Upper gastrointestinal bleeding: what has changed during the last 20 years?

AIM OF THE STUDY: The purpose of this study was to assess the clinical, epidemiological, therapeutic and prognostic changes observed in patients with upper gastrointestinal bleeding (UGIB) during the last two decades. METHODS: Two cohorts of 200 patients with UGIB consecutively recruited during the period 1984-1987 (cohort A) then during the period 2004-2006 (cohort B) were compared. RESULTS: Median age was 61.5 years in the cohort A and 67 years in the cohort B. The main etiologies remained variceal bleeding and peptic ulcer, but esophagitis and Mallory-Weiss syndrome were more frequently observed recently. The intake of gastrotoxic drugs did not decreased despite the widely acknowledged harmful effects of these drugs. Regarding management practices, a therapeutic intervention during the first endoscopy was performed in 36% of the cases in the cohort B but only in 2% of the cases 20 years ago. The frequency and the volume of blood transfusion dramatically decreased during the last two decades. Regarding the outcome, the requirement for surgery and the rate of recurrent bleeding decreased by half, but mortality remained unchanged. CONCLUSION: The main changes observed in patients admitted for UGIB 20 years apart concerned epidemiological features, treatment and prognosis.

Epidemiology of coeliac disease.

In this article we review recent worldwide epidemiological data of coeliac disease (CD). An emphasis is made on adult figures as there is reduction of infants cases that is counterbalanced by the increase of CD in older children or adults. We review data from Europe, USA, South America, Australia, Asia and Africa. Studies in mixed population and in patients undergoing endoscopy are also mentioned. The prevalence of the disease varies between 1/100-500 in different continents. It is possible that the low incidence of CD in some regions is due to the decrease of the prevalence of classic form of the disease.

Impact of hepatitis C virus infection on the aetiology of cirrhosis and hepatocarcinoma in three affiliated hospitals in southern Belgium.

In a consecutive series of 411 patients with cirrhosis attending the outpatient liver clinics of 3 general hospitals located in the southern part of Belgium, hepatitis C virus infection accounted for 20% of the cases, far behind alcohol (63%). However, in a consecutive series of 57 hepatocarcinoma superimposed on cirrhosis, hepatitis C virus infection was the main aetiological factor accounting for 44% of the cases.

[lymphocytic colitis associated with lansoprazole treatment]. / Colite lymphocytaire associée à la prise de lansoprazole.

We report two cases of lymphocytic colitis with severe diarrhea in patients treated by lansoprazole for six weeks. Complete remission occurred rapidly after lansoprazole withdrawal.

Surveillance for hepatocellular carcinoma: compliance and results according to the aetiology of cirrhosis in a cohort of 141 patients.

Surveillance for early detection of hepatocarcinoma (HCC) in patients with cirrhosis is widely accepted. In a cohort of 141 patients with cirrhosis collected during the year 1995, we conducted a surveillance program by performing liver ultrasonography and blood alpha-foetoprotein measurement every 6 months. The median follow-up was 34 months. This study addressed to two questions: the compliance to the surveillance schedule according to the aetiology of cirrhosis and the results in terms of emergence of HCC and outcome. Aetiology of cirrhosis was alcohol-induced in 86 (61%), HCV-related in 30 (21%) and from other origins in 25 (18%). Compliance to the program schedule was good in patients with HCV-related cirrhosis (29/30--97%) and patients with cirrhosis of "other origins" (20/25--80%) but was poor in patients with alcoholic cirrhosis (45/86--52%). The lack of compliance was significantly linked to the failure to achieve alcohol abstinence. During follow-up, 6 HCC lesions were observed in 6 male patients with median age of 68 years. All 6 HCC were single nodule, less than 4 cm and accessible to percutaneous acetic acid injection. Nevertheless, the outcome was disappointing, four patients dying 3-15 months later (median: 8 months), two of them with extensive HCC. One of the two patients still alive developed extensive HCC, 36 months after percutaneous acetic acid injection.

Thromboembolism in inflammatory bowel disease.

Thromboembolism represents a severe complication of inflammatory bowel disease occurring in young patient, with active disease. Deep venous thrombosis and pulmonary embolism are the most frequent thromboembolism manifestations. Arterial complications and unusual sites for thromboembolism are more rare. Overall, inflammatory bowel disease is a real prothrombotic state as almost all parameters of coagulation are enhanced. Anticoagulation during the episode of thromboembolism is mandatory, and sometimes may ameliorate the course of inflammatory bowel disease.

Hypoxic hepatitis: a difficult diagnosis when the cardiomyopathy remains unrecognized and the course of liver enzymes follows an atypical pattern. A report of two cases.

In a clinical setting of cardiac or circulatory failure, the diagnosis of hypoxic (ischaemic) hepatitis is easy and can be elicited on mere clinical and biochemical features. We report two cases of hypoxic hepatitis where cardiomyopathy remained unrecognized at admission due to the lack of conventional signs of congestive heart failure and where the increase in liver enzymes activities followed an atypical pattern, characterized by only moderate elevation of serum aminotransferases activities, low ASAT/ALAT ratio and elevated ALAT/LDH ratio. This atypical pattern not suggestive of hypoxic hepatitis, could be explained by a delay between the onset of hypoxic injury of the liver and admission to hospital. Moreover one case was complicated by frank jaundice, an unusual feature in hypoxic hepatitis. Consequently, diagnosis and appropriate inotropic treatment were delayed resulting in progressive deterioration and eventually death of both patients. The report of these two cases and the review of other similar cases previously published, enlighten some atypical features of hypoxic hepatitis.

Bacq and Alexander Award lecture--chemical radioprotection: past, present, and future prospects.

PURPOSE: To review and evaluate the development of effective radiation protectors. OUTLINE: Sulphydryl radioprotectors are the best radioprotectors known today. Their use encounters two great difficulties: their toxicity and the short period during which they are active. The biological response modifiers (BRM), developed mainly in the 1990s, demonstrated some protective effects. They can also modulate radiation injury when given after irradiation. In parallel with the use of single radioprotectors, observations have been made in mice using combined treatments with BRM and other radioprotectors. Low-to-moderate doses of several radioprotective agents acting via different mechanisms markedly improved the degree of protection in rodents while maintaining toxicity within acceptable limits, but applications in man remain doubtful. CONCLUSIONS: No radioprotective drug available today has all the requisite qualities to be an ideal radioprotector. Although combinations of radioprotective drugs acting via different mechanisms markedly improve the degree of protection and keep toxicity to acceptable levels in small rodents, attempts to use such treatments in large mammals have been less successful. It is thus questionable whether chemical protection has any prospects for the future.

Survival and diseases in C57BL mice exposed to X rays or 3.1 MeV neutrons at an age of 7 or 21 days.

Survival and causes of mortality were studied in 7- or 21-day-old male C57BL/Cnb mice exposed to 0.5, 1 or 3 Gy of 250 kVp X rays or 0.125, 0.25, 0.5 or 1 Gy of accelerator neutrons (modal energy 3.1 MeV). A total of 1287 animals were used in the experiments. Survival of irradiated animals was reduced significantly only in the mice receiving the highest doses (1 Gy neutrons, 3 Gy X rays ). Mice exposed to the lowest doses (0.125 Gy neutrons, 0.5 Gy X rays) lived significantly longer than controls, apparently reflecting a reduction in non-neoplastic lung and liver diseases. All malignant tumors increased significantly from (and including) doses of 0.5 Gy neutrons and 1 Gy X rays. Hepatocellular carcinoma was the principal contributor to the increase in tumor incidence, at least after exposure to neutrons. No significant increase in hepatocellular carcinoma was seen in 21-day-old mice exposed to X rays. An increase, especially after 3 Gy X rays, was also observed for all leukemias. Controls in the present study lived significantly longer than those in our earlier studies of irradiated adult mice, making a direct comparison of the radiation-induced effects in adult and infant mice difficult. Based on percentage life shortening, it appears that exposure during infancy does not shorten total survival or survival from cancer much more than exposure of adults, although such exposure, especially to neutrons, causes more hepatocellular carcinoma. Due to the nonlinearity of the dose-effect relationships, it is difficult to calculate the RBE of neutrons. For survival time at higher doses an RBE of about 3 is obtained. When the incidence of all malignant tumors and of hepatocellular cancer is fitted to a linear or a linear-quadratic function, an RBE from 5 to 8 is obtained. No RBE can be estimated for hepatocellular carcinoma in mice of an age of 21 days because exposure to X rays does not seem to cause this tumor at that age.

Severe nontyphoidal salmonellosis probably in relation with omeprazole treatment: report of 2 cases.

We report 2 cases of severe nontyphoidal salmonellosis (Salmonella enteritidis), occurring 4 and 5 weeks after starting a treatment with Omeprazole (20 mg a day). No other member of the families was sick, and none of the 2 patients took any meals outside home during the two weeks preceding the first symptoms. Gastric hypochlorhydria is a major risk factor for Salmonella enteritidis, and several cases of severe infection have been described with this condition. After a review of the literature we conclude that patients with diminished gastric acid run an increased risk of developing Salmonella infection and often with a more serious clinical course.

The effects of lintopride, a 5HT-4 antagonist, on oesophageal motility.

AIM: To evaluate the effects of various doses of lintopride, a new 5HT-4 antagonist with moderate 5HT-3 antagonist properties, on oesophageal body and lower oesophageal sphincter (LOS) motility in humans. METHODS: Eight healthy male volunteers, mean age 22 (19-28) years, without any history of digestive disease or chest pain, were randomized to three doses of lintopride (0.1, 0.3 and 0.5 mg/kg i.v.) and a placebo at 1-week intervals in a double-blind, crossover study. Oesophageal motility was recorded continuously for 4 h after each dose, using perfused catheters inserted at the level of the LOS and in the body of the oesophagus, at 5, 10 and 15 cm from the LOS. Peristalsis was studied during 10 wet swallows, at 30-min intervals (T0-T240 min). RESULTS: The LOS basal pressure (23.3 +/- 2.0 cmH2O; mean +/- s.d.) remained stable after dosing with placebo to T240. After lintopride, LOS basal pressure increased significantly vs. placebo (AUC comparison: 0.1 mg/kg, P = 0.036; 0.3 mg/kg, P = 0.027; 0.5 mg/kg, P = 0.052). In contrast, the duration and extent of LOS relaxation after swallowing was not affected by any of the three doses of lintopride. The amplitude of peristaltic waves in the oesophagus increased significantly at T30 after lintopride 0.3 mg/kg (34.5 cmH2O, P = 0.020) and 0.5 mg/kg (32.5 cmH2O, P = 0.027), at T60 after 0.3 mg/kg (48.8 cmH2O, P = 0.0009) and 0.5 mg/kg (29.1 cmH2O, P = 0.029) and at T90 after 0.3 mg/kg (34.5 cmH2O, P = 0.0018). CONCLUSIONS: Lintopride significantly increased the LOS basal tone without affecting LOS physiological relaxation after swallowing. Peristaltic waves were also enhanced by lintopride.

Effect of neutrons alone or combined with diethylnitrosamine on tumor induction in the livers of infant C57BL mice.

The possible combined effects of the initiator diethylnitrosamine (DEN)+neutrons on the induction of foci, adenomas and carcinomas in the livers of C57BL/Cnb mice were evaluated. Four groups of infant mice were treated as follows: DEN alone, neutrons alone, DEN followed by neutrons and neutrons followed by DEN. Ten mice in each group were killed at 10-week intervals over 70 weeks. The following parameters were measured: body weight, liver weight, number and size of superficial macroscopic liver lesions, and number and total surface area of the different types of microscopic liver lesions. The rate of appearance of foci increased significantly at different times when a dose of 0.125 Gy of neutrons was administered 7 days before or after a dose of 1.25 micrograms of DEN. No significant differences were observed in the total surface area of foci and/or adenomas and carcinomas when increasing doses of neutrons were given 7 days before or after the administration of 1.25 and 2.5 micrograms of DEN.

[Can the L/A ratio identify acute alcoholic pancreatitis?]. / Le rapport L/A permet-il d'identifier les pancréatites aiguës alcooliques?

Early distinction between acute alcoholic pancreatitis is important, because of possible emergency endoscopic sphincterotomy in case of biliary pancreatitis. The aim of this study was to evaluate the value of L/A ratio in the diagnosis of acute alcoholic pancreatitis. From 1990 to end 1993, 133 patients with acute pancreatitis were reviewed. Inclusion criteria were: 1) abdominal pain, 2) pathological serum amylase or serum lipase on admission or within 24 hours after beginning or abdominal pain, 3) acute pancreatitis at the echography or CT scan within 48 hours after admission. 60 patients met the inclusion criteria (31 alcoholic pancreatitis, 19 biliary pancreatitis and 10 pancreatitis of other causes). L/A ratio was studied in terms of delay from beginning of abdominal pain. There was no statistical difference between alcoholic and biliary pancreatitis at any time of the study, with the exception of admission. AST, ALT and alkaline phosphatase were higher in biliary pancreatitis than in alcoholic pancreatitis. AST and ALT were the best biochemical tests to diagnose biliary pancreatitis. Blamey's criteria can also contribute to diagnose biliary pancreatitis. These biochemical tests are the most helpful if they are collected very soon in the evolution of acute pancreatitis. It is concluded that L/A ratio is not helpful in the diagnosis of alcoholic acute pancreatitis.

[Relations between vasculotensional disease, sudden deafness and benign paroxysmal postural vertigo: value of anticochlear antibodies]. / Relations entre la maladie vasculotensionnelle, la surdité brusque et le vertige positionnel paroxystique bénin: intérêt des anticorps anticochléaires.

Some vasculotensional diseases may be associated, at a certain point of their evolution, with occurrences of sudden deafness or of benign paroxysmal positional vertigo. It seems that the efficiency of the treatments of sudden deafness and benign paroxysmal positional vertigo is not modified by those associations of pathologies. On the other side, the search for anticochlear antibodies gives a positive result in 45% of the vasculotensional diseases. When the vasculotensional disease is associated with sudden deafness, this percentage increases. On the contrary, it is lower when the vasculotensional disease is associated with benign paroxysmal positional vertigo. The presence of anticochlear antibodies may lead to a corticotherapy in case of failure of the classical treatments.

Assessment of the new immunological test Hemoblot for detecting occult blood in faeces.

Hemoblot, a new immunological faecal occult blood test, produced by Gamma, Angleur, Belgium, was characterized and compared with another immunological test (HemeSelect, SmithKline Diagnostics, USA) and with a guaiac test (Hemoccult II, SmithKline Diagnostics). The analytical sensitivity of Hemoblot is 0.15 mg haemoglobin/g faeces and the test is specific for human haemoglobin. In addition, 135 symptomatic patients who had to undergo a colonoscopy were tested using the three tests. Two criteria were considered for the analysis: (1) the blood criterion: any pathology likely to cause colorectal or other bleeding; and (2) the precancerous-cancerous criterion: the pathology being either a colorectal polyp > 0.5 cm or a colorectal cancer. Considering both criteria, the sensitivity of Hemoblot was significantly higher than the sensitivity of Hemoccult: 38% and 23%, respectively, for the blood criterion; and 54% and 29% for the precancerous-cancerous criterion. Sensitivity and specificity did not differ statistically between Hemoblot and HemeSelect but Hemoblot was faster and simpler to perform. It could be widely used in mass screening.