Gastroenterol. Insights, Volume 4, Issue 1 (January 2012) – 14 articles

Small bowel obstruction is a known complication of Crohn’s disease. Determining need for operation is a demanding task. The aim of this study was to fine tune the decision-making process by evaluating standard clinical and laboratory parameters in small bowel obstruction of any cause and compare etiologies. Consecutive patients with Crohn’s disease and small bowel obstruction were selected retrospectively and compared to a randomly selected group of non Crohn’s patients with obstruction over a 9 year period. Twenty-two clinical, laboratory and radiological variables were assessed for the following outcomes: i) diagnosis of Crohn’s; ii) operative or non operative treatment in Crohn’s; iii) operative or non operative treatment without Crohn’s; iv) exacerbation or adhesions causing obstruction among Crohn’s patients. Multivariable models were developed for each outcome using logistic regression. Age less than 50, history of smoking, Jewish ethnicity, white count >11x10E9, neutrophils >7.5x10E9 and platelet volume <9.9 fL, supported the diagnosis of Crohn’s disease. Operation in Crohn’s disease within the same admission was associated with a history of smoking, temperature >38˚, high pulse >100, leukocytosis (>11x10E9) and obstruction on abdominal scan, while operation in patients without Crohn’s in the sentinel admission, was associated with temperature >38˚, tachycardia, leukocytosis (>11x10E9) and previous operation. Confirmation of these predictive patterns in a validation group could help in clinical decisions regarding therapeutic options in an emergency setting. Full article

Spontaneous bacterial peritonitis (SBP) is a frequent and sever complication of cirrhotic patients with ascites. The aim of this study was to assess diagnostic value of leukocyte esterase reagent strip test (Medi-Test Combi) for the rapid diagnosis of SBP in cirrhotic patients with ascites in the University Hospital of Imam Reza in Tabriz, Iran. In this study, 132 consecutive samples from cirrhotic patients who underwent abdominal paracentesis were evaluated. These samples were tested by 3 methods: i) manual cell count with differential study, SBP was defined as having poly-morphonuclear cells count of ≥250/mm3; ii) culture of ascetic fluid samples; iii) all samples were tested by leukocyte esterase dipsticks. The sensitivity, specificity, positive and negative predictive values of two different colorimetric cut-off scales (1+ and 2+) were calculated and compared. The sensitivity, specificity, positive and negative predictive values of 1+ and 2+ cut-off scales to diagnose SBP were 97.5%, 84.6%, 74% and 98.7% for the 1+ cut-off scale and 87.8%, 96.7%, 92.3% and 94.6% for the 2+ cut-off scale. Leukocyte esterase reagent strip test can be used as a rapid test for screening of SBP. The higher cut-off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity. Full article

Endoscopic submucosal dissection (ESD) is a minimally invasive technique developed by Japanese endoscopists that allows one-piece endoscopic removal of early malignant lesions in the gastrointestinal tract. There is now a large and ever-increasing number of reports worldwide, and in the West use of this technique is on the increase. New materials and techniques have been developed to improve the technical aspects of ESD. Recent reports show successful clinical outcomes and improved overall 5-year survival rates for this technique. This review aims to offer an update of ESD based on the latest reports in the literature. Full article

Although Helicobacter pylori (H. pylori) infection has been known to be associated with several upper gastrointestinal disorders such as peptic ulcer and gastric cancer, the relationship between H. pylori infection and dyspeptic symptoms remains controversial. Furthermore, it is still not clear which factors are associated with H. pylori infection in the Iranian population. We investigated the prevalence of H. pylori infection in dyspeptic patients and factors associated with H. pylori infection in the Iranian population. In this cross-sectional study, 303 patients with dyspeptic symptoms underwent endoscopy. Clinical data and a questionnaire about gastrointestinal symptoms were collected from each patient. H. pylori status was evaluated by histological examination. Among the 303 patients, 263 (86.8%) were found to be positive for H. pylori. The prevalence of H. pylori infection decreased significantly with age. There was no difference in the prevalence of H. pylori infection between the patients with and those without a family history of gastroduodenal diseases. Among 250 patients with abdominal pain, 219 (87.6%) were infected with H. pylori. Among 211 patients with epigastric abdominal pain, 185 (87.7%) were infected with H. pylori. It was observed that belching was significantly associated with H. pylori infection (P = 0.03). Dyspepsia triggered by the consumption of tea was higher in H. pylori-positive patients than in H. pylori-negative patients (P = 0.03). The prevalence of H. pylori infection in dyspeptic patients was quite high in Iran. Belching and dyspepsia triggered by tea consumption was related with H. pylori infection. Full article

The duodenum is an exceptional location of the primary squamous cell carcinoma. Few cases have been reported in the literature. We report here the second case of this tumor in this exceptional location (transverse duodenum) in a sixty years-old women without medical history, who consulted for epigastric pain since 3 months, associated with an episode of melena and weight loss of 5 kg. The assessement and pathological study of endoscopic specimen confirms the squamous cell nature of the tumor. The treatment consisted of palliative chemotherapy with analgesic treatment. Full article

The clinicopathological and endoscopic features of dyspepsia have not been well studied in Nigeria due to the high cost of gastroscopes and lack of the relevant expertise. This study was designed to highlight these features and possible risk factors. This prospective study was conducted on adult dyspeptic patients who fulfilled the study criteria from November 2007 to December 2008 at a University hospital in Lagos, Nigeria. Demographic and clinical presentation including possible risk factors were obtained through a questionnaire administered by an interviewer followed by an upper gastrointestinal endoscopy and gastric biopsy. Of the 123 subjects who took part in the study, 100 gave their consent to an upper gastrointestinal endoscopy and biopsy. The male:female ratio was 1:1, mean age was 44.98 (SD 15.4) years and the modal age group was 38-47years. The prevalence of dyspepsia was 29% and epigastric pain was the most common presentation. Endoscopic findings were superficial mucosal lesion (21%), peptic ulcer (16%), features of gastroesophageal reflux disease (10%), and gastric cancer (2%), as well normal findings (44%). Non-steroidal antiinflammatory drug (NSAID) use as a risk factor had a significant association with positive endoscopic findings; relative risk for development of positive endoscopic findings was 1.5% (P =0.03). Histology showed rates of chronic gastritis to be 91% and normal values 9%. The most common type of gastritis was the non-specific form (59.3%), followed by H. Pylori-associated gastritis (36.3%). The topography of gastritis was mainly pangastritis (68.1%) and antral predominant in 23.1%. The prevalence of H. pylori by histology was 41%. The presence of H. pylori was not associated with severity, location or duration of symptoms. H. pylori was, however, found to be a significant contributor to the development of positive endoscopic findings (P=0.01; OR 2.92 95% CI 1.50-3.17). Alarm symptoms were found to be important markers of malignancy. Dyspeptic illness is common,with peak incidence in the 4th decade of life and no gender predilection. Epigastric pain has the most discriminatory value with alarm symptoms in cases of gastric cancer. Risk factors such as NSAID use and H. pylori infection had a very significant impact on endoscopic findings while presence of H. pylori, smoking and alcohol consumption were associated with increased risk of developing chronic gastritis. Full article

Stents cannulating the common bile duct and/or the pancreatic duct are frequently used during endoscopic retrograde cholangiopancreatography in both temporary and definitive management of several conditions. While plastic stents have a high risk of occlusion within a few months, metal stents have larger diameters and may, therefore, last longer. However, they tend to have a higher initial cost and once placed, tend to be more difficult to manipulate or remove. Emerging data are now showing that the removal of covered self-expandable metal stents can be achieved relatively easily without the risks of major complications. This review article investigates the indications and complications for stent insertion, as well as the recommended type of stent for each indication. Full article

Oral corticosteroids (CS) have been widely used for treatment of ulcerative colitis (UC) at the price of systemic side effects. Role of topically active oral beclomethasone dipropionate (BDP) in clinical practice is still unclear. The aim of this paper is to investigate efficacy and tolerability of a high dose BDP regimen in mild to moderately active UC. Twenty-five patients (9 males, aged 25-40 years) with mild to moderately active UC, unresponsive to oral and topical 5-ASA (4.8 gr daily) and BDP (5 mg daily), were enrolled. All patients continued 5-ASA plus high dose oral BDP (15 mg od for 4 weeks and than tapered). Clinical, endoscopic, histological and laboratory parameters were monitored. Mean disease activity index (DAI) score at study entry was 8.82±4. Response to treatment was observed in all patients after 2 weeks. Remission was observed in all patients within 4-6 weeks from entering the study (mean DAI score: 2.34±0.5) and maintained throughout 6-month follow-up. No major adverse events were documented. Quality of life global evaluation score improved. This study provides the first evidence of efficacy and safety of high dose oral BDP-scheme in UC demonstrating excellent tolerability and favourable acceptability profile. This new BDPscheme might be a valid alternative to conventional oral CS when standard dose BDP is not effective. Future studies are needed to explore further clinical indications. Full article

We report a case of a 48-year-old female, who presented with refractory haemetemesis. Her oesophago-gastroduodenoscopy showed only a healing ulcer but profuse bleeding was seen from duodenum. In spite of a negative oesophago-gastroduodenoscopy she was bleeding profusely with haemodynamic decompensation. Doppler coeliac trunk showed a suprapancreatic cystic lesion with yin-yang pattern of blood flow confirming a pseudo aneurysm involving the superior and inferior pancreatioduodenal arterial arcade using digital subtraction angiography. The conversion of a pancreatic pseudo cyst into a pseudo aneurysm is a potential lethal complication because, when rupture occurs, mortality rises up to 40%.She was diagnosed to have pancreatic pseudocyst, psedoaneurysm and haemosuccus pancreaticus with wirsungorrhagia and was offered arterial embolization following which she improved. Patients with chronic calcificpancratitis (CCP) could remain silent and can present with normal amylase and lipase. Complications such as pseudocysts or pseudoaneurysms can be asymptomatic. The pancreas should be considered a possible site of hemorrhage in CCP in cases of refractory upper gasrtrointestinal haemorrhage. We highlight the importance of looking for causes other than bleeding duodenal/gastic ulcer/oesophageal varices in case of a refractory hametemeis giving the patient option of a nonsurgical modality of treatment and it’s reduced risks.The effectiveness of embolistion for bleeding psuedoaneurysms is emphasized. Full article

Gastrostomy tube placements in children are associated with frequent postoperative complications. Children with gastrostomy tubes are frequent visitors to the emergency department and outpatient clinic. The aim of this study was to determine the incidence of postoperative gastrostomy complications and disclose if these were correlated to the patients’ age and diagnosis. This is a prospective study of children who had undergone laparoscopic gastrostomy tube placement from June 2006 through March 2011. Patient demographics, comorbidities, and complications were collected. Data were analyzed by Fisher’s exact test. P<0.05 is considered significant. One hundred and sixty-two children were evaluated, with the majority of patients < 2 years of age (106/162). All the patients had undergone laparoscopic-assisted gastrostomy with double U-stitch technique. Granulation tissue, vomiting, infection, leakage were the most common postoperative complications. The majority of patients with these complications had full resolution by the sixth postoperative month. Tube dislodgement was a complication, occurring 16 times in 14 of the patients (10%) and resulting in 16 emergency department (ED) visits. Diagnoses were predictive of complications, and age and gender were not. Granulation tissue, vomiting, infection, leakage and tube dislodgement are complications after gastrostomy placement in children. The age of the child, was not predictive of complications but children with congenital cardiac malformation and malignant diseases had more frequent postoperative complications. Full article

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction. This entity has been reported as either primary idiopathic or secondary to other diseases. We report SEP in 2 cirrhotic patients and review the literature. Both patients had decompensated cirrhosis and episodes of spontaneous bacterial peritonitis. One patient underwent a Denver shunt placement before developing SEP. This patient remains alive and is managed conservatively. The other patient deceased from multi-organ failure after the resection of gangrened small bowel. The manifestations of SEP are often nonspecific that leads to misdiagnosis and/or delayed diagnosis. Early diagnosis of SEP is difficult but not impossible. Surgical treatment is often required when intestinal obstruction is present. Nevertheless, patients with this problem can be treated conservatively with immunosuppressive therapy with or without total parenteral nutrition (TPN) before going for surgery. Full article

Continuous infusions of levodopa directly into the duodenum-yeyunum is an effective therapy to reduce daily off time in an advanced stage of Parkinson's disease, but it is not without complications, particularly device related problems. We present our experience in three Spanish hospitals with these complications, including a severe case with migration, several decubitus ulcers, and one case of perforation of the bowel and finally death. Full article

Gastric biopsy ssampling could affect accuracy of Helicobacter pylori clarithromycin resistance assessment due to coexistence of susceptible and resistant strains (i.e. heteroresistance) either in same gastric site (intraniche) or in two different gastric sites (interniche). This study aimed to assess differences in the H. pylori clarithromycin resistance prevalence in relation to the gastric biopsy sampling by using Taqman-real time polymerase chain reaction (PCR). The study enrolled 137 patients. Primary clarithromycin resistance was observed in 15 isolates exclusively in antrum, in 7 cases exclusively in gastric body, and in 3 patients in both gastric sites. The overall prevalence of clarithromycin resistance was 13.1% by using exclusively antral biopsies, and 18.2% by using biopsies from both gastric sites. Moreover, intra-niche heteroresistance was observed in 19 (76%) out of 25 patients harbouring resistant strains. Our data found a heterogeneous distribution of resistant H. pylori strains in the stomach. Similarly to culture, gastric biopsies from both antrum and gastric body are needed to increase the accuracy of PCR-based methods for clarithromycin resistance assessment. Full article

Postcholecystectomy syndrome (PCS) comprises a heterogeneous group of symptoms and disorders in patients who have previously undergone cholecystectomy. While it is relatively uncommon, it is defined by chronic recurring pain, often with no clear source. Recent studies suggest its pathogenesis depends on different factors, but it remains poorly understood and complex to treat. Here, we present a brief overview of this syndrome, review recent literature regarding its etiology, and present a systematic approach to diagnosis and management. Full article