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世界核心医学期刊文摘：胃肠病学分册

世界核心医学期刊文摘：胃肠病学分册

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世界核心医学期刊文摘：胃肠病学分册 >2006年第12期

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  • 摘要：Objective: To evaluate the performance of endoscopic transmural drainage of pancreatic fluid collections (PFCs) in outpatients. Patients and Methods: We retrospectively reviewed 19 consecutive outpatient cases in 18 patients who underwent attempted endoscopic transmural drainage of PFCs by a single endoscopist at the Mayo Clinic in Rochester, MN, over a 5- year period (October 1998 to October 2003). All drainages were performed without EUS- guided entry, using an aspiration needle and no cautery. Two 10- Fr stents were placed after dilation of the entry site. Results: The study group consisted of 12 men and 6 women (median age, 48 years; range, 28- 79 years), with 14 cases of pseudocysts and 5 cases of pancreatic necrosis. Transmural drainage approaches included 13 transgastric, 5 transduodenal, and 1 combined transgastric/transpapillary. Drainage was established in 16 of 19 (84% ) cases. Hospitalization was noted in 6 of 19 (32% )cases, with median hospitalization duration of 1.5 days (range, 1- 19 days). Three patients were hospitalized for overnight observation only. In all instances, the decision to hospitalize was made while the patient was still in recovery. No deaths occurred. Follow- up imaging was available in 15 of 16 (94% ) cases in which drainage was established, demonstrating PFC resolution in all 15. Conclusions: Endoscopic transmural drainage of PFCs can be performed safely and effectively in selected outpatients. It is our opinion that outpatient drainage of PFCs be considered only by experienced therapeutic endoscopists with readily available inpatient facilities. Future studies should seek to identify predictors of hospitalization and address cost- effecness.
  • 摘要：Goal: To assess the sensitivity/specificity of the serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti- saccharomyces cerevisiae antibody (ASCA) in children diagnosed with inflammatory bowel disease (IBD), living in West Virginia. Background: In recent years, serologic markers have been used to differentiate between CD and UC diseases in children. The clinical usefulness of these markers in children was restricted by their low sensitivity and specificity. Racial and ethnic diversity may alter the accuracy of these markers in children. The demographic homogeneity of the West Virginia population may offer a better clinical setup to reassess the utility of those markers in children with IBD. Study: A retrospective analysis of all the charts of children diagnosed with IBD was performed at the gastroenterology clinics of Marshall University, Huntington, WV; and West Virginia University. Charleston Division, Charleston, WV The diagnosis of IBD was established according to clinical, radiologic, and endoscopic data. Laboratory data and serum markers were recorded, and their accuracy to diagnose UC or CD was assessed. Results: A total of 101 charts were reviewed, of which only 90 (89% ) included serologic markers and were considered for further analysis. Disease distribution included: UC- 41, CD- 44, and indeterminate colitis (IC)- 7 (2 patients changed diagnosis after colectomy). Serum antibody pANCA had a sensitivity of 73% and specificity of 84% for UC, but only 16% and 35% for CD, respectively. Serum antibody ASCA had a sensitivity of 58% and specificity of 92% for CD, but only 7% and 49% for UC. respectively. The outer membrane porin to Escherichia coli antibody (anti- OmpC) was available in 54 (59% ) children and demonstrated a very poor sensitivity for both diseases (sensitivity< 11% ). Conclusion: Despite our homogeneous patient population, pANCA and ASCA antibodies had an inadequate sensitivity/specificity for children with UC or CD. Those antibodies were not useful for our small number of patients with IC.
  • 摘要：Background: The pediatric colonoscope is superior to the standard colonoscope in some patients with a fixed,angulated colon. A colonoscope thinner than the pediatric one is thought to out- perform even the pediatric colonoscope in such cases. This study was conducted to assess the efficacy of an ultrathin colonoscope, 9.8 mm in diameter, comparing it with pediatric and standard colonoscopes. Methods: Three types of colonoscopes were used: ultrathin, pediatric, and standard. A total of 287 consecutive patients were assigned to three groups: ultrathin (n = 94), pediatric (n = 98), and standard (n = 95). First assessment was the ratio of cecal intubation and the reasons for unsuccessful colonoscopy. The second was the time to cecal intubation. Results: Cecal intubation rates were not different among three groups (96% in each). The main reasons for failed colonoscopy were looping in the ultrathin group, and angulation or stricture in the pediatric and standard groups. Mean time to the cecum was slightly longer in the ultrathin group (6.5 minutes) than the pediatric group (5.6 minutes) and standard group (6.1 minutes), but there were no significant differences among three groups. Conclusion: Colonoscopy with the ultrathin colono- scope was as successful as with the pediatric and standard colonoscopes. The advantage of the ultrathin colonoscope might be notable in cases with stricture or severe angulation.
  • 摘要：Background: Monounsaturated and polyunsaturated fats act as inhibitors of cholesterol cholelithiasis in animal experiments. Objective: To examine the association between long term intake of cis unsaturated fats and the incidence of gallstone disease in humans. Design: Prospective population based cohort study. Setting: The Health Professional Follow up Study. Participants: 45 756 men, age 40 to 75 years in 1986, who were free of gallstone disease. Measurements: Consumption of cis unsaturated fats was assessed starting in 1986 as part of the 131 item semi quantitative food frequency questionnaires. Questionnaires were mailed to participants every 2 years. The main outcome measure was self reported newly diagnosed symptomatic gallstone disease. Results: During 14 years of follow up, 2323 new cases of gallstone disease were documented. After adjustment for age and other potential risk factors, the relative risk for gallstone disease among men in the highest quintile of dietary intake of cis unsaturated fats compared with men in the lowest quintile was 0.82 (95%CI, 0.69 to 0.96; P for trend = 0.006). The relative risk among men in the highest quintile of polyunsaturated fat consumption compared with men in the lowest quintile was 0.84 (CI, 0.73 to 0.96; P for trend = 0.01), and the relative risk among men in the highest quintile of monounsaturated fat consumption compared with men in the lowest quintile was 0.83 (CI, 0.70 to 1.00; P for trend = 0.01). Limitations: Outcomes were restricted to men with cholecystectomy or diagnostically confirmed but unremoved symptomatic gallstones. Conclusions: A high intake of polyunsaturated and monounsaturated fats in the context of an energy balanced diet is associated with a reduced risk for gallstone disease in men.
  • 摘要：Objective: To quantify the risks of malignancy and mortality in people with coeliac disease compared with the general population. Design: Population based cohort study. Setting: General practice research database. Participants: 4732 people with coeliac disease and 23 620 matched controls. Main outcome measures: Hazard ratios for malignancy and mortality. Results: Of the 4732 people with coeliac disease, 134 (2.8%) had at least one malignancy and 237 (5.0%) died. The overall hazard ratios were: for any malignancy 1.29 (95%confidence interval 1.06 to 1.55), for mortality 1.31 (1.13 to 1.51), for gastrointestinal cancer 1.85 (1.22 to 2.81), for breast cancer 0.35 (0.17 to 0.72), for lung cancer 0.34 (0.13 to 0.95), and for lymphoproliferative disease 4.80 (2.71 to 8.50). The increased risk was primarily in the first year after diagnosis, with only the risk for lymphoproliferative disease remaining significantly raised thereafter. After excluding events in the year after diagnosis, the hazard ratio for malignancy was 1.10 (0.87 to 1.39) and for mortality was 1.17 (0.98 to 1.38), giving absolute excess rates of 6 and 17 per 10 000 person years, respectively. Conclusions: People with coeliac disease have modest increases in overall risks of malignancy and mortality. Most of this excess risk occurs in the first year after diagnosis. People with coeliac disease also have a noticeably reduced risk of breast cancer. The mechanism of this merits further attention as it may provide insights into the cause of this common malignancy.
  • 摘要：Background: In chronic gastrointestinal bleeding, success rates in the range of 48% to 76% have been reported for diagnosing clear bleeding sources using capsule endoscopy. The influence of patient selection on the numbers of positive findings yielded by capsule endoscopy is as yet unclear. Methods: From April 2001 to June 2003, capsule endoscopy was carried out in 74 of a total of 127 patients (58% ) who presented for capsule endoscopy with a high suspicion of gastrointestinal bleeding in the small- bowel region. Seventy of the 74 patients were included in the analysis. This group of patients was divided into a study group (32 patients) and a post- study group (38 patients), and the two groups were compared. Results: Stricter patient selection was carried out in the study group than in the post- study group: 49% of those in the study group underwent capsule endoscopy, compared with 65% of those in the post- study group. The overall success rate for detecting relevant bleeding sources was 54% ; in the study group, the rate was 66% ; whereas in the post- study group, it was only 45% . Significant differences observed between the two groups of patients included the lowest hemoglobin value (5.9 ± 1.4 g/dL in the study group, compared with 7.7 ± 2.1 g/dL in the post- study group) and transfusion requirements (a median of 10 units in the study group, vs. 2 units in the poststudy group). None of the patients who had a minimum hemoglobin value a 10 g/dL had a positive capsule result. Conclusions: Patient selection has a considerable influence on the success rate of capsule endoscopy. In patients with chronic gastrointestinal bleeding, the minimum hemoglobin value and transfusion requirements appear to be the decisive parameters.
  • 摘要：Background: Although Helicobacter pylori has been established as a major etiologic factor of chronic gastritis and makes an important contribution to peptic ulceration, the reason why H. pylori causes different gastroduodenal diseases in different people is at present not clear. Goals: The aim of this study is to identify risk factors associated with duodenal ulcers in H. pylori- infected patients in a multivariate context. Study: Demographic data, personal habi- ts, stressful life events, psychologic distress, severity of histology of antral mucosa, and serum pepsinogen I concentrations were studied in 54 consecutive dyspeptic patients with duodenal ulcers and 40 patients with functional dyspepsia. Results: As compared with functional dyspepsia patients, duodenal ulcer patients had more smokers (53.7% vs. 12.5% , P = 0.000), higher pepsinogen I levels (median 96.0 vs. 74.5 ng/mL; P = 0.002), more males (74.1% vs. 42.5% , P = 0.004),more single (22.6% vs. 7.5% , P< 0.05), and less in religion belief (44% vs. 70% , P < 0.05). Only smoking remained significant on multivariate analysis (odds ratio = 10.86, 95% CI = 2.92- 40.41, P < 0.001). Among non- smokers, only serum pepsinogen I level was found higher in duodenal ulcer patients as compared with functional dyspepsia patients (88 vs. 71, P < 0.05). Conclusions: Smoking and hyperpepsinogenemia are associated with increased risk for duodenal ulcer in H. pylori- infected patients.
  • 摘要：Background/Aims: The outcome of infection with the hepatitis C virus (HCV) has been shown to be influenced by genetic host factors. The G protein β 3 subunit (GNB3) C825T polymorphism has been shown to determine immune cell functions in vitro. We investigated the association of GNB3 genotypes with treatment response in HCV- infected patients. Methods: We genotyped 1781 HCV- free blood donors and 232 HCV- infected patients treated with interferon- alfa/ ribavirin. Sustained virologic response (SVR) was defined by undetectable HCVRNA 24 weeks after discontinuation of therapy. Non- response (NR) was defined by positive HCV- RNA at the end of at least 24 weeks of treatment. GNB3 genotypes were determined by DNA restriction enzyme analyses. Results: Genotype distribution was not significantly different in healthy controls and HCV- infected patients. Only in HCV genotype 1- infected patients a significant correlation between GNB3 CC genotype and NR could be observed (6 TT, 42 TC, 54 CC) versus SVR (11 TT, 25 TC, 19 CC) patients (P=0.004). In a logistic regression analysis including biochemical and virologic characteristics, only GNB3 CC genotype was significantly associated with NR (OR 4.9; 95% CI=1.4- 16.5; P=0.011). Conclusions: The GNB3 825 CC genotype is associated with NR in HCV- 1- infected patients.
  • 摘要：Context: Reduction of gastric acid secretion by acid suppressive therapy allows pathogen colonization from the upper gastrointestinal tract. The bacteria and viruses in the contaminated stomach have been identified as species from the oral cavity. Objective: To examine the association between the use of acid suppressive drugs and occurrence of community acquired pneumonia. Design, Setting, and Participants: Incident acid suppressive drug users with at least 1 year of valid database history were identified from the Integrated Primary Care Information database between January 1, 1995, and December 31, 2002. Incidence rates for pneumonia were calculated for unexposed and exposed individuals. To reduce confounding by indication, a casecontrol analysis was conducted nested in a cohort of incident users of acid suppressive drugs. Cases were all individuals with incident pneumonia during or after stopping use of acid suppressive drugs. Up to 10 controls were matched to each case for practice, year of birth, sex, and index date. Conditional logistic regression was used to compare the risk of community acquired pneumonia between use of proton pump inhibitors (PPIs) and H2 receptor antagonists. Main Outcome Measure: Community acquired pneumonia defined as certain (proven by radiography or sputum culture) or probable (clinical symptoms consistent with pneumonia). Results: The study population comprised 364 683 individuals who developed 5551 first occurrences of pneumonia during follow up. The incidence rates of pneumonia in non acid suppressive drug users and acid suppressive drug users were 0.6 and 2.45 per 100 person years, respectively. The adjusted relative risk for pneumonia among persons currently using PPIs compared with those who stopped using PPIs was 1.89 (95%confidence interval, 1.36-2.62).Current users of H2 receptor antagonists had a 1.63 fold increased risk of pneumonia (1.07-2.48) compared with those who stopped use. For current PPI users, a significant positive dose response relationship was observed.For H2 receptor antagonist users, the variation in dose was restricted. Conclusion:Current use of gastric acid suppressive therapy was associated with an increased risk of community acquired pneumonia.
  • 摘要：Background/Aims: T- lymphocyte reactivity against viral antigens may represent the only immunological marker of host contact with a virus. Aim of the present study was to investigate whether vertical exposure to hepatitis C virus (HCV) could activate HCV- specific T- cell responses that may represent a biomarker of previous contact with the virus, and possibly contribute to the low rate of vertical HCV transmission. Methods: We studied 28 children born from chronically HCV- infected mothers. HCV- specific activation and proliferation of CD4+ lymphocytes and cytokine production were evaluated in cultures of peripheral blood mononuclear cells (PBMCs) stimulated in vitro with HCV- peptides. Results: HCV- specific CD4+ cell reactivity was observed in 20 out of the 28 children (71% ). The proliferation of HCV- specific CD4+ cells was more frequent and vigorous in children than in their mothers. In children, but not in the mothers, activation of CD4+ cells upon stimulation with HCV- peptides was directly correlated with proliferation. Early upon stimulation with HCV- peptides, lymphocytes from children produced lower levels of IL- 10 than lymphocytes from the mothers. Conclusions: Vertical exposure to HCV induces the development of viral- specific CD4+ cell- mediated immune responses, possibly endowed with protective function against infection, which may contribute to the low rate of vertical HCV transmission.
  • 摘要：Context: The rates of appendiceal rupture and negative appendectomy in children remain high despite efforts to reduce them. Both outcomes are used as measures of hospital quality. Little is known about the factors that influence these rates. Objective: To investigate the association between hospital and patient level characteristics and the rates of appendiceal rupture and negative appendectomy in children. Design, Setting, and Patients: Retrospective review using the Pediatric Health Information System database containing information on 24 411 appendectomies performed on children aged 5 to 17 years at 36 pediatric hospitals in the United States between 1997 and 2002. Main Outcome Measures: Rates of negative appendectomy and appendiceal rupture; the odds ratio (OR) of negative appendectomy and appendiceal rupture by hospital, patient age, race, and health insurance status, and hospital fiscal year and appendectomy volume. Negative appendectomy rate was defined as the number of patients with appendectomy but without appendicitis divided by the total number of appendectomies. Results: The median negative appendectomy rate was 3.06%(range, 1%-12%) and the median appendiceal rupture rate was 35.08%(range, 22%-62%). The adjusted OR for appendiceal rupture was higher in Asian children (1.66; 95%confidence interval , 1.24-2.23)and black children (1.13; 95%CI, 1.01-1.30) compared with white children. Children without health insurance and children with public insurance had increased odds of appendiceal rupture compared with children who had private health insurance (adjusted OR, 1.36; 95%CI, 1.22-1.53 for self insured; adjusted OR, 1.48; 95%CI, 1.34-1.64 for public insurance). No correlation existed between negative appendectomy rate and race, health insurance status, or hospital appendiceal rupture rate. The negative appendectomy rate improved as the hospital appendectomy volume increased. Conclusion: The rate of appendiceal rupture in school aged children was associated with race and health insurance status and not with negative appendectomy rate and therefore is more likely to be associated with prehospitalization factors such as access to care, quality of care, and patient or physician education.
  • 摘要：Background/Aims: Nucleic acid damage by reactive nitrogen and oxygen species may contribute to inflammation- related carcinogenesis. To investigate the extent of nucleic acid damage in hepatitis C virus infection and its change after interferon treatment, we measured 8- nitrogua- nine and 8- hydroxy- 2’ - deoxyguanosine (8- OHdG) in the liver of patients with chronic hepatitis C (CHC) before and after interferon therapy. Methods: Hepatic accumulation of 8- nitroguanine and 8- OHdG was immunohistochemically evaluated in 20 CHC patients and 7 control patients with non- alcoholic fatty liver. Results: Immunoreactivities of 8- nitroguanine and 8- OHdG were strongly detected in the liver from patients with CHC, but not in control livers. 8- Nitroguanine accumulation was found not only in infiltrating inflammatory cells, but also hepatocytes particularly in the periportal area. The accumulation of 8- nitroguanine and 8- OHdG increased with inflammatory grade (8- nitroguanine; P=0.0019, 8- OHdG; P=0.0009). In the sustained virological responder group after interferon therapy, 8- nitroguanine and 8- OHdG accumulationweremarkedly decreased in the liver (8- nitroguanine; P=0.018, 8- OHdG; P=0.018). Conclusions: In this study,we demonstrated for the first time that 8- nitroguanine accumulated in the liver of patients with CHC. 8- Nitroguanine is a useful biomarker to evaluate the severity of HCV- induced chronic inflammation in relation to hepatocellular carcinoma.
  • 摘要：Background/Aims: Longitudinal studies on the relationship between hepatitis B virus (HBV) genotypes and reactivation of hepatitis B and progression to cirrhosis were very rare. Methods: Liver biochemistry, virological markers and ultrasound were monitored in 202 hepatitis B e antigen (HBeAg)positive patients with normal alanine aminotransferase (ALT) at baseline for 3- 20 (average 10.8) years, and the outcome was correlated with HBV genotypes. Results: There were 150 genotype B and 52 genotype C patients. Hepatitis activity during the HBeAg- positive phase showed no significant difference. However, genotype B was associated with a significantly earlier and higher rate of HBeAg seroconversion. HBeAg seroconversion correlated with age at entry for genotype B and with ALT levels for genotype C. Reactivation of hepatitis B was significantly more common in genotype C patients. Five genotype B and 10 genotype C patients progressed to cirrhosis. Multivariate analysis revealed that genotype C (P=0.03) and reactivation of hepatitis B (P=0.0004) were independent factor predictive of cirrhosis. Conclusions: Rate and factors of HBeAg seroconversion, and rate of reactivation of hepatitis B differed between genotype B and genotype C patients. Genotype C and reactivation of hepatitis B were associated with increased risk of cirrhosis.
  • 摘要：Background/Aims: To identify patterns of HCV spread in the Nile Delta of Egypt. Methods: Residents in a Nile Delta village were invited to participate in a cohort study of HCV infection. Risk factors for past or current infection were identified at cohort intake using generalized estimated equations models. Attributable fractions were calculated for all independent risk factors. Results: The prevalence of HCV antibodies increased from 2.7% in those< 20 years of age to more than 40% in males aged 40- 54 years. The peak in HCV prevalence in the 40- 54 year age group corresponds to the aging of the cohort of children infected through schistosomiasis intravenous treatments in the 1960s- 70 s (accounting for 12.4% of all HCV infections observed today among adults). Following this initial founding event, the HCV epidemic has spread in the community through iatrogenic factors, and particularly injections (37.9% of the overall attributable fraction in adults). In children, however, no iatrogenic factors were associated with increased risk of infection, suggesting a change in the pattern of HCV spread. Conclusions: While HCV infections in adults could be attributed to iatrogenic factors, and particularly injections, infections in children could not be explained by similar routes of transmission.
  • 摘要：Background/Aims: Prediction of sustained virologicalresponse (SVR) during treatment would allow clinicians to identify patients most likely to benefit from therapy. Methods: Retrospective analysis of data from 1121 adults with chronic hepatitis C treated for 48 weeks with peginterferon alfa- 2a (40 KD) 180 μ g/week plus placebo or ribavirin (1000/1200 mg/day), or interferon alfa- 2b 3 MIU three times/week plus ribavirin in a randomized, multinational, study. Results: 67% of patients treated with peginterferon alfa- 2a (40 KD)/ribavirin with early virological responses (HCV RNA negative or ≥ 2 log10 decrease) at week 12 had SVRs at week 72 (HCV RNA < 50 IU/mL). The negative predictive value (NPV) was 97% . The probability of an SVR increased with the rapidity of HCV RNA suppression. The highest SVR rates were achieved in patients with rapid virological responses at week 4, but the corresponding NPV (74% ) is too low for a decision criterion. In patients with early virological responses by week 12, the SVR rate was ≈ 20% lower in those who received< 80% compared with patients who received ≥ 80% of the planned ribavirin dose. Conclusions: Early, sustained suppression of HCV replication portends an SVR. Cessation of treatment may be contemplated in patients without a ≥ 2 log10 reduction in HCV RNA after 12 weeks.
  • 摘要：BACKGROUND: The effectiveness of antiviral therapy in preventing disease progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis is unknown. METHODS: Patients with chronic hepatitis B who had histologically confirmed cirrhosis or advanced fibrosis were randomly assigned in a 2 ∶1 ratio to receive lamivudine (100 mg per day) or placebo for a maximum of five years. Of 651 patients, 436 were assigned to receive lamivudine and 215 to receive placebo. The primary end point was time to disease progression, defined by hepatic decompensation, hepatocellular carcinoma, spontaneous bacterial peritonitis, bleeding gastroesophageal varices, or death related to liver disease. An independent data and safety monitoring board monitored the progress of the study and performed interim analyses of the data. RESULTS: We randomly assigned 651 patients (98 percent Asian and 85 percent male) to receive lamivudine or placebo. The study was terminated after a median duration of treatment of 32.4 months (range, 0 to 42) owing to a significant difference between treatment groups in the number of end points reached. End points were reached by 7.8 percent of the patients receiving lamivudine and 17.7 percent of those receiving placebo (hazard ratio for disease progression, 0.45; P=0.001). The Child Pugh score increased in 3.4 percent of the patients receiving lamivudine and 8.8 percent of those receiving placebo (hazard ratio, 0.45; P=0.02), whereas hepatocellular carcinoma occurred in 3.9 percent of those in the lamivudine group and 7.4 percent of those in the placebo group (hazard ratio, 0.49; P=0.047). Genotypic resistance YMDD mutations developed in 49 percent of the patients treated with lamivudine, and the Child Pugh score was more likely to increase in patients with these mutations than in the other patients treated with lamivudine (7 percent vs.< 1 percent). Overall, 12 percent of the patients in the lamivudine group and 18 percent of the patients in the placebo group reported serious adverse events. CONCLUSIONS: Continuous treatment with lamivudine delays clinical progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis by significantly reducing the incidence of hepatic decompensation and the risk of hepatocellular carcinoma.
  • 摘要：Objective. Endoscopic mucosal ablation is a promising technique that is used to treat dysplastic Barrett’ s oesophagus. The purpose of this study was to investigate the efficacy and cost- effectiveness of two promising techniques, argon plasma coagulation (APC) and photodynamic therapy (PDT), in the ablation of dysplastic Barrett’ s oesophagus. Material and methods. Twenty- six patients with dysplastic Barrett’ s oesophagus (21 M, median age 60 years, median length 4 cm, 23 low- grade dysplasia (LGD), 3 high- grade dysplasia (HGD)) were randomized to APC: 13 patients, PDT: 13 patients. APC was performed at a power setting of 65 W and argon gas flow at 1.8 1/min in 1- 6 sessions (mean 5). PDT was performed 48 h after intravenous injection of Photofrin 2 mg/kg with a 630 nm red laser light, 200 J/cm through a PDT balloon in one session. All patients received treatment with high- dose proton pump inhibitors. Cost analysis was undertaken and the results were assessed by endoscopy and biopsies at 4 months and 12 months after therapy. Results. All patients in both groups showed a reduction in the length of Barrett’ s oesophagus. The median length of Barrett’ s oesophagus eradicated at the 4- month follow- up: APC 65% , PDT 57% and at the 12- month follow- up: APC 56% , PDT 60% . Dysplasia eradication at 4 months: APC 62% , PDT 77% , p = 0.03 (95% CI 0.66- 0.96) and at 12 months APC 67% , PDT 77% . Buried columnar glands with intestinal metaplasia were seen in both groups, with one patient in the PDT arm developing adenocarcioma under the neo- squamous epithelium. Severe adverse events included APC 2/13 (15% ) stricture, 1/13 (8% ) odynophagia, chest pain and fever; PDT 2/13 (15% ) photosensitivity, 2/13 (15% ) stricture. PDT would cost an additional ￡ 266 for every percentage reduction in Barrett’ s length and ￡ 146 per percentage reduction in dysplasia compared with APC treatment. Conclusions. APC and PDT are equally effective in eradicating Barrett’ s mucosa, with PDT being the more expensive treatment. However, PDT is more effective in eradicating dysplasia and the extra benefits of PDT are generated at an extra cost. The occurrence of buried columnar glands and carcinoma warrants caution. Long- term follow- up is needed to assess cancer prevention and the durability of the neo- squamous epitheliumto justify these interventions.
  • 摘要：An increasing frequency of hepatic granulomas, up to 10%, in chronic hepatitis C patients is reported, and their presence is considered to be a predictor of treatment success. However, there is only one prevalence study on granuloma in chronic hepatitis B, and its significance for treatment outcome is unknown. We aimed to determine the prevalence of hepatic granulomas in a larger group of chronic hepatitis B patients and to compare their presence with the response to interferon therapy. Biopsy specimens of chronic hepatitis B patients were reevaluated for the presence of hepatic granulomas. All patients with hepatic granuloma were screened for other granulomatous diseases by tuberculin skin test, chest X ray and computed tomography, venereal disease research laboratory, Brucella agglutination tests, and exposure to hepatotoxic agents. We screened 663 cases of chronic hepatitis B. Hepatic granulomas were found in 10 cases (1.5%). The granulomas could not be ascribed to any other reason. Of the 10 patients with hepatic granulomas, 4 responded to interferon therapy, 2 dropped out, and 4 were nonresponders. We conclude that hepatic granuloma is a rare finding in chronic hepatitis B and its presence does not seem to predict the response to interferon therapy.
  • 摘要：Objective. Helicobacter pylori infection has not been stud- ied thoroughly in elderly patients. The aim of this study was to evaluate the reliability of stool antigen assay (HpSA) in the assessment of H. pylori infection in hospitalized, frail, elderly patients. Material and methods. The study population consisted of 85 consecutively recruited elderly patients (≥ 65 years old) hospitalized between May 1999 and December 2001 with diagnostic indications for upper gastrointestinal endoscopy. Twenty- nine subjects had been receiving treatment with proton- pump inhibitors (PPIs), such as omeprazole (10- 20 mg/day) for 2- 15 days, and 56 were not receiving treatment. HpSA was evaluated versus UBT (urea breath test), serology and histology: patients with at least two positive results out of the latter three tests were considered positive for H. pylori infection, while patients with at least two negative tests out of three were considered negative. Results. The sensitivity and specificity of HpSA in the 56 untreated patients were, respectively, 76% (true positives TP = 22; false negatives FN = 7) and 93% (true negatives TN = 25; false positives FP =2). The sensitivity and specificity of HpSA in the 29 patients on PPI treatment were, respectively, 82% (TP = 9; FN = 2) and 83% (TN = 15; FP = 3). Conclusions. HpSA is an accurate, noninvasive and easy method for diagnosing H. pylori infection in elderly patients.
  • 摘要：Nonalcoholic fatty liver disease (NAFLD) is a common and potentially serious form of chronic liver disease that occurs in patients who do not abuse alcohol. Present dietary recommendations for all Americans, including those with NAFLD, endorse a low calorie, low fat diet. However, little is known about the effect of diet composition on liver histopathology in patients with NAFLD. The aim of this study was to determine whether overall calorie intake and diet composition are associated with the severity of NAFLD histopathology. Seventy four consecutive morbidly obese patients presenting for bariatric surgery from January 2001 to March 2002 were retrospectively reviewed. In addition to a standard surgical and psychological evaluation, all patients underwent a preoperative dietary evaluation using a standardized 24-hr food recall. Food intake was evaluated for total calories and macronutrients and compared to liver histopathology from biopsies routinely obtained during surgery. Associations with the severity of steatosis and the presence of inflammation or fibrosis were assessed separately using chi square for categorical variables and ANOVA for continuous variables. Further, we conducted multiple logistic regression analyses for each histological outcome. There were no significant associations between either total caloric intake or protein intake and either steatosis, fibrosis, or inflammation. However, higher CHO intake was associated with significantly higher odds of inflammation, while higher fat intake was associated with significantly lower odds of inflammation. In conclusion, present dietary recommendations may worsen NAFLD histopathology.
  • 摘要：Objective. Dietary modification improves symptoms in irritable bowel syndrome (IBS). Identification of offending foods by dietary elimination/re- challenge is cumbersome. IgG4 antibodies to common food antigens are elevated in IBS. The aim of this article was to evaluate the effect of exclusion diet based on IgG4 titres on IBS symptoms and rectal sensitivity and compliance. Material and methods. The study comprised 25 patients with IBS (3M, 22 F,mean age 43 years,Rome II criteria). IgG4 titres to 16 foods (milk, eggs, cheese, wheat, rice, potatoes, chicken, beef, pork, lamb, soya bean, fish, shrimps, yeast, tomatoes and peanuts) were measured. Foods with titres >250 μ g/l were excluded for 6 months. Symptom severity was assessed with a previously validated questionnaire at baseline, at 3 months and at 6 months. Rectal compliance and sensitivity were measured in 12 patients at baseline and at 6 months. Results. IgG4 antibodies to milk, eggs, wheat, beef, pork and lamb were commonly elevated. Significant improvement was reported in pain severity (p < 0.001), pain frequency (p = 0.034), bloating severity (p = 0.001), satisfaction with bowel habits (p = 0.004) and effect of IBS on life in general (p = 0.008) at 3 months. Symptom improvement was maintained at 6 months. Rectal compliance was significantly increased (p = 0.011) at 6 months but the thresholds for urge to defecate/discomfort were unchanged. Conclusions. Food- specific IgG4 antibody- guided exclusion diet improves symptoms in IBS and is associated with an improvement in rectal compliance.
  • 摘要：Objective. Adult lactose intolerance, which affects the majority of the population in the world, has been associated with a single nucleotide polymorphism, C- 13910T, located upstream of the lactase gene. Material and methods. Adult patients undergoing lactose tolerance tests with lactose challenge and plasma glucose measurements were included in the study comprising 44 Swedes and 7 non- Swedish individuals. A real- time PCR method was established for the genotyping. Results. Out of 51 patients 48 had concordant results on genotyping and lactose tolerance tests, e.g. - 13910T/T and - 13910C/T genotypes had high glucose elevations. All patients with the heterozygous genotype, - 13910C/T, had high glucose elevations, and no gene- dose relationship was observed when comparing maximal glucose increases for cases with - 13910C/T and - 13910T/T genotypes. Conclusions. Genotyping could replace lactose challenge as a first- stage screening test in adults of European descent, but should be used together with tolerance tests in children and patients where secondary lactose intolerance is suspected.
  • 摘要：Autonomic neuropathy (AN) is common in patients with chronic liver disease. For hitherto unknown reasons, in longitudinal studies, the presence of AN has been found to be an independent predictor of mortality in patients with cirrhosis. We hypothesized that patients with AN are more likely to develop hepatic encephalopathy (HE) due to prolonged intestinal transit time. In this study, we examined the incidence of newonset HE in patients with and without AN. Seventy two patients (Child A/B/C = 35/31/6) without evidence of HE at the time of autonomic function testing (AFT) were followed for 39.5 ±27.3 months. The end point of the study was the development of new onset HE. Patients were followed until death or liver transplantation. Of the 72 patients, 42 (58%) patients did not develop HE (group A) while 30 (42%) developed HE (group B) during the follow up. Both groups had similar baseline demographics. AN was more common in group B (27/30; 90%) compared to group A (28/42; 67%) (P = 0.02). Kaplan Meier analysis showed a trend toward a higher incidence of HE in patients with AN. Mortality was higher in group B (12/30; 40%) compared to group A (8/42; 19%) (P=0.04). Patients with AN were more likely to develop new onset HE. Although an independent effect of AN on HE was not established in this study, we speculate that delayed intestinal transit secondary to AN may explain the higher incidence of HE in patients with AN.
  • 摘要：Dual sensor esophageal pH monitoring is routinely used to diagnose GERD. However, the proximal sensor may not be in proximal esophagus in patients with shortened esophagi. Our objective was to determine how often the proximal sensor was misplaced and to determine the effect on pH monitoring. Superior margins of the upper and lower esophageal sphincters (UES and LES) were determined prospectively in consecutive patients. Dual sensors were placed 20 and 5 cm above the LES with a fixed 15 cm spacing pH catheter. Patients were classified into subgroups based on the actual location of the proximal sensor. In 661 patients, the proximal pH sensor was in the hypopharynx in 9%of patients, within the UES in 36%, and in the proximal esophagus in 55%. Spearman’s correlation for acid exposure was very good between the dual sensors when the proximal sensor was in the proximal esophagus (R=0.76)but was poor when the proximal sensor was misplaced in the hypopharynx (R=0.28). The proximal sensor was misplaced in 45%of patients undergoing dual sensor esophageal pH monitoring. It is important to locate the UES by manometry before interpreting the proximal esophageal pH data.
  • 摘要：Objective. An association between polymorphism in the gene coding for the anti- inflammatory cytokine interleukin- 1- receptor antagonist (IL- 1Ra) and ulcerative colitis (UC) has been reported. To date, there is no report from India confirming this association. In the present study the aim was to assess the allele frequencies and carriage rates of different alleles of 86 bp (base pair) variable number tandem repeat (VNTR) in intron 2 of the IL- 1Ra gene in patients with inflammatory bowel disease (IBD) and healthy controls from northern India. Material and methods. Eighty- two patients with UC, 21 with Crohn’ s disease (CD) and 141 ethnically matched controls were enrolled in this study. Genotyping was done using a polymerase chain reaction (PCR) amplification of the intron- 2 fragment harboring a VNTR nucleotide sequence. The PCR products were separated on 2% agarose gel. Statistical analysis was performed using the chi- squared (χ 2) test. Results. The frequencies of allele 2 in UC, CD and healthy controls were 26% , 50% and 24% , respectively. The frequency of allele 2 in CD was higher than that in UC (p = 0.002; OR = 2.9) and healthy controls (p = 0.001; OR = 3.1; 95% CI = 1.5- 6.3). Alleles 3 and 4 were absent in patients with CD, while allele 5 was absent in all three groups. Conclusions. The present study demonstrated an association between allele 2 and patients with CD but not with UC. Interestingly, the allele frequency and carriage rates of allele 2 were significantly higher in patients with CD than in patients with UC and in healthy subjects. Ethnic differences, genetic heterogeneity and sample size could be the reasons for such differences in comparison with studies from the West.
  • 摘要：The cell surface and/or intracellular expression of the matrix metalloproteinases (MMP -2,-7, and -9 and MT1 MMP) and their inhibitors (TIMP-2 and -4) were investigated in tumor and tumor infiltrating lymphocytes (TIL) in gastric carcinoma (n = 15) from the primary locus, metastatic gastric carcinoma (n = 20) from malignant ascites, and benign gastric mucosa (n = 20) for the control. The quantitative analysis was based on the percentage of positive cells by flow cytometry. The results clearly showed increased cell surface expression of MMP 2, -7, and -9, MT1 MMP, and TIMP-2 and -4 in both tumor cells and TIL during the development of invasion and/or metastasis of gastric carcinoma. There were equilateral correlations with cancer progression and frequency of cell surface expression of MMPs and their inhibitors, TIMPs, suggesting not only the aggressive nature of particularly metastatic gastric carcinoma, but also the presence of MMPs complexed with TIMPs on tumor cells and TIL. The enhanced cell surface expression of MMPs and TIMPs on TIL within metastatic carcinoma nests showed the result of a host response induced by tumors. These suggest that the increased cell surface expression of MMPs and TIMPs, and tumor induced host response play a key role in gastric cancer invasion and/or metastasis.
  • 摘要：Objective. There may be advantages in using magnetic resonance imaging (MRI) in small- bowel disease. The aims of this study were to optimize the MRI examination technique and to evaluate the capabilities of MRI compared with those of conventional enteroclysis (CE). Material and methods. MRI and CE were performed in 36 patients suspected of Crohn’ s disease. Based on 26 pilot studies optimal oral administration of plum juice and bulk fibre laxative was found. T2- weighted and gadolinium enhanced T1- weighted images were obtained using a breath- holding technique and butylscopolamine. Virtual endoscopy was performed. Conventional enteroclysis entailed duodenal intubation and administration of barium and air. Two radiologists evaluated the examinations independently. Finally, each patient scored the degree of discomfort, and preference for either MRI or CE was found. Results. The MRI technique ensured sufficient distension of the small bowel and small- bowel changes were found in 12 patients. In 3 patients this was not seen on conventional enteroclysis, which did not reveal any pathology that was not already seen on MRI. Pathological abdominal changes were found in 70% more patients during MRI than during conventional enteroclysis (p < 0.001). Endoscopic examination corresponded with the MRI findings. The examination quality decreased with increasing age (p = 0.002) and the interobserver agreement of the pathological changes was high (p < 0.001). Virtual endoscopy resulted in excellent demonstration of the mucosal surface. The examination discomfort scores obtained during the MRI were lower than those during conventional enteroclysis (p< 0.001). Conclusions. MRI using the current technique is preferable to conventional enteroclysis because of superior demonstration of the entire small- bowel pathology, low level of patient discomfort and absence of radiation exposure.
  • 摘要：Alterations of the APC, K ras, and β catenin genes are defined as early events in colorectal tumorigenesis. These alterations are well known as constitutents of Vogelstein’s pathway, however, the relationship among them is unclear. For understanding colorectal tumorigenesis it is important to evaluate their relationship. We analyzed the relationship between β catenin and K ras gene mutations in clinical colorectal samples. Sixty four cases of colorectal cancers (44 proximal, 20 distal) without a family history of colorectal cancer were used for this study. We purified genomic DNAs from fresh surgical samples and, thus, analyzed the mutations of β catenin (exon 3) and K ras (codons 12 and 13) by PCR direct sequencing method using Big Dye terminator cycle sequencing with AmpliTaq polymerase FS. We found 27%(17/64) K ras mutations (proximal 25%, 11/44; distal 30%, 6/20). The frequency of β catenin mutations was 11%(7/64; proximal 9%, 4/44; distal 15%, 3/20). All cases with β catenin mutation had no mutation of K ras. All sites of β catenin mutation have been reported previously (codons 33, 34, 41, 45). In cell lines, it has been reported previously that β catenin and K ras play the same roles in activation of cyclin D1 transcription. Our results may support this report and suggest that some colorectal cancers with β catenin mutation will progress without K ras mutation. Further study may disclose a new pathway or new mechanism of colorectal tumorigenesis.

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