Efficacy of mesalazine or beclomethasone dipropionate enema or their combination in patients with distal active ulcerative colitis.

OBJECTIVE: Mesalazine or Beclomethasone dipropionate (BDP) enema have been shown effective in treatment of distal active ulcerative colitis (UC). This study was aimed to determine whether the combination of topical mesalazine and BDP is superior to topical mesalazine or BDP used alone in patients with distal active UC. PATIENTS AND METHODS: One-hundred and twenty patients with clinical, endoscopic and histological diagnosis of distal active UC were randomly assigned to a regimen with mesalazine tablets 2.4 g/day associated to either mesalazine enema 4 g/day (group A, n=40), BDP 3 mg/60 ml every day (group B, n=40) or the combination treatment with the two compounds in a single administration (group C, n=40) for eight weeks. After four weeks of treatment all patients underwent clinical controls but only 109 patients returned back for clinical, endoscopic and histological controls at the end of the treatment period. RESULTS: After eight weeks, complete remission rates were of 52%, 47% and 65% respectively, in group A, B and C. From baseline to 4 and 8 weeks the CAI score decreased significantly in all the three groups (p < 0.0001). CONCLUSIONS: All the three combinations achieved equivalent results in terms of symptoms in inducing symptoms relief and mucosa healing in distally active UC.

Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD).

BACKGROUND AND AIM: Periampullary diverticula (PAD) are found in 9-32% of patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). PAD are acquired lesions which are rare in patients <40 years, but increasing with age. Several endoscopic studies have revealed an association between PAD and common bile duct (CBD) stones. The presence of a papilla located in the diverticula is also frequent (6.8-54.9%) and represents a restrictive factor for successful cannulation. MATERIALS AND METHODS: A retrospective analysis has been made of data related to the patients with PAD treated at our GI Unit (small center with low case volume), who underwent ERCP in the period 1st January 2010 to 31st March 2014. For each patient were analyzed data regarding sex, age at diagnosis, indication to ERCP, cannulation rate, endoscopic treatment and complications. PAD were classified in 3 different types according to the position of the major papilla. RESULTS: A total of 647 ERCPs have been performed of which 77 (16.5%) in pts with PAD (48 F, 29 M, mean age: 78.3 years; range: 48-95). PAD type I (inside the diverticulum) were found in 22 pts (28.6 %), Type II (in the margin of the diverticulum or between two PADs) in 36 pts (46.7 %) of which 12 cases between two PADs, type III (near the diverticulm) in 19 pts (24.7 %). The indication for ERCP were: 72 CBD stones (93.5%), 3 cholangiocarcinoma (3.9%) and 2 pancreatic head cancer (2.6%). In cases of difficult cannulation, precut was performed in 12 pts (15.6%). Deep CBD cannulation and endoscopic sphincterotomy (ES) was achieved in 70 cases (90.9%). The other 7 case of failure were all in patients with CBD stones. Complete clearance of CBD stones was achieved in 57 patients (87.7%) (57/65 ERCP/ES). Stent placement was necessary in 8 cases (12.3%) (8/65 ERCP/ES), due to multiple large stones. The adverse events related to ERCP/ES included 4 intraprocedural bleeding (5.7%) (4/70 ERCP/ES) and 1 mild pancreatitis (1.4%) (1/70 ERCP/ES), all managed conservatively. CONCLUSIONS: Our data show that ERCP is a safe procedure also in patients with PAD, with a good success rate and low complications.

Role of endoscopic sphincterotomy of the minor papilla in pancreas divisum.

BACKGROUND: Pancreas divisum (PD) is a common anatomical variant of the pancreatic duct system. Only a little percentage of patients with this altered anatomy develop symptoms: acute recurrent pancreatitis (ARP), chronic pancreatitis (CP) and pancreatic-type pain alone. These have been supposed to arise from an obstruction to outflow of the pancreatic dorsal duct due to a stenosis of the minor papilla. Endoscopic sphincterotomy of the minor papilla (MiES) can be considered an effective treatment for patients with PD and ARP supported by stenosis or obstruction of the minor papilla. On the other hand, the access through the minor papilla is essential for therapeutic pancreatic endoscopy in patients with PD and CP, but the effectiveness of MiES in these patients is extremely controversial. MATERIALS AND METHODS: Aim of this brief review has been to evaluate the short and long-term effects of endoscopic pancreatic interventions in patients affected by symptomatic PD who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy of the minor papilla (MiES). The main literature database was Medline (1966-2013). RESULTS: Data come from a personal overview of articles emerging from the same search strategy. CONCLUSIONS: Nowadays, when endoscopic pancreatic drainage is indicated in patient with symptomatic PD, access through the minor papilla (MiP) is required. Therapeutic endoscopic interventions provide less invasive alternatives to the surgical approach.

Large symptomatic simple hepatic cyst with gastric compression treated with percutaneous drainage.

Nonparasitic hepatic cysts consist of a heterogeneous group of disorders, which differ in etiology, prevalence, and manifestations. Simple hepatic cysts are considered nonparasitic ones. These are a result of congenital anomalies of the biliary system, and these may be single or multiple. Generally, hepatic cysts are incidentally found during occasional laparotomy or laparoscopy, necropsy, and even during routine ultrasound or computerized tomography (CT) scan. Nowadays, with improving diagnostic techniques, hepatic cysts are becoming more common. Generally these lesions are asymptomatic. However, if they grow, they may become symptomatic. Symptoms depend on the size and location. When symptoms developed, these must be treated. Compressive complications due to local "liver mass" effect include: portal hypertension, edema due to caval compression, jaundice and arrhythmia and duodenal obstruction. Gastric extrinsic compression by liver cysts has been poorly described. Herein, we present a case of a female in whom percutaneous drainage of a large simple hepatic cysts not complicated was performed in order to reduce signs of gastric compression.

Patient with chest pain refractory to proton pump inhibitor: report of a case of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is the most common form of gastrointestinal disorders associated with eosinophilia. Typically, an inappropriate accumulation of eosinophils is found in the esophageal mucosa. EoE can be well managed and treated with several options that include an elimination diet, drug therapy (oral and topical steroids) and esophageal dilatations. We herein, report a case of a 49-year-old male affected by EoE associated to chest pain, treated with proton pump inhibitor without clinical response. The patient suffered from long lasting postprandial fullness and gastroesophageal reflux disease-like symptoms. He had a history of episodic asthmatic attacks and allergic rhinitis but had not dysphagia or food impaction. The patient recovered completely after an adequate treatment.

Benign pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG) feeding tube placement: do not be afraid!

In order to ensure enteral feeding, placement of a percutaneous endoscopic gastrostomy (PEG) is considered a standard care for patients with oropharyngeal malignancies. Benign pneumoperitoneum is a complication of PEG feeding tube placement and it is usually an incidental finding that arises, generally, immediately following the procedure. We report a case of a benign pneumoperitoneum, developed 48 hours after the procedure, which was treated conservatively.

Quality of life in ulcerative colitis patients treated medically versus patients undergoing surgery.

OBJECTIVES: Approximately one third of patients with ulcerative colitis (UC) require surgery. AIM: Aim of this study was to assess the quality of life (QoL) of UC patients who have undergone surgery with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) compared to UC patients not operated. PATIENTS AND METHODS: Fifty consecutive UC patients for each group observed between 1988-2010 were included. To all patients was administered a self completed questionnaire with four different scores: intestinal symptoms (IS), systemic symptoms (SS), emotional function (EF), social function (SF) and an overall QoL score. RESULTS: Overall QoL score and three dimensions (SS, EF, SF) resulted not significantly different in the three groups, except for IS that resulted worst in the IRA-Group. According to the activity of disease it appeared that UC and IRA patients with mild activity had an overall QoL score similar to patients with complicated IPAA. A higher statistically different score of overall QoL was observed in patients with UC and IRA with moderate/severe disease. CONCLUSIONS: Results of the study demonstrate that overall QoL score is poorer in patients with UC and IRA with mild activity and in patients with complicated IPAA and is worst in patients with UC and IRA with moderate/severe activity.

Azathioprine treatment in inflammatory bowel disease patients: type and time of onset of side effects.

BACKGROUND: Azathioprine (AZA) and 6-mercaptopurine (6-MP), purine analogues, are the immunosuppressant drugs most frequently used for inducing and maintaining remission in inflammatory bowel disease (IBD). The occurrence of adverse effects is a major drawback in the use of these drugs, and short- and long-term toxicity represent a major limitation to their use. AIM: The present study investigated the prevalence, type and time of onset of AZA-related adverse events, in a cohort of IBD patients in a single referral Centre. PATIENTS AND METHODS: The records of consecutive IBD outpatients, referred to our Institution between 1987-2009, were retrospectively evaluated. RESULTS: We reviewed 2014 patients, in whom AZA was prescribed in 302 of them, 139 (46%) with ulcerative colitis (UC) and 163 (54%) with Crohn's disease (CD). Side-effects were complained by 98 (32.4%) out of 302 patients, 50 UC and 48 CD, (36% UC vs 29.4% CD, p = 0.26). In 20 (20.4%) patients, 11 UC and 9 CD, side-effects recovered after dosage reduction whilst in 78 (79.6%), 39 UC and 39 CD, the treatment was discontinued (dose-dependent side-effects in 42 patients and dose-independent in 36). Overall, side-effects were observed after a mean period of 14.5 ± 7.8 months (range 0.5-123) of AZA treatment. The majority (76%) of the dose-dependent adverse events were reported between 12-18 months after the beginning of treatment. CONCLUSIONS: The prevalence of side effects leading to withdrawal of AZA treatment, in our series of Italian patients, was higher respect to data reported in the literature (25.8%).

Comparison of endoscopic retrograde cholangiopancreatography between elderly and younger patients for common bile duct stones.

BACKGROUND: Choledocholithiasis is increasing in elderly subjects. The introduction of endoscopic retrograde cholangiopancreatography with biliary sphincterotomy has almost replaced surgery in the treatment of this condition. The aim of the present study was to evaluate the rates of successful clearance of common bile duct stones and the endoscopic techniques used in a population aged 75 years or older compared with those in a younger age group. MATERIALS AND METHODS: A retrospective analysis was made of data related patients who underwent endoscopic retrograde cholangiopancreatography for choledocolithiasis in the period 2010-2011. For all patients, factors such as sex, age at diagnosis, endoscopic treatment (stone extraction using baskets and balloon, mechanical lithotripsy and balloon dilatation of the ampulla, placement of a stent or a naso-biliary tube) and need of surgery were analysed. Two groups of patients were identified: patients aged <75 years (Group A) and patients aged ≥75 years (Group B). For the statistical analysis Mann-Whitney test and Fischer's Exact test were used. RESULTS: A total of 234 patients were enrolled in the study (94 in Group A, 140 in Group B). No statistically significant differences were observed as far concerns sex, previous cholecystectomy, gallbladder stones and periampullary diverticula, but only for common bile duct dilatation. Complete clearance of common bile duct stones was achieved in 230 patients (97.5%). CONCLUSIONS: The present data are in keeping with those presented in the literature, which confirm that endoscopic retrograde cholangiopancreatography is a safe and effective procedure also in older patients.

Self-expandable metal stent placement for treatment of severe sphincterotomy bleeding.

One of the most frequent complications of endoscopic sphincterotomy (ES) is bleeding. When post-ES bleeding does not respond to the use of typical endoscopic therapy, the only alternative is angiography or surgery. A 82-year-old female was admitted for jaundice. A RMN-cholangiography revealed multiple stones in the common bile duct (CBD). She underwent endoscopic retrograde cholangiopancreatography (ERCP). The papilla major was located between two large periampullary diverticula. During the ES, a severe bleeding was observed from the upper part of the biliary cut. Several methods of hemostasis (injection of adrenaline, thermal methods and balloon tamponate) were performed without efficacy. A partially covered metallic stent was placed across the biliary orifice, in order to compress mechanically the bleeding site archiving the hemostasis.

Gastric Dieulafoy's lesion successfully treated by "adjuvant" arterial embolization and endoscopic clipping.

While it is well recognized that peptic ulcer disease is the most common cause of nonvariceal upper gastrointestinal bleeding, other lesions cause of haemorrhage, even if rare, may potentially life-threatening. These include arteriovenous malformations such as Dieulafoy's lesion, defined as caliber-persistent submucosal vessel. The endoscopy with its hemostatic techniques is usually the treatment of choice for such patients. In those cases, in which these techniques fail due to the difficult in the correct localization, angiography with embolization may be a good alternative. The use of microcatheters and new embolic agents have improved this procedure. In fact, transcatheter arterial embolization represents a minimally invasive alternative to surgery when endoscopic treatment fails to control gastrointestinal bleeding, especially for the upper tract. This technique proved to be safe, fast and effective. According to our knowledge, only one case of a Dieulafoy's lesion of the duodenum treated with "adjuvant" embolization followed by laser coagulation has been reported in literature. Herein, we report a case of a Dieulafoy's lesion of the stomach, in which "adjuvant" transcatheter arterial embolization has permitted a more easier endoscopic diagnosis and treatment.

Ictero-haemorraghic leptospirosis with pulmonary involvement and acute renal failure: case report.

Leptospirosis is a spirochetal zoonosis with a worldwide distribution affecting both animals and humans. These are infected only occasionally by direct contact with infected animals or through contaminated water and soil. Generally, this disease is commonly found in tropical regions. Infected patients usually present with non-specific features. In fact, the clinical manifestations of leptospirosis are variable, ranging from occult infection to Weil's disease with fatal complications. Often the disease remains underdiagnosed due to the broad spectrum of signs and symptoms. Here we are reporting a case of a woman with an ictero-haemorraghic leptospirosis complicated by acute renal failure and pulmonary involvement that received intensive care unit support including intubation and ventilation and promptly resolved with appropriate therapy.

Simultaneous primary gastric and duodenal MALT lymphoma presenting with gastrointestinal bleeding.

The gastrointestinal tract, particularly the stomach, is the most common site of mucosa-associated lymphoid tissue lymphoma (MALToma). Many studies describe primary MALT lymphoma arising from the gastric mucosa, especially in association with Helicobacter pylori infection. On the contrary, primary MALT duodenal lymphoma is a very rare neoplasm. We report a case of a patient with gastrointestinal bleeding in whom primary gastric and duodenal MALT lymphoma were occurred simultaneously.

Hematemesis from esophageal varices associated with esophageal perforation: sclerotherapy and endoscopic clipping.

A 46-year-old man was referred to our Unit for hematemesis. The medical history of the patient revealed an HCV-related cirrhosis, a human immunodeficiency virus (HIV) infection and recent and persistent episodes of emesis. An urgent gastroscopy disclosed evidence of active bleeding from varices of the lower third of the esophagus and a concomitant laceration of the esophageal wall due to the emesis. These two conditions have been endoscopically diagnosed and successfully treated by sclerotherapy and endoscopic clipping.

[Use of argon plasma coagulation in digestive endoscopy: a concise review]. / Utilizzo della coagulazione con argon plasma in endoscopia digestiva: revisione della letteratura.

Argon plasma coagulation (APC) is a non-contact thermal method of hemostasis that has generated much attention in recent years. This endoscopic procedure is used primarily to control bleeding from lesions in the gastrointestinal tract, and also sometimes to debulk tumours in the case of patients for whom surgery is not recommended. APC involves the use of a jet of ionized argon gas (plasma) that is directed through a probe passed through the endoscope. The probe is placed at some distance from the lesion, and tissue damage is limited to superficial layers. The depth of coagulation is usually only a few millimetres. Theoretical advantages of APC include facility application, speedy treatment of multiple lesions in the case of angiodysplasias or wide areas (the base of resected polyps or tumor bleeding), safety due to reduced depth of penetration, and lower cost compared to laser.

[Endoscopic therapy with balloon dilatation in patients with colonic post anastomotic strictures. Personal experience]. / Trattamento endoscopico con dilatazione pneumatica nei pazienti affetti da stenosi coliche post-anastomotiche. Esperienza personale.

BACKGROUND AND AIM: Colorectal post anastomotic benign strictures are not uncommon. The purpose of this study was to investigate the results of endoscopic balloon dilatation of anastomotic strictures. MATERIALS AND METHODS: The study was on a retrospective survey. Records of 14 consecutive patients with anastomotic strictures (5 F, 9 M; median age 64 years; range: 50-87 years), attending our GI Unit from February 1st 2008 to December 31st 2009, were analyzed. All patients had been operated for colon carcinoma. All of them were treated with balloon dilatation. RESULTS: All the patients presented symptoms of obstruction. The total number of dilatation sessions was 37 and the median number of sessions by patient was 1,5 (range: 1-7). After the procedures, all patients had an improvement of symptoms. No complications were observed. CONCLUSIONS: Our experience underlines that endoscopic ballon dilatation, in patients with post anastomotic benign strictures, is a safe technique with a low rate of complications.

Microscopic colitis: a concise review.

Microscopic colitis is an increasingly common cause of chronic watery diarrhoea, and often a causes of abdominal pain of unknown origins. The increase of interest for this clinical entity is due to a misdiagnosis of any symptoms that have been frequently attributed to diarrhea-predominant irritable bowel syndrome, often for many years before diagnosis. Presumably, most estimates of incidence and prevalence understate the true frequency of microscopic colitis for this reason. The aim of this paper is to evaluate the importance of microscopic colitis as cause of chronic non bloody diarrhoea, on the basis of literature review. These kind of colitis are characterized by normal colonic mucosa at endoscopy or barium enema but with increased inflammation in colonic biopsies. Microscopic colitis consists of two main subtypes, collagenous colitis and lymphocytic colitis, distinguished by the presence of absence of a thickened subepithelial collagen band. Several models of pathogenesis has been proposed but no convincing mechanism has been identified, although is difficult to characterize this clinical entity as an independent phenomenon or a simple manifestation or related factors active to induce microscopic changing in the colonic mucosa. A rational approach to therapy does not exist and was conduct with several types of drugs after the exclusion of other causes, commonly characterized by this symptoms and the definitive histological assessment in the biopsies specimens. In the majority of cases this condition tends to follow a self-limited course but potentially can assume the characteristics of relapsing course with the necessity to a chronic therapy. Several long-term follow-up studies excluded a possible progression to neoplastic malignancies of microscopic colitis.