeding event, Dagradi's classification proved more sensitive than JRSPH or NIEC, but the latter classifications were more specific and assessed a higher predictive value for a positive test. Endoscopic observation probably needs integration with other methods if a reliable bleeding prediction is to be made.

Bile acid inhibition of taurocholate uptake by rat hepatocytes: role of OH groups.

To define further the structural specificity of the taurocholate uptake site, we studied the ability of a variety of taurine-conjugated bile acids with differing hydroxyl substituents on the sterol moiety to inhibit [14C]taurocholate uptake. Rat hepatocytes isolated by collagenase perfusion were incubated in a tris(hydroxymethyl)aminomethane-phosphate buffer containing [14C]taurocholate (2.5-100 microM) in the presence or absence of inhibitor bile acid. Stronger inhibitors were studied at a fixed concentration of 5 microM, weaker ones at 25 microM. Initial uptake velocity was measured by sedimenting an aliquot of cells through silicone oil into 3 N KOH every 15 s for 1 min. Uptake velocity (nmol X mg protein-1 X min-1) could then be related to taurocholate concentration and a Vmax and Km could be determined by applying a nonlinear least squares fit to the data obtained with or without inhibitor. The kinetic parameters allowed the determination of the type of inhibition and of inhibition constants (Ki) of the various test bile acids. The data indicate that bile acids containing a 6- or 7-OH group exhibit competitive inhibition, whereas bile acids with no 6- or 7-OH group exhibit noncompetitive inhibition. Of the compounds exhibiting competitive inhibition, Ki varied with the number of hydroxyl groups on the sterol moiety. We conclude that the presence or absence of a 6- or 7-OH group dictates the mechanism of inhibition; the number of hydroxyl substituents determines the potency of competitive inhibition.

[Concentrations of IgM and IgA in the umbilical cord blood of 400 newborn infants: possible significance and correlations with prenatal infections (preliminary note)]. / Concentraziona di IgM ed IgA nel sangue funicolare di 400 neonati: possibili significati e correlazioni con infezioni prenatali (nota preliminare).

IgM and IgA dosed in cord sera of 400 infants. IgM are present in all samples; 16.25% of them show levels 25 mg/100 cm3. IgA are present in 5.75%, but only 2.25% show levels 6 mg/100 cm3. Our controls have confirmed they depend on maternal blood contamination. Correlations between IgM and IgA levels and perinatal infections are considered. Further studies are required to determine the presumptive nature of infectious agents.