Gastroenterol. Insights, Volume 2, Issue 1 (January 2010) – 12 articles

The molecular mechanisms involved colon cancer tumorigenesis and development of colon cancer remain unclear. The aim of this study is to explore the inhibitive effects of NM-3 on lymphatic vessel density and vascular endothelial growth factor of micrometastatic lesion of orthotopic implantated colon cancer in the severe combined immune deficiency (SCID) nude mice. Human colon cancer SW1116 cells were orthotopically implantated into the colon of the nude mice. Twenty-eight SCID nude mice were randomly divided into four groups (7 mice for each group) after one week feeding and then the nude mice were treated with carboplatin and NM-3 via intraperitoneal injection twice a week for 8 weeks. The mice were sacrificed after 8 weeks and the vascular endothelial growth factor-C (VEGF-C), VEGF-D, VEGF-R-3 and lymphatic vessel density (LVD) were analyzed using immunohistochemistry staining assay. LVD in NM-3 treated mice was significantly lower than that of control (normal saline treated) mice. The expression of VEGF-C, VEGF-D, and VEGF-R-3 and the expression of mRNA of VEGF-C, VEGF-D, and VEGF-R-3 in NM-3 treated mice were significantly lower than that of control mice. The NM-3 inhibited the growth of colon cancer in the SCID mice of orthotopic implantatation model, and this effect may be related to the inhibitive effects of NM-3 on the lymphangiogenesis and vascular endothelial growth factor in colon cancer. NM-3 and carboplatin played a synergistic role in inhibiting lymphangiogenesis of human colon cancer in SCID nude mice and the further investigation of molecular mechanisms involved in colon cancer metastasis will provide an important evidence for understanding of lymphangiogenesis of human colon cancer. Full article

Irritable bowel syndrome (IBS) is a common disease, and constitutes a large portion of pa-tients admitted to gastroenterology units. We wanted to examine whether there is a need for patients with suspected IBS to have a thorough examination by a gastroenterologist to estab-lish the diagnosis, or whether other specialist or subspecialist physicians could better or equally identify the problems. From April 2003 to April 2005, females admitted with presumed IBS and consequently scrutinized by a gastroenterologist in our department were included. They were examined by a physician to establish a diagnosis. Four years later, the medical records were again scrutinized including abdominal symptoms, laboratory analyses and X-ray findings, to check if the findings were identical to the original diagnoses. Fifty admissions were identified. Nine of the patients did not want to participate, and 2 pa-tients did not keep the appointment. The diagnosis of IBS was confirmed in only 20 (51%) and the other 19 (49%) had another diagnosis other than IBS. At follow up, 3 patients included with the IBS diagnosis had organic diseases, and 4 with another diagnosis also had IBS. Thus, 46% of the examined women with expected IBS had another diagnosis. A thorough examination of the patient and confirmation of the symptoms by a gastroenterologist is necessary before diagnosis of IBS is confirmed. For this purpose, patients need to meet a specialist when diagnosis is uncertain. Full article

Irritable bowel syndrome (IBS) is a common chronic disorder characterized by recurrent abdominal pain, bowel movement changes, diarrhea, constipation, or both and affect approximately 10-20% of the general population. Today, IBS is considered a disorder of dysregulation of the so called brain-gut axis and evidence also suggests that gastrointestinal inflammation may be of great importance in the majority of cases of IBS. In addition to gastrointestinal symptoms, many patients have atopic symptoms. The aim of this study was to study the prevalence of atopic manifestations in volunteers with IBS in a Brazilian urban community. Volunteers over 18 years of age were enrolled and evaluated. The participants were evaluated by a gastroenterologist of the Group of Study of Intestinal Diseases at Hospital Universitario Antonio Pedro. All volunteers were evaluated to determine if patients had symptoms compatible with the diagnosis of IBS based on Rome III criteria. The identification of the atopic manifestations was based in a structured questionnaire for atopy. Three hundred and fifty volunteers were enrolled. Of them, 330 volunteers were evaluated: 78 (23.6%) of the volunteers had symptoms compatible with IBS (Group I) and 252 (76.3%) without symptoms compatible with IBS (Group II). Atopic manifestations were present in 46 (65.3%) in Group I and 105 (41. 0%) in Group II (P=0.0107, OR-2.01 95%CI -1. 20-3. 37). The association between atopic manifestations and the presence of IBS was relevant in patients in this Brazilian urban community. This fact may have implications for diagnosis and treatment of patients with IBS. Full article

The rate of successful deep common bile duct cannulation (DCBD) at endoscopic retrograde cholangiopancreatography (ERCP) is usually used as a surrogate marker of competence at ERCP. There are few data regarding the time spent on cannulation at ERCP. This prospective study aimed to evaluate the time spent on DCBD cannulation at ERCP and to provide a rationale for establishing the DCBD cannulation time as another parameter in assessment of ERCP competence. This is a prospective study performed in a single tertiary university-based referral center. DCBD cannulation time as well as the fluorescence time and the cost of cannulation tools during DCBD cannulation were measured. The mean DCBD cannulation was 12.5±13.6 minutes. Eighty-percent of the cannulation was achieved within 10 min, 10% achieved in 10-30 min, and the remaining in longer than 30 min. The longer cannulation time was associated with increased the cost of cannulation ($79/cannulation versus $387/ cannulation, P<0.001), as well as increasing the radiation exposure times (3.1 min/cannulation vs. 25 min/cannulation, P<0.001). In addition to the success rate of DCBD cannulation, the DCBD cannulation time should be considered as another parameter in the assessment of endoscopic competence in ERCP. Full article

The laparoscopic placement of gastrostomy buttons for feeding tubes is the preferred method of gastrostomy in children with feeding requirements. This intervention often leads to some minor postoperative problems, including gastrostomy site leakage. The aim of our study was to test the hypothesis that the postoperative leakage after a video-assisted gastrostomy is correlated to the dimension of the gastrostomy button used during the oper­ation. Included in the study were 164 children with nutritional problems who consecutively underwent surgery; they had a video-assisted gastrostomy operation. In the first 87 children, a 14 French (Fr) gastrostomy button was used and in the last 77, a 12 Fr button was used. After the operation, the children were followed up prospectively and all complications were documented according to the study protocol. Our study revealed a significant correlation between the dimension of the gastrostomy button and the postoperative leakage at the gastrostomy site. The rate of leakage at the gastrostomy site was 37% in the children who had 14 Fr gastrostomy buttons compared to 18% (P=0.038) in the children who had 12 Fr gastrostomy buttons, during the first six months postoperatively. These results suggest that postoperative gastrostomy site leakage was significantly higher in children who had 14 Fr gastrostomy buttons than in those with 12 Fr buttons. To avoid this complication, 12 Fr gastro­stomy buttons should be used. Full article

Effects of a health program comprising reassurance and patient education, diet management, administration of probiotics and regular exercise on symptoms and quality of life in patients with IBS were investigated. A total of 143 patients (95% women and 5% men), with an average age of 32 years (range, 18-58 years), were included in the study. Ninety-six of these patients had diarrhea and 47 had constipation as the predominant symptom. The patients went through a program combining reassurance and IBS education, guidance in diet management, intake of probiotics, and regular exercise. The patients were asked to complete the Birmingham IBS symptom score questionnaire, the SF-36 questionnaire and the IBS-quality of life (IBS-QoL) questionnaire before starting the program and three, six, 12 and 24 months after completing the program. The total score of symptoms, as well as all the 3 dimensions (pain, diarrhea and constipation), were diminished significantly at all observation times after completing the program. The total score of quality of life, as assessed by the SF-36 questionnaire and by the IBS-QoL questionnaire, was significantly improved at all observation times after completing the program. This improvement included all health concepts of the SF-36 and all the domains of the IBS-QoL except physical and mental role limitations, food avoidance and sexual relations. There was no statistical difference between patients with IBS with diarrhea- or constipation-predominant symptoms. Combining reassurance and patient education, diet management, probiotics administration and regular exercise in a health program improves symptoms and quality of life in patients with IBS. Full article

Severe bleeding sometimes occurs after percutaneous endoscopic gastrostomy (PEG) placement using a modified introducer method (direct method). We hypothesized that using a smaller diameter dilator rather than the 27F dilator contained in the commercial kit would reduce the incidence of this complication. The aim of this study was to compare procedure-related complications with the use of 27F dilators and 20F/24F dilators. Consecutive patients who underwent the direct method for PEG placement were studied. The 27F dilator was used from January 2007 to July 2008 (27F dilator group) and the 20F and 24F dilators were used from August 2008 to December 2009 (20F/24F dilator group). The success rates, procedure times, and procedure-related complications within 30 days of the procedure were evaluated retrospectively in 136 patients: 66 in the 27F dilator group and 70 in the 20F/24F dilator group. The success rates and mean procedure times of the groups were similar. Severe bleeding occurred in five patients in the 27F dilator group versus none in the smaller dilator group (P=0.025). Complications such as peristomal infection, peritonitis, and respiratory depression did not occur in either group. There was no significant difference in 30-day mortality between the groups (2 vs. 1, P=0.61). We concluded that the direct method using 20F/24F dilators has less procedure-related severe bleeding than that using the 27F dilator contained in the commercial kit of 24F button-bumper-type devices. Full article

In a developing country, the percutaneous endoscopic gastrostomy (PEG) procedure is being performed at an increasing rate. However, there is sparse information on the sedation for this procedure. The aim of our study was to evaluate the clinical efficacy of assisted sedation compared with general anesthesia for the PEG procedure in patients in a teaching hospital in Thailand. We undertook a retrospective review of records of patients who underwent PEG procedures from October 2006 to September 2008. All patients with ASA physical status III and IV were classified into two groups according to the type of anesthetic technique: Group S, intravenous sedation (IVS); and Group G, general anesthesia (GA). The primary outcome of the study was the successful completion of the procedure. The secondary outcomes were sedation/anesthesia-related complications during and immediately after the procedure. One hundred and eighty-four patients were enrolled with 116 (M, 52; mean age, 71.4±15.8 years) in Group S and 68 (M, 37; mean age, 67.8±18.5 years) in Group G. There were no significant differences between the two groups in age, gender, weight, and duration of procedure. All patients in both groups concluded with the successful completion of the procedure. Overall adverse events in group S occurred significantly less commonly than in group G (p=0.003). All complications were treated easily with no adverse sequelae. We concluded that in the setting of the developing country, assisted sedation for the PEG procedure in patients by trained anesthetic personnel with appropriate monitoring was safe and effective. Full article

Sedation-related colonoscopic perforation (CP) has been under much debate. Our aim was to assess and compare the CP rate during colonoscopy by using sedation with or without propofol adjuvant. All patients who underwent colonoscopic procedure at the WGO Endoscopy Training Center, Siriraj Hospital, Thailand from March 2005 to October 2007 by using the intravenous sedation (IVS) technique were analyzed. The primary outcome was the CP rate; the secondary outcomes were sedation-related complications and death during and immediately after the procedure. There were 6140 colonos-copies and 1532 flexible sigmoidoscopies during the study period, of which 6122 colonoscopic procedures were performed by using IVS. All of these procedures were categorized into two groups: group A, the IVS technique was propofol-based sedation and group B, the IVS technique was non-propofol-based sedation. After matching the indications of procedure, there were 2022 colonoscopies in group A and 512 colonoscopies in group B. Colonoscopic procedures were performed by staff endoscopists (10.8%) or residents and fellows (89.2%). The characteristics of patients and sedative agents used in perforated patients in both groups were not significantly different. In group A, five patients (0.25%) suffered from perforation and two of them died. In group B, one patient (0.20%) had CP; the difference was not significant (P=0.829). Our data showed that colonoscopy under propofol-based sedation did not increase the perforation rate. Serious complications are uncommon. Full article

Fructose has several interactions in man, including intolerance and promotion of some diseases. However, fructose in fruits and in prebiotics may be associated with benefits. Adaptation to regular fructose ingestion as defined for lactose could support a beneficial rather than a deleterious effect. This study was undertaken to evaluate symptomatic response and potential underlying mechanisms of fecal bacterial change and breath hydrogen response to short term regular fructose supplementation. Forty-five participants were recruited for a 3 day recall diet questionnaire and a 50 g fructose challenge. Breath hydrogen was measured for 4.5 hrs and symptoms were recorded. Thirty-eight subjects provided stool samples for analysis by selective culture of 4 groups of bacteria, including bifidobacteria and lactobacilli. Intolerant subjects returned a second time 15 days later. Ten of these served as controls and 16 received 30 g fructose twice a day. Ten of the latter returned 27 days later, after stopping fructose for a third challenge test. Student’s paired, unpaired t-tests and Pearson correlations were used. Significance was accepted at P<0.05. After fructose rechallenge there were no significant reductions in symptoms scores in volunteers in either the fructose supplemented or non supplemented groups. However, total breath hydrogen was reduced between test 1 and test 2 (P=0.03) or test 3 (P=0.04) in the group given fructose then discontinued, compared with controls. There were no statistically significant changes in bacterial numbers between test 2 and 1. This study shows that regular consumption of high dose fructose does not follow the lactose model of adaptation. Observed changes in hydrogen breath tests raise the possibility that intestinal carriers of fructose may be induced potentially aggravating medical problems attributed to fructose. Full article

The gastrointestinal tract has always been difficult to visualize in its entire length. New technology such as magnetic resonance imaging enterography, computed tomography ente­ro­­graphy, single- and double-balloon entero­scopy, and video capsule enteroscopy have improved the possibilities for visualizing mucosal changes and pathology in the small intestine. We describe here a case of a patient with gastrointestinal signs and symptoms suggesting recurrent intestinal obstruction over a period of several years, who had mostly normal morphology on endoscopic examination. Nonetheless, after some delay, the patient underwent explorative surgery because of his accelerating symptoms. Abdominal exploration revealed a Meckel’s diverticulum, which had led to inflammatory adhesions of the small intestine with a sharp bend and proximal intestinal dilation. After the operation the patient’s health was restored. We concluded that in certain situations the clinician should rely on the patients’ symptoms and clinical findings more than on technological examinations and the clinical picture should guide clin­icians’ interventions, even though we live in a high-technique era. Full article

Thrombophilia, either congenital or acquired, has foremost consequences in the abdominal vessels. We review here the cases of patients admitted with abdominal vessel thrombosis over a five-year period. Our data focused on gender and age at diagnosis, site of thrombosis, previous thromboembolic events, underlying conditions, and family history. Investigations included measurement of protein C, protein S, activated PC resistance, and antithrombin, and screening for factor V Leiden, prothrombin G20210A, the C677T variant of the methylenetetrahydrofolate reductase gene, and V617F JAK2 mutation, r lupus anticoagulant, antiphospholipid antibodies and paroxysmal nocturnal hemospherinouria, and also serum folate, vitamin 12, and total homocysteine concentrations. Twenty-nine patients were admitted and 18 of their family members also underwent the same thrombophilia investigations. Eighteen patients (62.1%) presented with portal vein thrombosis (PVT), five patients (17.2%) with mesenteric vein thrombosis (MVT), four patients (13.8%) with splenic vein thrombosis (SVT), and two (6.9%) patients with hepatic vein thrombosis (HVT). There was a high incidence of congenital thrombophilia (37.9%), acquired thrombophilic conditions (27.6%), or both (20.7%). Sixteen of 18 patients with PVT, four of five patients with MVT, all four patients with SVT, and one of two patients with HVT had one or more thrombophilic risk factors. In 13.8% of the patients no underlying condition was identified. We concluded that thrombophilia may have major implications in the pathogenesis of abdominal vessel thrombosis in adult life, and a thorough thrombophilia investigation should be performed in all these patients. Full article