Area under pH 4: a more sensitive parameter for the quantitative analysis of esophageal acid exposure in adults.

OBJECTIVE: Traditional quantitative analysis of 24-h esophageal pH monitoring data does not include the pH of reflux episodes. Area under pH 4 (AU4) is a recently introduced parameter that describes the acid exposure rate through both duration and depth of pH falls. METHODS: In Study A, we enrolled 20 healthy controls and 42 patients (18 without esophagitis, 24 with Savary I-III esophagitis) in a study evaluating reference values for 24-h reflux time at pH <4 (RT) and 24-h AU4 by means of receiver operating characteristic (ROC) discriminant analysis. For Study B, we next prospectively applied the resulting cutoffs to 16 healthy controls and to 110 gastroesophageal reflux (GERD) patients (55 with esophagitis) to adjust sensitivity, specificity, and predictive values of both RT and AU4. RESULTS: In Study A, the best cutoff values were 5.1% for RT (Area Index +/- SE, 0.899 +/- 0.038; 95% confidence interval [C.I.], 0.796 +/- 0.961) and 36.1 pH x min for AU4 (Area Index +/- SE, 0.935 +/- 0.03; 95% C.I., 0.842 +/- 0.981); AU4 gave the best performance (p = 0.038 vs RT) in discriminating controls and GERD patients. In Study B, RT was abnormal in three controls and 79 patients; AU4 identified all the controls and patients with abnormal RT and also 10/31 patients (32.3%) with so-called "normal" acid exposure (according to RT). In the whole GERD group of patients, AU4 and RT specificity was 81.2%, whereas sensitivity was 71.8% for RT and 80.9% for AU4 (chi2, 61.831; DF, 1; p < 0.005); PPV/NPV were 96.3%/29.5% for RT, and 96.7%/38.2% for AU4. CONCLUSIONS: AU4 appears to be a simple and sensitive quantitative parameter to measure the esophageal acid exposure in adults submitted to 24-h pH monitoring, and it could be an useful clinical aid in evaluating normal RT tests where, from a clinical point of view, a reflux disease is highly likely.

Selection criteria for pre-operative endoscopic retrograde cholangiography and endoscopic-laparoscopic treatment of biliary stones.

OBJECTIVE: Pre-operative endoscopic retrograde cholangiography (ERCP) prior to laparoscopic cholecystectomy (LC) is the most common treatment of gallbladder and common bile duct (CBD) stones. In this study we evaluate our selection criteria for pre-operative ERCP and the results of endoscopic-laparoscopic treatment in patients with CBD stones. DESIGN: Consecutive adult patients admitted to the department of surgery because of symptomatic cholelithiasis were included in a prospective open trial. PARTICIPANTS: Between January 1996 and December 1996, 841 patients underwent LC at our hospital. ERCP pre-LC was performed in 95 of the 841 patients, on the basis of our selection criteria. INTERVENTIONS: The indication to perform ERCP was suggested by a dilatated CBD (> 10 mm) or ductal stones, abnormal serum liver tests, persisting for more than 3 days, jaundice, cholangitis or pancreatitis. Twelve months after surgery, all patients were contacted by telephone to exclude symptoms related to residual stones. RESULTS: Cannulation of the CBD was successful in 94 of 95 patients submitted to pre-LC ERCP. CBD stones were found in 87 patients (95.6%) in 22 of whom (25.2%) they were in the form of small stones or sludge. In only three of 94 patients (3.2%) no alterations of the CBD or papilla were found. Complications occurred in eight of 98 patients (in five after endoscopic sphincterotomy (ES), and in three after LC). CONCLUSIONS: Pre-operative ES in selected patients with coexisting gallbladder and CBD stones has been a good approach and the criteria that we used for selection of patients to be submitted to pre-operative ERCP/ES seem to be effective.

Accuracy of the plasma amino acid-consumption test in detecting pancreatic diseases is due to different methods.

The aim of this study was to evaluate the controversial specificity of the plasma amino acid (AA)-consumption test in detecting pancreatic diseases by using two different quantitative methods. A total of 55 subjects: 13 healthy subjects, 13 patients with chronic pancreatitis (three mild/moderate, eight severe), 13 patients with pancreatectomy and complete suppression of the exocrine pancreatic secretion, eight patients with chronic liver disease (five with impaired synthetic function), and eight patients with chronic renal failure. Total plasma AAs were quantified by a colorimetric method (p-benzoquinone) in all subjects, at 0, 30, 45, and 60 min during and 30 min after minute 60 of i.v. cerulein infusion (50 ng/kg/h). Either total and individual AAs were quantified by chromatography (high-performance liquid chromatography; HPLC) in 10 healthy subjects, 10 patients with pancreatectomy, and 10 with chronic pancreatitis at 0 and 60 min after the start of the cerulein infusion. For the colorimetric method, healthy subjects had maximal percentage decreases of total AA concentrations not significantly different from those of patients with pancreatectomy and significantly higher than those of patients with chronic pancreatitis (p < 0.0001) or chronic liver disease (p < 0.001). Pancreatic function, as assessed by fecal elastase-1 test, was not significantly correlated to the maximal percentage decrease in total plasma AAs. For the chromatographic method, total AA concentrations were not significantly correlated to those determined by colorimetry. The concentration of each of the individual plasma AAs varied considerably in each group. Fecal elastase-1 values were normal (> or = 200 microg/g) in all patients without pancreatic disease and in only one of 11 patients with chronic pancreatitis and exocrine insufficiency. The type of method used can explain the different results of the AA-consumption test. This test is not very specific for the pancreas.

Outcome of ulcerative colitis after treatment with transdermal nicotine.

OBJECTIVE: Transdermal nicotine appears to be of benefit in the short-term treatment of patients with ulcerative colitis. The aim of this study was to determine its long-term effects. DESIGN: A randomized, comparative study. PATIENTS AND METHODS: Patients with mild to moderate clinical relapses of left-sided ulcerative colitis during maintenance treatment with mesalamine 1 g b.i.d. were allocated to an additional treatment with either transdermal nicotine or prednisone for 5 weeks. The first consecutive 15 patients per group, with clinical and endoscopic signs of remission, were followed up for 6 months, while continuing mesalamine maintenance treatment. RESULTS: Relapses of active colitis were observed in 20% of patients formerly treated with nicotine and in 60% of patients in the prednisone group (P = 0.027). Relapses occurred earlier in the latter group. CONCLUSION: Our results confirm that nicotine is useful in cases of ulcerative colitis with mild or moderate activity and suggest that remissions induced by nicotine may last longer than those obtained with oral corticosteroids.

Measurement of rectal blood flow by laser Doppler flowmetry in inflammatory bowel disease.

BACKGROUND/AIMS: Vascular alterations have been suggested as pathogenic factors in inflammatory bowel disease, particularly Crohn's disease. The aim of our study was to assess rectal blood flow in patients with active inflammatory bowel disease involving the rectum. METHODOLOGY: Endoscopic measurement of rectal blood flow was performed by laser Doppler flowmetry in 45 subjects divided into three groups: healthy controls, ulcerative colitis and rectal Crohn's disease. RESULTS: Rectal perfusion was found to be significantly impaired in patients with ulcerative colitis, but not in those with Crohn's colitis. CONCLUSIONS: Our results confirm the role of local ischemia in ulcerative colitis, but do not support the theory that vascular factors play a key role in the pathogenesis of Crohn's disease.

Is endoscopy useful for early diagnosis of ischaemic colitis after aortic surgery? Results of a prospective trial.

BACKGROUND: Ischaemic colitis is an infrequent, but potentially fatal, complication of abdominal aortic surgery. Its presentation is often underestimated on account of a paucity of symptoms, thus the real incidence of ischaemic colitis may be higher. AIM: To determine the prognostic value and sensitivity of endoscopy, early postoperative endoscopic findings were evaluated. METHODS: Over a period of three years a prospective study was undertaken in a consecutive series of 105 patients (mean age 68.9 years, range 51-85) undergoing routine rectosigmoidoscopy within 72 hours of aortic reconstructive surgery. RESULTS: Colonic ischaemia was found in 12 patients (11.4%); five had endoscopic evidence of mild ischaemic colitis, ulcerations were identified in five and diffuse superficial necrosis in two. Seven of the 12 patients were symptomatic. Laparotomy was never deemed necessary and all patients were successfully treated with a conservative regimen. There were no deaths. Elective reconstruction or urgent procedure did not correlate with the development of colonic ischaemia, nor did duration of aortic cross-clamp time, patency of the inferior mesenteric artery and its possible ligation or reimplantation or patency of the hypogastric arteries. CONCLUSIONS: Rectosigmoidoscopy is effective for early diagnosis of ischaemic colitis. Early endoscopy should be routinely performed only for patients in whom impaired blood flow is suspected on the basis of the intraoperative objective assessment of the colon and in presence of symptoms.

Brief communication: smoking and duodenal blood flow.

Smoking promotes an increase in both the incidence and the recurrence of duodenal ulcers, but the mechanisms responsible for its adverse effects on the duodenal mucosa are still poorly understood. The aim of the present study was to investigate the effect of chronic cigarette smoking on duodenal blood flow. In 20 dyspeptic patients (10 non-smokers and 10 smokers) with endoscopically normal duodenum, mucosal blood flow was measured in the duodenal bulb by laser Doppler flowmetry during endoscopy. Basal bulbar perfusion was found to be significantly lower (P < 0.05) in smokers. Our results suggest that duodenal blood flow is reduced in heavy smokers. This may promote duodenal damage because of both local ischaemia and the reduced secretion of protective bicarbonate.

Multidisciplinary conservative treatment of difficult bile duct stones: a real alternative to surgery.

56 patients with large CBD or intrahepatic stones underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock wave lithotripsy. Percutaneous access to the biliary tract was chosen when an endoscopic approach was not possible (hepaticojejunostomy in 5 patients, 1 juxtapapillary diverticulum and 1 inflammatory bile duct stricture). Visualization of stones was achieved radiologically in 32 patients and by ultrasound in 24. The procedure was successful in 47 of 56 treated patients (83.9%). Clearance of the biliary tract was obtained in 25 cases (53%), whereas in 22 cases (47%) complete clearing of biliary tract was obtained only after endoscopic extraction of fragments (17 cases) or percutaneous (5 cases). The median number of shock waves in each session was 1725 (range 300-3166), which were applied during one (n = 30), two (n = 22) or three sessions (n = 4). The only complications were 1 case of symptomatic hyperamylasemia and 3 cases of macrohematuria. In conclusion, extracorporeal lithotripsy combined with endoscopic and/or percutaneous treatment is a real alternative to surgery for difficult stones.

Italian National Survey of Digestive Endoscopy Disinfection Procedures.

BACKGROUND AND STUDY AIMS: Inadequate disinfection of endoscopes and associated instrumentation can result in transmission of bacterial infections to patients. The aim of this study was to investigate the disinfection procedures carried out in the Italian centers of digestive endoscopy. MATERIALS AND METHODS: An anonymous postal questionnaire on the methods of cleaning and disinfecting endoscopy equipment in Italy was sent to 781 digestive endoscopy centers; 386 units (49.4 %) replied. RESULTS: Automatic washers were available in 47.6% of units. Nearly all the respondets (99.2%) cleaned the instruments before disinfection, using detergent, germicidal or enzymatic cleaner, but only 69.7% carried out brushing. Most centers (89.2 %) used a glutaraldehyde-based disinfectant (51 % used 2 % glutaraldehyde; 26.9% used 0.4% glutaraldehyde with 1.41% phenol and 0.26% sodium phenate; 5.9% used either; 5.4% did not specify glutaraldehyde formulation). The contact time of the disinfectant was < 10 minutes (1.8%), between 10 and 19 minutes (47.4%), between 20 and 29 minutes (31.9 %) and > or = 30 minutes (16.6%). The use-life of the disinfectant was > or = 14 days in 27.3 % of the centers with automatic washers and 30.8% in all centers. Only 25.4% of the centers carried out some form of sterilization for biopsy forceps. The majority (83.4 %) modified their disinfection procedures in the case of infectious disease patients. Quality control tests on the efficacy of the endoscopy disinfection procedures were carried out in 44.6 % of units. Only 43 % of the centers were based in hospitals with an infection control (surveillance) program. CONCLUSIONS: The data collected in the study showed that, in general, there is compliance with the Società Italiana di Endoscopia Digestiva (SIED) and Società Italiana di Gastroenterologia (SIGE) guidelines, although with some important exceptions.

Gabexate for the prevention of pancreatic damage related to endoscopic retrograde cholangiopancreatography. Gabexate in digestive endoscopy--Italian Group.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with elevated levels of pancreatic enzymes and pancreatitis. Gabexate, a protease inhibitor, has been used to prevent pancreatic damage related to ERCP. METHODS: We conducted a multicenter, double-blind comparison of gabexate (1 g given by intravenous infusion starting 30 to 90 minutes before endoscopy and continuing for 12 hours afterward) with placebo (mannitol and sodium chloride, administered in the same fashion). A total of 435 adults scheduled to undergo ERCP and, when indicated, endoscopic sphincterotomy underwent randomization; 17 were excluded from the final analysis for various reasons. The remaining 418 patients (mean age, 60.4 years)--208 in the gabexate group and 210 in the placebo group--were analyzed. Acute pancreatitis was considered to be present if serum amylase or lipase levels (or both) were five times greater than the upper limits of normal in association with the onset of pancreatic pain. RESULTS: After the procedures, 276 patients (66 percent) had elevated pancreatic-enzyme levels; the frequency was similar in the two groups. Mean serum amylase values were higher in the placebo group than in the gabexate group through 24 hours of observation (P=0.03). Twelve patients in the gabexate group and 29 in the placebo group had abdominal pain (6 percent vs. 14 percent, P=0.009). Sixteen patients in the placebo group and five in the gabexate group had acute pancreatitis (8 percent vs. 2 percent, P=0.03). Two patients treated with gabexate and six given placebo had adverse events, all of which resolved. Two patients given placebo died of acute pancreatitis; one was excluded from the evaluation because pancreatitis was present before endoscopy. One patient in the gabexate group died, from a myocardial infarction. CONCLUSION: Prophylactic treatment with gabexate reduced pancreatic damage related to ERCP, as reflected by reductions in the extent but not the frequency of elevated enzyme levels and in the frequency of pancreatic pain and acute pancreatitis.

Pilot trial of nicotine patches as an alternative to corticosteroids in ulcerative colitis.

In ten patients with mild to moderate clinical relapses of ulcerative colitis during treatment with mesalazine (1 g t.i.d.) and with a previous history of poorly tolerated steroid courses, transdermal nicotine (15 mg daily) was added for 4 weeks. Clinical findings were assessed by employing Rachmilewitz's activity index. In 7 of the patients, clinical remission was achieved, the results persisting for up to 3 months after nicotine withdrawal. Endoscopic and histological examination, when performed, confirmed the clinical findings. Nicotine patches may represent a good alternative to steroids in selected patients with mild to moderate relapses of ulcerative colitis. The precise mechanism of action remains unknown.

Precancerous gastric lesions and Helicobacter pylori.

BACKGROUND/AIMS: Previous publications in the literature have reported an association between incidence of Helicobacter pylori (HP) infection and gastric cancer. The role of HP in precancerous gastric lesions or in their evolution towards neoplastic disease is not so clear. MATERIALS AND METHODS: We studied 174 patients with atrophic gastritis. RESULTS: Intestinal metaplasia (IM) was detected in 165 subjects of the patients and different grades of dysplasia were observed in 32 subjects. HP was found in 75 (52.8%) of 165 subjects with IM, in 7 (34.7%) with both IM and dysplasia and in 3 with dysplasia alone. There was no significant difference in the prevalence of HP infection in the three IM types, type I (47.7%), type II (54.7%) and type III (48.4%) (p = n.s.). In contrast, the prevalence of HP positive patients was significantly lower in dysplasia (10/32 vs 22/32; p < 0.005). At the same time, the frequency of HP was significantly lower for subjects with IM and dysplasia than for those with type I IM (41/83 vs 7/32; p = 0.01). CONCLUSIONS: At present, in our experience, HP infection is rather infrequent in type III IM and it is found less often in cases of dysplasia. We have taken these results to suggest that the modified gastric mucosa becomes inhospitable for HP and, consequently, that other factor are probably responsible for promoting gastric carcinogenesis.

Gastric microcirculation and bicarbonate production in heavy smokers.

OBJECTIVE: To determine the effect of chronic cigarette smoking on gastric mucosal blood flow and bicarbonate secretion. METHODS: Three groups, each consisting of eight dyspeptic patients with normal endoscopic features, were studied: group A contained non-smokers, group B light smokers (< 10 cigarettes/day) and group C heavy smokers (> 10 cigarettes/day). Blood flow was measured in the gastric antrum by laser-Doppler flowmetry, and basal bicarbonate secretion was determined in fasting gastric juice by the method of Feldman. RESULTS: Both mucosal blood flow and bicarbonate secretion were significantly reduced (P < 0.01) in group C. CONCLUSION: In heavy smokers, gastric mucosal perfusion and alkali production are impaired. This can contribute to the noxious effects of smoking on the gastric mucosa. It remains to be determined whether these effects of smoking are causally related.

Rectal blood flow in ulcerative colitis.

OBJECTIVE: To determine the state of local blood flow in ulcerative colitis. METHODS: Rectal blood flow was measured by means of laser Doppler flowmetry during endoscopy in 20 patients with active or inactive ulcerative colitis and in 20 healthy controls. RESULTS: A significant (p < 0.01) reduction in the values of rectal perfusion was observed in ulcerative colitis patients both in active phase and in clinical and endoscopic remission. CONCLUSIONS: Impaired local blood flow may have a pathogenetic role in ulcerative colitis. Remission of the disease is not accompanied by normalization of local microcirculation, which may predispose to relapses.

Colloid bismuth versus famotidine in the treatment and prevention of duodenal ulcer relapse: results of a double-blind, double dummy randomized study.

Fifty-three consecutive patients with active duodenal ulcer (DU) were randomly included in a double-blind, double-dummy study to test the healing and relapsing rate of two treatment regimens: famotidine 40 mg nocte for 4-8 weeks, followed by 20 mg for 12 months after healing of the ulcer and colloidal bismuth (CBS) (240 mg bid) for 4-8 weeks, followed by placebo maintenance treatment. The results of the short term period confirmed the efficacy of CBS in healing DU (24/25 in CBS group and 19/23 in famotidine group). However, the relapse rate in the CBS-treated group was higher (77.8% at 12 months) than in the famotidine group (35.7%) (p = 0.041). Only 7 patients (41.2%) were cleared from Helicobacter pylori (HP) after CBS treatment. In conclusion, the high relapse rate observed in CBS treated patients may be related to the high percentage of patients with HP infection in the tested group and support the hypothesis that lack of efficacy of CBS in preventing DU recurrence is related to its poor eradication of HP.

Does Helicobacter pylori affect gastric microcirculation?

Chronic gastritis is frequently accompanied by Helicobacter pylori infection and associated with a reduced gastric blood flow. To investigate the possible relationship between the two phenomena, 20 outpatients with histological antral gastritis with or without concomitant duodenal ulcer, 10 of them Hp positive and 10 negative, were selected and compared with a matched group of ten healthy controls. Mucosal blood flow was measured in the gastric antrum by laser Doppler flowmetry during endoscopy. In both groups of patients with chronic gastritis the values were significantly lower than normal (p < 0.01), the difference between Hp+ and Hp- cases being statistically not significant. In six of the Hp+ patients, eradication therapy with omeprazole+amoxycillin was carried out because of concomitant duodenal ulcer. At 6 weeks eradication was successful in four patients, but perfusion values remained unchanged. Mucosal blood flow in chronic gastritis is reduced regardless of concomitant H. pylori infection and eradication has no influence on gastric perfusion. Therefore H. pylori appears to have no direct effects on gastric microcirculation.