Acute upper gastrointestinal bleeding in central Greece: the role of clinical and endoscopic variables in bleeding outcome.

The objectives of this work were to portray the incidence of upper gastrointestinal bleeding in central Greece and to define subsets at higher risk of poor outcome or death. Two hundred and sixty-four cases were recorded. The incidence was 116 per 100,000 per year (95% CI: 102-130). Re-bleeding was noted in 7.9% of patients. The case fatality was 7.2% and population mortality 8 per 100,000 per year (95% CI: 4-12). Independently significant risk factors for re-bleeding were stigmata of bleeding at endoscopy (OR: 3.11; 95% CI: 1.06-9.13, P = 0.04), smoking (OR: 3.39; 95% CI: 1.08-10.62, P = 0.03), and the use of anti-coagulant drugs (OR: 2.64; 95% CI: 1.00-7.13, P = 0.05), while the independently significant risk factor for death was re-bleeding (OR: 5.74; 95% CI: 1.40-23.52, P = 0.03). We conclude that patients with stigmata of bleeding at endoscopy and on anti-coagulant therapy should be under close surveillance because of the higher risk of re-bleeding. Smoking also increases the risk of re-bleeding. Patients with re-bleeding episodes must be managed intensively because of the higher risk of death.

Is Ki-67 a better proliferative marker in the colon than proliferating cell nuclear antigen?

Endogenous markers of proliferating cells have increasingly supplanted the use of incubation of biopsy tissues in vitro with tritiated thymidine or with bromodeoxyuridine, thus avoiding the potential variation resulting from the incubation procedure. Antibodies to proliferating cell nuclear antigen (PCNA) such as PC10 have been promoted as optimal for this purpose, although considerable variation in colonic proliferating cells with this antibody has been reported. We have compared the detection of colonic proliferating cells in normal mucosa and adenomata using the PC10 monoclonal antibody (mAb) to PCNA and the Mib-1 mAb to Ki-67 in formalin-fixed tissues using antigen retrieval solutions with microwaving. The PC10 antibody showed variable immunostaining of proliferating and nonproliferating cells with minor changes in primary antibody concentration or microwave conditions and between normal and adenomatous tissue. In contrast, Mib-1 immunostaining was quite constant with differing antigen retrieval and antibody conditions and similar staining of proliferating cells in colonic adenomas. Some loss of immunoreactivity occurred if the cut sections were not immunostained within approximately 1 week. These data suggest that whereas PCNA immunohistochemistry is satisfactory when carefully controlled in large chemopreventive studies, the Mib-1 mAb to Ki-67 is superior to PCNA antibodies in immunostaining proliferating cells in the formalin-fixed human colon.

Efficacy of repeated therapeutic endoscopy in patients with bleeding ulcer.

BACKGROUND/AIMS: Although therapeutic endoscopy is regarded as the procedure of choice for bleeding ulcers, the disease mortality is barely altered. The aim of the present study was to evaluate the efficacy of repeated therapeutic endoscopy in patients with bleeding ulcer. METHODS: From January 1990 to April 1995, 727 patients with bleeding ulcers were admitted to hospital under the care of one gastroenterologist who endoscoped every patient within 18 hours of admission. Epinephrine (1:10,000) was injected into the lesions of patients found to have active bleeding, a non-bleeding visible vessel, or adherent red clot. After the initial diagnostic-therapeutic procedure, all patients admitted from 1990-92 (group A) were treated conservatively, and referred for operation if re-bleeding was uncontrolled. Patients admitted from 1993 to April 1995 (group B) were treated aggressively with re-endoscopy one day later, and repeat hemostasis if re-bleeding was evident. During hospitalization, diagnostic/therapeutic endoscopy was then repeated if re-bleeding was diagnosed by either a fall in hematocrit of > 3%, or on clinical criteria. Patients were transfused if the hematocrit fell to < 30%. RESULTS: Repeated hemostasis was needed in 30 group B patients; one patient requiring 7 therapeutic endoscopies. The outcome of patients in group B was better than group A, with fewer emergency operations (3 vs 10) (p < 0.05) and deaths (0 vs 4) (p < 0.05), while no difference was seen in transfusion requirements (4.1 vs 3.9 units) (p > 0.1), or in length of hospital stay (6.8 vs 7.1 days) (p > 0.1). CONCLUSION: Repeated diagnostic/therapeutic endoscopy benefits patients with bleeding ulcers.

Solitary juvenile polyps in children and colon cancer.

BACKGROUND/AIMS: Solitary Juvenile Polyps (SJP) are quite common in preschool children, although they may occur at any age. It is not known whether the existence of a single juvenile polyp in a child predisposes to future development of new SJP or is related to colorectal neoplasia. The present study was designed to follow up young patients who had undergone polypectomy for SJP and their first degree relatives to elucidate the development of adenomatous polyps or colon cancer. MATERIALS AND METHODS: From 31 children polypectomized for histologically proven SJP between 1983-1995, we were able to contact and gather information on 24. From our records and the information collected we studied age, gender, site of the polyp in the bowel, personal history, and family history. RESULTS: Mean time of follow up was 4.1 years (range 0.4-10, SD +/- 3.1) Mean age was 4.6 years (Range 3.5-9, SD +/- 1.2). There were 14 boys and 10 girls (ratio 1.4/1). Eighteen polyps were located at the rectosigmoid area, 5 in the lower descending colon, and one in the splenic flecture. From the 24 children, only one girl developed rectal bleeding at the age of 15 years, 8 years after polypectomy. However, subsequent evidence from the large bowel did not reveal any abnormality and the symptom was attributed to hemorrhoidal bleeding. Thorough investigation of the history of 146 first degree relatives (dead or alive) siblings, parents, and grandparents revealed that none of them were diagnosed with adenomatous polyps or colorectal cancer. CONCLUSION: SJP does not predispose to future development of new juvenile polyps and is not associated with a high risk of colorectal malignancy.