Relationship between acid reflux episodes and gastroesophageal reflux symptoms is very inconstant.

In this prospective study 244 consecutive patients presenting with typical and chronic signs of gastroesophageal reflux were included. Conventional 24-hr esophageal pH monitoring was carried out to establish the symptom association probability, the concordance index, and the symptom sensitivity index. The symptom association probability could be calculated in 110 patients (45%). Two groups were identified: group 1 had normal duration of esophageal acid exposure; subgroup la (nonsignificant symptom association probability) included 39 patients (35.5%) and subgroup lb (significant symptom association probability) included 24 patients (21.8%); group 2 had abnormal duration of esophageal acid exposure; subgroup 2a (nonsignificant symptom association probability) included 21 patients (19.1%) and subgroup 2b (significant symptom association probability) included 26 patients (23.6%). In all, 56.6% of the patients presented typical symptoms of reflux not directly determined by one or repeated acid reflux episodes. The correlation between symptom association probability and the symptom sensitivity index allows for more accurate determination of esophageal acid sensitivity (subgroups lb and 2b).

Effective use of argon plasma coagulation in the treatment of severe radiation proctitis.

PURPOSE: Chronic radiation proctitis, a well described complication of pelvic radiation therapy, can result in severe bleeding that is refractory to conventional treatment. Argon plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. The aim of this study was to assess the efficacy and safety of argon plasma coagulation in the management of severe radiation proctitis resistant to medical treatment. METHODS: Eleven patients (10 males) aged between 54 and 86 years (mean +/- standard error of the mean, 73 +/- 3 years), with chronic radiation proctitis after radiotherapy for prostate (n = 9), uterine (n = 1) or rectal (n = 1) cancer were enrolled in this prospective study. Traditional therapies had failed including mainly topical steroids, 5-aminosalicylic acid and sometimes sucralfate. All patients had active bleeding from diffuse telangiectasias responsible for chronic anemia and seven of them required blood transfusions. The mean duration of the sessions was 20 minutes and one to five sessions (mean, 3.2 +/- 0.4), usually without anesthesia, were required to stop bleeding. Mean follow-up time was 19 +/- 2 (range, 7-30) months. RESULTS: Rectal bleeding disappeared in nine patients and was greatly reduced in two. All the patients were free of transfusions during the mean follow-up of 19 months. The mean hemoglobin level was 7.7 +/- 2.8 g/dl at the first session and increased significantly (P = 0.003) to 11.5 +/- 2.6 g/dl after treatment. In two patients, a rectal stenosis appeared 7 and 11 months after the first session. CONCLUSION: Argon plasma coagulation is a simple, inexpensive and effective treatment for severe refractory radiation proctitis with telangiectasias. Follow-up supervision is in progress to evaluate long term benefits and the risk of rectal stenosis.

A malignant gastrointestinal stromal tumour in a patient with multiple endocrine neoplasia type 1.

Loss of heterozygosity for polymorphic markers flanking the multiple endocrine neoplasia type 1 (MEN-1) gene in parathyroid and pancreatic islet tumours from subjects with MEN-1 has been well documented and has led to the hypothesis that the MEN-1 gene functions as a recessive tumour suppressor gene. We report a case of MEN-1 with duodeno-pancreatic gastrinoma, parathyroid hyperplasia, pituitary adenoma, adrenal adenoma, and lipomas, whose rare association with a malignant gastrointestinal stromal tumour (GIST) represents an undescribed combination. MEN-1 mutation in this family was shown as a frameshift (1607delA) in exon 10. To assess the role of the MEN-1 gene in the pathogenesis of tumours less commonly associated with MEN-1, we studied GIST DNA for loss of the unaffected MEN-1 gene allele. Stromal tumour and peripheral leucocyte DNAs from our patient were examined for loss of heterozygosity using the PYGM microsatellite polymorphism and an intragenic polymorphism (D418D in exon 9) in the MEN-1 gene. We showed no evidence for loss of the wild-type MEN-1 allele in GIST. The MEN-1 germline inactivating mutation 1607delA-ter558 in exon 10 was detected in the stromal tumour DNA, but no somatic mutation in the wild-type MEN-1 allele in GIST DNA was detected. Occurrence of GIST could be consistent with the possibility that this MEN-1-related uncommon neoplasm arose independently by a mechanism unrelated to the MEN-1 gene.

[Is argon plasma coagulation an efficient treatment for digestive system vascular malformation and radiation proctitis?].

BACKGROUND AND AIMS: Argon beam coagulation is an innovative no-touch electrocoagulation technique in which high-frequency monopolar alternating current is delivered to the tissue through ionized argon gas. The aim of this prospective study was to evaluate the efficacy and safety of argon plasma coagulation (APC) for the treatment of hemorrhagic digestive vascular malformations and hemorrhagic radiation proctosigmoiditis. METHODS AND PATIENTS: From March 1998 through April 1999, we used endoscopic APC (ERBE, Lyon, France, argon gas source ICC 300, high-frequency electrosurgical generator ICC 200, gas flow 1 L/min, power setting 50 W) to treat 39 consecutive patients (mean age 70.3 +/- 10 years). The indications for treatment were anemia (n =10), active or oozing haemorrhage (n =15) from digestive angiodysplastic lesions (n =25), hemorrhagic antral telangiectatic vascular lesions (n =2), and hemorrhagic radiation proctosigmoiditis (n =12) after failure of medical treatments (5-aminosalicylic acid, corticosteroids, or sucralfate enemas). The efficacy of APC treatment was evaluated on symptoms, transfusion requirement, bleeding recurrence, hemoglobin value before and 6 months after APC therapy. RESULTS: On the average, 1 +/- 0.5 sessions per patient was required to treat digestive vascular malformations. Definitive haemostasis of digestive angiodysplastic lesions with active or oozing haemorrhage was achieved in one session in all patients. No bleeding recurrence was observed during the follow-up period of 6 months. Anemia recurrence was observed in 2 patients (7%). Average hemoglobin levels recorded before and 6 months after APC therapy were 78.8 +/- 21.2 g/L and 108 +/- 13.7 g/L, respectively (P<0.05). On the average, 2.8 +/- 0.8 sessions per patient were required to treat hemorrhagic radiation proctosigmoiditis. Ten patients (83%) reported improvement or cessation of rectal bleeding, most of them immediately after APC therapy. Endoscopic control was performed one month after APC therapy and showed complete disappearance of lesions in 8 patients (66%). Average hemoglobin levels recorded before and 6 months after APC therapy were of 102.7 +/- 21 g/L and 120 +/- 19.5 g/L, respectively (P <0.05). Complications were observed in 5 cases (13%): pneumoperitoneum in 2 cases, chronic rectal ulcerations in 2 cases, and nonsymptomatic rectal stenosis in 1 case. CONCLUSION: APC appears to be a simple, safe, and effective technique in the management of hemorrhagic radiation-induced proctosigmoiditis and hemorrhagic lesions.

[Self-expandable metal stent in the treatment of obstructive cancer of the left colon. Preliminary results and review of the literature]. / La prothèse métallique auto-expansible dans le traitement du cancer obstructif du côlon gauche. Résultats préliminaires et revue de la littérature.

AIM: To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject. PATIENTS AND METHODS: From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required. RESULTS: There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results. CONCLUSION: Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.

[Are self-expanding metallic esophageal prostheses an effective treatment for malignant stenosis of the esophagus? A prospective study of 32 cases]. / Les prothèses oesophagiennes métalliques expansives sont-elles un traitement efficace des sténoses malignes de l'oesophage?. Etude prospective de 32 cas.

UNLABELLED: The treatment of esophageal carcinoma is frequently palliative. The aims of this prospective study were to evaluate the functional results of covered self expanding esophageal metal stents in patients with malignant obstruction of the esophagus and to compare two models of stent. PATIENTS AND METHODS: From April 1994 to August 1996, 32 patients were treated with 35 metal stents (Cook Z Stent Wilson Cook: n = 21; Ultraflex Boston Scientific: n = 14). Ten patients had a fistula. Previous treatment was effective in 30 patients. Initial score of dysphagia was 2.68 +/- 0.7. Initial score of Karnofsky was 60 +/- 10%. The metal stents could be placed in 100% of cases. The 30-day mortality was 0%. The morbidity of device placement of metal stents was 28%. The treatment of fistulas was effective without complication in 100% of cases. At month 3, we observed a significant decrease of dysphagia score (0.43 +/- 0.25) and a significant increase of Karnofsky score (75 +/- 10%) (P < 0.001). The mean duration of hospitalization was 5.4 +/- 1.3 days. During mean follow-up of 18 +/- 3.5 months, 14 patients (44%) died. Any difference concerning mortality and functional results was observed between 2 kinds of metal stents. We only observed a significant decrease of retrosternal pain in patients treated with Ultraflex prothesis. CONCLUSION: Self-expanding esophageal metal stents are a simple and effective palliative treatment of malignant obstruction of the esophagus. However, their high cost need other cost-efficacy studies to define their indications.

[Value of high-dose interferon-alpha in chronic viral hepatitis C patients non-responder to a 1st treatment. Pilot study prospective and randomized trial]. / Intérêt de l'interféron alpha à forte dose chez les malades atteints d'une hépatite virale chronique C non répondeurs à un premier traitement. Etude pilote prospective et randomisée.

OBJECTIVES: The aim of this study was to evaluate the efficacy of two different doses of alpha interferon (IFN) for retreatment in chronic hepatitis C patients who were non responders to initial treatment by IFN at a dose of 3 MIU TIW for 6 months. METHODS: This open, pilot, prospective, randomized and bicentric study included patients with biopsy-proven chronic hepatitis C. Non response was defined as serum ALT levels > 2 upper limit of normal for the entire first treatment period, HCV RNA positivity by PCR at the end of the first treatment period, and the persistence of histologically-proven chronic active hepatitis after the first treatment period. Patients were randomized into two groups: group I received IFN alpha 2b 10 MIU TIW for 2 months, then 6 MIU TIW for 4 months, group 2 received IFN alpha 2b 6 MIU TIW for 6 months. RESULTS: Twenty three patients (17 male, 6 female, mean age: 38.7 +/- 9.1 years) were included: 14 were randomized in group 1 and 9 in group 2. Both groups were similar for the main clinical, biochemical, and histological variables. At the end of retreatment, 2 patients (14.2%) had biochemical and virological response in group 1 and 4 in group 2 (44.4%) (non significant). Only one biochemical and virological sustained response was observed in group 2 (11.1%) (non significant). There was no difference between the groups for complete and sustained response. An overall statistical significant improvement of Knodell score was observed (7.8 +/- 3.8 vs 9.6 +/- 3.2, P < 0.02) in the 18 patients who had a second biopsy 6 months after the end of therapy, while the Knodell score did not change at the end of the first treatment period. This improvement was statistically significant in group 2 (5.4 +/- 3.0 vs 9.2 +/- 9.5 before treatment, P < 0.02) and concerned intralobular necrosis (P < 0.05). The Metavir index did not change. The number of side-effects was similar in both groups. CONCLUSIONS: These results suggest that histological improvement may be obtained after IFN retreatment in some patients who are non-responders to the first treatment, despite an absence of biochemical and/or virological response.

[Severe and recurrent digestive hemorrhage: an uncommon form of colonic schistosomiasis]. / Hémorragie digestive grave et récidivante: une forme exceptionnelle de bilharziose colique.

Schistosoma mansoni infection is frequent in certain areas of the world in which it is endemic. It is characterised by colonic and hepatic lesions. Gastrointestinal hemorrhages due to rupture of esophageal varices in case of hepatic involvement or moderate rectal bleeding due to colonic involvement may also be observed. We report a case of colonic Schistosoma mansoni infection presenting exclusively with recurrent episodes of serious gastrointestinal hemorrhage without hepatic lesions. All diagnostic investigations were negative. The diagnosis was only established on histological examination of the operative left hemicolectomy carried out with the utmost emergency for the serious recurrent hemorrhage. Histological examination revealed the presence of mucosal micro-ulcers, capillary neovascularization in the submucosa and serosa, and the presence of fibrous nodules and giant cell granulomas surrounding the eggs of Schistosoma mansoni in the serosa. This case is original by its clinical presentation and the difficulty to diagnose the Schistosomiasis.

Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial.

The aim of this prospective double-blind study was to evaluate the value of long-term antibiotic prophylaxis using ciprofloxacin for the prevention of spontaneous bacterial peritonitis (SBP) in 60 cirrhotic patients with low ascitic fluid protein levels (< 15 g/L). The patients were assigned to two groups: group I (n = 28) ciprofloxacin 750 mg per os once a week for 6 months, group II (n = 32) placebo. The two groups were similar for clinical and laboratory characteristics. Twelve patients developed an intercurrent disorder, and 10 patients died during the trial. There were no adverse effects in the treated group. There was a significant decrease in the incidence of SBP (3.6 vs. 22%) (P < .05) and duration of hospitalization (9.3 +/- 4.5 vs. 17.6 +/- 6.2 days) (P < .05) in the treated group as compared with the placebo group. The bacteriological study showed no acquired resistance to ciprofloxacin after 6 months' treatment. These results suggest that long-term preventive antibiotic prophylaxis based on the weekly administration of 750 mg of ciprofloxacin is effective in the prevention of SBP in cirrhotic patients.

Hepatitis C virus RNA in plasma and blood mononuclear cells in patients with chronic hepatitis C treated with alpha-interferon.

Hepatitis C virus (HCV), a positive stranded RNA virus, is the main causative agent of post-transfusion and sporadic non-A non-B hepatitis worldwide. Paired samples of plasma and peripheral blood mononuclear cells (PBMC) from 11 patients with chronic hepatitis C treated with alpha-interferon (IFN) were tested, using a single step polymerase chain reaction (PCR), for the presence of HCV RNA. Before treatment, the viral genome was detected in all the plasma samples and 81.8% of PBMC. After 3 months of treatment, HCV RNA was still present in 63.6% of plasma samples but in only 27.3% of PBMC. A good correlation was observed between serum alanine aminotransferase level normalisation and disappearance of the viral genome in plasma. Among the six responder patients, five relapsed shortly after IFN withdrawal; HCV RNA became detectable again, especially in PBMC. These results show the presence of HCV in PBMC from most patients infected chronically. IFN therapy had an inhibitory effect on viral replication in lymphoid cells, but frequent relapses observed after cessation of treatment with IFN suggested persistence of HCV in these cells.

High prevalence of hepatitis C virus RNA in the supernatant and the cryoprecipitate of patients with essential and secondary type II mixed cryoglobulinemia.

Detection of hepatitis C virus RNA by polymerase chain reaction was performed in 26 patients with type II mixed cryoglobulinemia, and compared with anti-HCV antibody detection. The patients were divided into two groups according to etiology: 15 had essential type II mixed cryoglobulinemia and 11 had secondary type II mixed cryoglobulinemia. In the essential type II mixed cryoglobulinemia group, the prevalence of hepatitis C virus RNA detected by polymerase chain reaction was 60% in the supernatant and 93% in the cryoprecipitate. In the secondary type II mixed cryoglobulinemia group the prevalence of hepatitis C virus RNA was 45% in the supernatant and 55% in the cryoprecipitate. The differences between the two groups were not statistically significant. In both patient groups, detection of hepatitis C virus RNA in the cryoprecipitate was the most sensitive test for hepatitis C virus infection. These results suggest that hepatitis C virus might be involved in the origin of mixed cryoglobulinemia.

[Is the intestinal lavage with a solution of mannitol effective in the prevention of post-hemorrhagic hepatic encephalopathy in patients with liver cirrhosis? Results of a randomized prospective study]. / Le lavage intestinal par une solution au mannitol est-il efficace dans la prévention de l'encéphalopathie hépatique post-hémorragique chez le malade atteint de cirrhose?

OBJECTIVES: The aim of this study was to evaluate the usefulness of whole gut irrigation with a mannitol solution in the prevention of hepatic encephalopathy in patients with cirrhosis and bleeding oesophageal or gastric varices. METHODS: The randomized prospective study included 40 patients with a mean age of 59.6 +/- 9.6 years. Bleeding was controlled by a Blakemore or Linton haemostatic tube, in all cases. The patients were divided into a "mannitol" group (n = 20) treated by whole gut irrigation with a 5 L solution containing 40 g/L of mannitol, and a "control" group (n = 20). The two groups did not differ for age, sex, aetiology of cirrhosis or gastrointestinal bleeding, Child-Pugh classification, delay of minimum fare or the number of transfused blood units. The onset of hepatic encephalopathy was investigated within the first 48 hours after the beginning of gastrointestinal bleeding. The grade of hepatic encephalopathy was established using an index with 4 criteria (mental status, asterixis, number connection test, arterial ammonia concentrations), each with 5 grades of severity. RESULTS: There were no adverse side-effects in the mannitol group. The incidence of hepatic encephalopathy (5 vs 30%) and the length of hospitalization (8.2 +/- 2.3 vs 13.6 +/- 3.1 days) were significantly decreased in the mannitol group (P < 0.05). Mortality was not different between the 2 groups (P = 0.4). CONCLUSION: Whole gut mannitol irrigation appears to be an effective, simple, inexpensive, well tolerated technique in the prevention of hepatic encephalopathy after variceal bleeding in patients with cirrhosis.

[Can early recurrent hemorrhage in gastroduodenal ulcer be predicted?]. / Peut-on prédire la récidive hémorragique précoce des ulcères gastroduodénaux?

OBJECTIVE: To evaluate clinical, biological and endoscopic predictive factors of early recurrent bleeding from gastric or duodenal ulcers. PATIENTS AND METHODS: Seventy six patients (26 females and 50 males) with a mean age of 65.9 years (SD = 17.2) were included in a prospective study. Among the 76 patients, there were 39 NSAIDs users (51.3%). An endoscopy was performed systematically until 12 hours after admission. Treatment modalities were identical for all patients. The predictive value of 11 factors was evaluated through an univariate and multivariate analysis. RESULTS: Three factors had independent significant predictive value: a) the number of blood units used to treat a shock and to increase the haemoglobin level up to 100 g/L (P < 0.05); b) "high endoscopic risk" of recurrent bleeding including Forrest Ia, IIa and IIb ulcers (P < 0.05); c) a non steroidal anti-inflammatory treatment was associated with no recurrent bleeding contrary to the other factors (P < 0.05). Based on a second multivariate analysis including clinical factors only, a predictive score was calculated: 5 + number of blood units -5 x (NSAID = 0/1). The cut off point with maximum discrimination was 6 (specificity = 79.6%; sensitivity = 77.2%). CONCLUSION: A combination of clinical and endoscopic factors is useful to predict ulcer recurrent bleeding. Our clinical predictive score is interesting because of its simplicity. Its predictive value is of interest but have to be evaluated in another sample of patients.

[Is there a relationship between the presence of autoantibodies or mixed cryoglobulinemia and the clinical and histological characteristics of chronic viral hepatitis C?]. / Existe-t-il un lien entre la présence d'auto-anticorps ou d'une cryoglobulinémie mixte et les caractères cliniques et histologiques de l'hépatite virale chronique C?

The purpose of this prospective work was to study a possible relationship between autoantibodies, cryoglobulinaemia and liver histologic lesions in chronic hepatitis C. Ninety three patients (mean age: 43.3 years) with histologically proven chronic hepatitis were studied. Chronic hepatitis was associated with cirrhosis in 18 cases. Auto-antibodies detection was performed in the serum of all patients and cryoglobulinaemia detection was performed in 47 patients. The prevalence of auto-antibodies was also studied in 45 blood donors (control group) and 30 patients with chronic hepatitis B. Histologic study included Knodell score and semi-quantitatively expressed histologic lesions considered as more specific of chronic hepatitis C. Twenty six of the 93 patients (28%) had at least an autoantibody with a level > or = 1/100. The autoantibodies prevalence was: smooth muscle: 15%, antinuclear: 15%, LKM 1: 1.2%, mitochondrial: 0. A mixed cryoglobulinaemia was present in 23 of 47 patients (49%). The prevalence of anti-smooth-muscle autoantibodies was significantly increased in hepatitis C patients compared with the control group (P < 0.05). The histologic Knodell score was 7.3 +/- 3.6. The histologic lesion prevalence was: portal tract lymphoid follicles: 97%, acidophil bodies: 85%, intra-sinusoidal lymphoid infiltrates: 71%, steatosis: 61%, microgranulomas: 54%, biliary duct tract damages: 53%. No statistical significant correlation was found between autoantibodies prevalence and liver histologic lesions. The Knodell score was only significantly increased in patients with mixed cryoglobulinaemia (8.4 +/- 3.6 vs 6.2 +/- 2.8) (P < 0.05). These results suggest that the autoantibodies presence in chronic hepatitis C does not change hepatic histologic lesions.(ABSTRACT TRUNCATED AT 250 WORDS)