A strange congenital disease, familial megaduodenus: review of the literature

Familial megaduodenum is an extremely rare congenital disease, with few cases described in the literatura, that is caused by chronic duodenal obstruction of functional type. It presents in the form of nonspecific clinical pseudo-obstruction from infancy, which causes a delay in its diagnosis and treatment. Conservative treatments are rarely sufficient in and of themselves to control the disease, making surgery an effective option in selected patients for relieving or avoiding obstruction, as well as improving duodenal emptying and restoring gastrointestinal tract continuity, paying special attention to the duodenal papilla. We present a case treated at the General Surgery and Digestive Apparatus Service of the Hospital of Mérida and a review of the existing literature. (AU)

Genetic and flow cytometry analysis of seronegative celiac disease: a cohort study.

Background: Seronegative celiac disease (CD) poses a diagnostic challenge. Aims: Characterize and identify differences between seronegative and seropositive CD. Patients and methods: Retrospective cohort study examining adult patients diagnosed with CD (1980-2017). Clinical, analytical, histological, genetic and immunophenotypic data were compiled. Seronegative CD was defined as a anti-tissue transglutaminase type 2 IgA and endomysial antibodies (EMA) negative and HLA-DQ2 and/or DQ8 positive, showing clinical signs of CD plus an abnormal duodenal biopsy, and responding to a gluten-free diet (GFD). Factors associated with seronegative CD were identified through binomial logistic regression. Results: Of 315 CD patients, 289 were seropositive (91.7%) and 26 seronegative (8.3%). Among the seronegative patients, higher prevalence was observed for autoimmune thyroiditis (26.9% vs. 9.7%, p = .016), HLA-DQ8 heterozygosity (23.1% vs. 2.5%, p ˂ .001) and Marsh I lesion (34.6% vs. 3.7%, p ˂ .001). The two groups showed similar flow cytometry-determined duodenal immunophenotypes and rates of refractory CD. Conclusions: Seronegative CD differs mostly in genetic (more HLA-DQ8) and histologic (milder atrophy) features as compared with seropositive. Intestinal intraepithelial immunophenotype by flow cytometry, similar in both modalities, is a useful tool to diagnose seronegative CD.

Dysgenesis of enteroendocrine cells in Aristaless-Related Homeobox polyalanine expansion mutations.

OBJECTIVES: Severe congenital diarrhea occurs in approximately half of patients with Aristaless-Related Homeobox (ARX) null mutations. The cause of this diarrhea is unknown. In a mouse model of intestinal Arx deficiency, the prevalence of a subset of enteroendocrine cells is altered, leading to diarrhea. Because polyalanine expansions within the ARX protein are the most common mutations found in ARX-related disorders, we sought to characterize the enteroendocrine population in human tissue of an ARX mutation and in a mouse model of the corresponding polyalanine expansion (Arx). METHODS: Immunohistochemistry and quantitative real-time polymerase chain reaction were the primary modalities used to characterize the enteroendocrine populations. Daily weights were determined for the growth curves, and Oil-Red-O staining on stool and tissue identified neutral fats. RESULTS: An expansion of 7 alanines in the first polyalanine tract of both human ARX and mouse Arx altered enteroendocrine differentiation. In human tissue, cholecystokinin, glucagon-like peptide 1, and somatostatin populations were reduced, whereas the chromogranin A population was unchanged. In the mouse model, cholecystokinin and glucagon-like peptide 1 populations were also lost, although the somatostatin-expressing population was increased. The ARX protein was present in human tissue, whereas the Arx protein was degraded in the mouse intestine. CONCLUSIONS: ARX/Arx is required for the specification of a subset of enteroendocrine cells in both humans and mice. Owing to protein degradation, the Arx mouse recapitulates findings of the intestinal Arx null model, but is not able to further the study of the differential effects of the ARX protein on its transcriptional targets in the intestine.

Duodenal gastric heterotopia, sporadic or fundic gland polyp-associated, frequently carries ß-catenin mutation.

Duodenal gastric heterotopia (DGH) is a benign asymptomatic condition assumed to be of congenital origin. Since DGH is often associated with fundic gland polyps (FGPs) that frequently carry a somatic ß-catenin gene mutation, we examined whether DGH, either sporadic or FGP-associated, is attributable to alterations of the Wnt/ß-catenin pathway. Genetic analysis revealed frequent somatic ß-catenin gene mutations in DGH; some of which showed the same mutation pattern as coexisting FGPs. All missense mutations were confined to codons 32, 33, and 37. No such mutations were observed, however, in any of the specimens from focal gastric foveolar metaplasia (GFM). Therefore, DGH is not a mere congenital lesion due to aberrant migration of normal gastric mucosa or a simple reactive metaplasia after regenerative stimuli of the duodenal mucosa, but a distinct condition based upon molecular genetic changes in the Wnt/ß-catenin pathway.

Is a gluten-free diet necessary in Marsh I intestinal lesions in patients with HLADQ2, DQ8 genotype and without gastrointestinal symptoms?

PURPOSE OF REVIEW: To describe whether a gluten-free diet (GFD) is indicated in Marsh I gluten-sensitive enteropathy where gastrointestinal symptoms are not present. Arguments are provided to prescribe a GFD to manage extraintestinal symptoms. By contrast, there are not enough reasons to prescribe a GFD to prevent long-term complications. RECENT FINDINGS: Population-based and prospective observational studies have found that lymphocytic duodenosis may be due to not just gluten-sensitive enteropathy but also due to other aetiologic factors. Marsh I type lesions may be the cause of iron-deficiency anaemia of unknown aetiology which is reverted by a GFD. A similar effect seems to occur with bone mineralization and hypertransaminasemia. The beneficial influence of a GFD reducing lymphoma and coeliac disease-related mortality remains controversial. SUMMARY: An appropriate differential diagnosis of the lymphocytic duodenosis is essential before a GFD is indicated. As a third of patients remained undiagnosed, in spite of genetic study and specific coeliac serology, flow cytometry and transglutaminase antibodies in duodenal tissue may be helpful in establishing gluten-sensitive enteropathy diagnosis. Future studies should assess whether lymphoma risk is reduced by a GFD in Marsh I patients. Also a more precise benefit in bone mineralization in this setting is needed.

Hyperplastic polyp of the duodenum: a report of 9 cases with immunohistochemical and molecular findings.

Benign serrated polyps are commonly found in the colorectum but have rarely been described in other parts of the gastrointestinal tract. We report a series of 9 serrated polyps arising in the duodenum with clinicopathologic features, immunohistochemical expression profile of mucins (MUC2, MUC5AC, MUC6), and molecular analysis for BRAF and KRAS. The polyps were diagnosed as incidental endoscopy findings in 9 different patients, comprising 3 male and 6 female patients, with a mean age of 52.2 years (range, 21-72 years). The second part of the duodenum was the most common site (n = 5), followed by the ampulla (n = 1) and the distal duodenum (n = 1), with the location of the 2 remaining polyps unspecified. Other upper gastrointestinal tract pathology features included Barrett esophagus for 5 patients, Helicobacter gastritis for 1 patient, and mild chronic gastritis for 1 patient. The histologic appearance of the polyps was similar to microvesicular hyperplastic polyp in the colorectum. Immunostaining for mucins showed MUC6 expression in the crypt bases of all polyps, MUC5AC expression in 8 cases (89%), and mucin 2 expression in 6 cases (67%). Molecular testing was successful in 6 polyps, showing BRAF mutation (V600E) in 2 polyps, KRAS mutation in 2 polyps, and no mutation for either gene in 2 polyps. Colonoscopy reports were available for 6 patients, of whom 4 were diagnosed with hyperplastic polyps or sessile serrated polyps in the colorectum. However, no patient met the criteria for serrated polyposis. Although probably rare and of uncertain malignant potential, hyperplastic polyp should be considered in the differential diagnosis of benign duodenal polyp.

[Population association features of interleukine gene polymorphism in khakases with gastroduodenal diseases].

AIM: To investigate association of polymorphisms of IL-1 genes and antagonist of IL-2 receptor (IL1Ra). MATERIAL AND METHODS: Patients with chronic gastritis and ulcer were examined using the method of restriction analysis. RESULTS: It was found that CCILbeta and R4/R4IL1Ra are most prevalent allel variants in khakas population. CONCLUSION: It is expedient to define population risk and protective genotypes of development of ulcer associated with Helicobacter pylori in khakases.

[The relationship among IL-10, TNF gene polymorphisms, Helicobacter pylori infection and gastroduodenal diseases in Hubei Han ethnic].

OBJECTIVE: To study the distribution of IL-10 and TNF gene polymorphisms in patients with gastroduodenal diseases in Hubei Han ethnic and their association with Helicobacter pylori (Hp) infection. METHODS: Six hundred and five patients with gastroduodenal diseases (196 chronic gastritis, 189 gastroduodenal ulcer and 220 gastric cancer) as well as 624 healthy controls were genotyped with PCR-RFLP method for IL-10-1082,-819,-592 and TNFalpha-308, lymphotoxin-alpha (LTalpha) Nco I and AspH I gene polymorphisms. Hp infection status was determined with ELISA. RESULTS: (1) There was significant difference of IL-10-1082 AG + GG genotype among the gastric cancer group with the non-malignant gastric diseases groups and healthy control group (P < 0.05). There was no significant difference of IL-10-592 and -819 gene polymorphisms among gastric cancer patients, non-malignant gastric disease patients and healthy controls (P > 0.05). The genotype frequencies of IL-10-819 were the same as those of IL-10-592. (2) Frequency of IL-10-1082 AG + GG genotype in gastric cancer patients with positive Hp was significantly higher than that in the other three groups (P < 0.05). (3) Frequency of LTalpha Nco I AG genotype in gastric cancer patients with Hp infection was significantly higher than that in Hp positive healthy controls (P < 0.05). There were no other associations between TNFalpha-308, LTalpha Nco I and AspH I gene polymorphisms and Hp infection in gastroduodenal diseases. CONCLUSIONS: (1) Allele AG + GG of IL-10-1082 was associated with gastric cancer in Han nationality of Hubei province. (2) IL-10-1082 AG + GG, LTalpha Nco I AG heterozygous genotype may be associated with Hp infection in patients with gastric cancer in Han nationality of Hubei province.

[Association of IL-10 gene polymorphisms with gastroduodenal diseases in Hubei Han population].

OBJECTIVE: To study the distribution of IL-10 gene polymorphisms in patients with gastroduodenal diseases in Hubei Han population and their association with helicobacter pylori (Hp) infection. METHODS: Six hundred and five patients with gastroduodenal diseases (220 gastric cancer, 196 chronic gastritis and 189 gastroduodenal ulcer) and 624 healthy controls were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method for IL-10 -1082, -819, -592 gene polymorphisms. Hp infection status was determined by ELISA. RESULTS: (1) There was significant difference of IL-10 -1082 AG+GG genotypes between gastric cancer group and gastric cancer-free and healthy control groups (P<0.05). (2) There was no significant difference of IL-10 -592 and IL-10 -819 gene polymorphisms among gastric cancer, gastric cancer-free and healthy control groups (P>0.05). (3) The frequency of IL-10 -1082 AG+GG genotypes in the Hp positive gastric cancer patients was significantly higher than that of control groups (P<0.05). CONCLUSIONS: (1) Genotypes AG+GG of IL-10 -1082 were associated with gastric cancer in Hubei Han population. (2) The IL-10 -1082 AG+GG genotypes were associated with Hp infection in patients with gastric cancer.

Lymphocytic duodenosis and the spectrum of celiac disease.

OBJECTIVES: Celiac disease (CD) is a chronic inflammatory disease of the small bowel that is characterized by increased intraepithelial lymphocytes (IELs) and villous atrophy of the mucosa. It is unclear how often intraepithelial lymphocytosis in the absence of atrophy is a manifestation of gluten sensitive enteropathy. The objective of this study was to identify factors that discriminate patients with CD from those with lymphocytic duodenosis (LD, intraepithelial lymphocytosis without villous atrophy). We compared Class 2 HLA type, presenting symptoms, and serology in patients with LD and CD. METHODS: Retrospective review of 124 systematically assessed patients with LD compared with 454 CD patients with villous atrophy. All patients had duodenal biopsies and Class 2 HLA typing performed. HLA type, symptoms, serology pattern, and response to a gluten-free diet were analyzed using univariate logistic regression modeling, adjusted for age and gender. RESULTS: Half of the (63 (51%)) LD patients lack the Class 2 HLA genotypes encoding DQ2 or DQ8 whereas only 11 (2%) CD patients had neither DQ2 nor DQ8, P<0.001. The genes encoding DQ2 were much more prevalent in CD (91%) than that in LD (37%, P<0.001), however, the rate of carriage of DQ8 did not differ between the two groups (15% vs. 15%, P=0.9). Although diarrhea and weight loss were equally frequent in LD and CD patients, LD patients were less likely to be associated with anemia (P=0.007), malaise (P=0.006), skin disorder (P=0.007), or a family history of CD (P<0.001). The LD subjects were much less likely to have tissue transglutaminase or endomysial antibodies than were CD subjects (12% or 0% vs. 87% and 87%; P<0.001, respectively). CONCLUSIONS: The LD cohort differs significantly in terms of HLA type, serology, and clinical features, suggesting that the majority of patients with LD do not belong in the spectrum of CD.

Duodenal duplication cyst of the ampulla of Vater.

A 35-year-old man presented with the complaint of epigastric discomfort. Gastrointestinal endoscopy and endoscopic ultrasonography revealed a cystic lesion 20 mm in size at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed that the cystic lesion communicated with both the common bile duct and pancreatic duct via the common channel. Choledochocele was ruled out by close examination of the ERCP findings. The cystic lesion was surgically resected. Since histological findings revealed that the mucosa inside the lesion was duodenum-like and contained a layer of smooth muscle, the lesion was diagnosed as a congenital duplication cyst of the duodenum.

Pancreatic intraepithelial neoplasia in heterotopic pancreas: evidence for the progression model of pancreatic ductal adenocarcinoma.

Morphologic, clinical, and genetic evidence suggests that pancreatic intraepithelial neoplasia (PanIN) is a precursor to ductal adenocarcinoma. But understanding precursor lesions in a pancreas with existing tumor is hampered by the fact that chronic pancreatitis often accompanies carcinoma, and the possible interactions between tumor, chronic pancreatitis, and PanIN are complex. Furthermore, cancerization of ducts can mimic high-grade PanIN. Heterotopic pancreas has a genetic make-up, physiologic function, and local environmental exposure similar to that of the pancreas. It offers an opportunity to study putative precursor lesions in a setting with fewer confounding factors. We identified 6 pancreatic cancer patients who had heterotopic pancreas removed at the time of surgery. All 6 cases were immunostained for p53, cyclin D1, and p16. Molecular analysis of K-ras mutation was also done. All 6 cancer-associated heterotopias had PanIN-1A or 1B; 5 had PanIN-2 and 1 had PanIN-3. Three of 6 cases harbored the same K-ras codon 12 mutation as the PanINs in orthotopic pancreas, and a similar pattern of p53, cyclin D1, and p16 expression was observed between heterotopic and orthotopic pancreas in all 6 cases. There was no chronic pancreatitis in the cancer-associated heterotopias, but chronic pancreatitis was seen adjacent to carcinoma in 5 of 6 cases. The presence of PanIN in heterotopic pancreas from patients with ductal adenocarcinoma supports the progression model.

[Relationship between iceA1, iceA2 and babA2 genes of Hp in Xi'an and gastroduodenal diseases].

AIM: To investigate the distribution of iceA1, iceA2 and babA2 genes of helicobacter pylori (Hp) in Xi'an and analyse the relationship between these genes and gastroduodenal diseases. METHODS: 88 Hp strains were isolated from the patients with different gastric duodenal diseases. After genomic DNA was extracted, iceA1, iceA2 and babA2 genotypes of Hp were determined by polymerase chain reaction (PCR). The results were analyzed statistically by chi(2) test. RESULTS: 88 Hp strains were detected from 163 samples and the detection rate was 54%. The positive rate of iceA1, iceA2 and babA2 of the 88 Hp strains was 76.1%, 21.6% and 25%, respectively. These genotypes showed no statistical difference in the distribution of different gastric duodenal diseases (P>0.05). CONCLUSION: iceA1 of Hp ispredominated in Xi'an area. These genotypes have no correlation with the clinical outcome of Hp infection.

Genotypic characterization of Helicobacter pylori cagA and vacA from biopsy specimens of patients with gastroduodenal diseases.

BACKGROUND: Helicobacter pylor i infection is closely associated with gastroduodenal diseases. H. pylori infection with different vacA and cagA genotypes may result in divergent consequences. The aim of the present study was to investigate the prevalence of H. pylori infection and the correlation between cagA and vacA genotypes with the consequences of H. pylori infection in Taiwan. METHODS: Genomic DNA from 97 gastric biopsies of patients with various gastroduodenal diseases was collected, and the prevalence of H. pylori infection, cagA genotypes and vacA genotypes, was analyzed by polymerase chain reaction. In addition, the correlations between cagA and vacA genotypes and the consequences of H. pylori-infection were statistically examined. RESULTS: Our results indicated that 57.7% of this sample of patients with gastroduodenal diseases were infected with H. pylori. Prevalence of cagA(+) strain in H. pylori -infected patients was 71.4%. All of the genotypes of the cagA(+) H. pylori strains among our patients were type A. Prevalence of vacA signal region s1 and middle region m2 genotype in H. pylori- infected patients was 98.2% and 53.6%, respectively. CONCLUSIONS: Our study demonstrated that individuals infected with H. pylori strains that carried cagA gene and vacA s1/m2 genotypes were associated with the development of gastroduodenal diseases, compared to those infected with cagA(-) gene and vacA(-) H. pylori strains.

Pseudotrisomy 13 syndrome: a case with left ventricular hypoplasia and duodenal stenosis.

We report a case of a female child born at 32 weeks of gestation. Birth weight was 1200 g (<3rd centile), length 40 cm (10th-50th centile) and head circumference 23.5 cm (<3rd centile). Clinical examination revealed microcephaly, hypotelorism, microphthalmia, a flat rudimentary nose with a single nasal cavity, high palate, thick dysplastic low-set ears, a short neck, postaxial polydactyly of the upper limbs, and single palmar creases. Investigations showed alobar holoprosencephaly, absence of the third ventricle and midline structures of the brain, microphthalmia, hypotelorism, left ventricular hypoplasia, a large atrial septal defect, and duodenal stenosis. The karyotype was 46,XX. A hypoplastic left ventricle and duodenal stenosis have not been previously reported in pseudotrisomy 13 and this case might aid in the further delineation of this syndrome.

Gastroduodenal disease, Helicobacter pylori, and genetic polymorphisms.

Over the past 20 years, there has been marked progress in our understanding of the role of genetic and environmental factors in the etiology of gastroduodenal disease. Helicobacter pylori infection now is recognized to be the most important environmental factor for both noncardia gastric cancer and peptic ulcer disease. The likelihood of the infection resulting in significant disease depends on genetic polymorphisms influencing the virulence of the organism. However, the specific pattern of disease induced by the infection is determined to a great extent by genetic polymorphisms in the host that govern the local gastric immune response elicited. Genetic factors also are important in the treatment of gastroduodenal diseases. Polymorphisms of host CYP2C19 influence the pharmacokinetics and clinical efficacy of proton pump inhibitor therapy.

Gastroduodenal Crohn's disease is associated with NOD2/CARD15 gene polymorphisms, particularly L1007P homozygosity.

Limited data exist on the specific association between gastroduodenal Crohn's disease (GDCD) and NOD2/CARD15 gene polymorphisms. The aim of this study was to assess the association between NOD2 polymorphisms and GDCD, and to assess the specific association between each of the 3 major allelic variants G908R, L1007P, and R702W and the clinical features of Crohn's disease. We retrospectively reviewed the records of 202 patients with confirmed Crohn's disease and complete data was performed. Seventy-one patients (35%) had at least 1 allelic variant: 55 had 1 variant, 4 were homozygous for L1007fs, 2 homozygous for R702W, and 10 were compound heterozygous. Eighteen patients with confirmed GDCD were identified; 10 (56%) had wild type, 4 (22%) had 1 variant, and 4 (22%) had 2 allelic variants (2 were L1007P homozygous and 2 compound heterozygous). Compared to patients without gastroduodenal involvement, those with GDCD were more likely to have 2 allelic variants (22% vs. 6%; odds ratio [OR] 2.7; 95% confidence interval [CI] 1.6-7.3) and to be homozygous for L1007P (11% vs. 1%; OR 5.2; 95% CI 2.5-9.4). G908R heterozygosity was associated with ileal involvement (OR 1.4; 95% CI 1.1-2.9) and smoking habits (OR 2.4; 95% CI 1.2-3.8), whereas L1007P homozygosity was associated with GDCD (OR 5.8; 95% CI 2.6-10.8). L1007P variation was associated with younger age at diagnosis as well. There was no specific association between R702W homo- or heterozygosity and any of the characteristics examined. In conclusion, GDCD is associated with double dose of the NOD2/CARD15 gene variants, particularly L1007P homozygosity. There is evidence of specific variant-phenotype associations. G908R heterozygosity is associated with ileal involvement and smoking, whereas L1007P homozygosity is strongly associated with GDCD and younger age at diagnosis.