Gastric polyps: Association with Helicobacter pylori status and the pathology of the surrounding mucosa, a cross sectional study

aim:To assess the endoscopic characteristics of gastric polyps and their association with Helicobacter pylori(H.pylori)status in a predominantly Hispanic population.m ETHODS:We conducted a retrospective study of all esophagogastroduodenoscopies performed at our institution.Demographic,endoscopic and histopathological data were reviewed.Categorization of patients into Hispanic and Non-Hispanic was based on selfidentification.Patients without resection/biopsy were not included in the analysis.Identification of polyps type was based on histological examination.One way analysis of variance was used to compare continuousvariables among different polyp types and Fisher’s exact test was used compare categorical variables among polyp types.Unadjusted and adjusted comparisons of demographic and clinical characteristics were performed according to the H.pylori status and polyp type using logistic regressions.RESULTS:Of 7090 patients who had upper endoscopy,335 patients had gastric polyps(4.7%).Resection or biopsy of gastric polyps was performed in 296 patients(88.4%)with a total of 442 polyps removed or biopsied.Of 296 patients,87(29%)had hyperplastic polyps,82(28%)had fundic gland polyps and 5(1.7%)had adenomatous polyps.Hyperplastic polyps were significantly associated with positive H.pylori status compared with fundic gland polyps(OR=4.621;95%CI:1.92-11.13,P=0.001).Hyperplastic polyps were also found to be significantly associated with portal hypertensive gastropathy compared with fundic gland polyps(OR=6.903;95%CI:1.41-33.93,P=0.0174).Out of 296 patients,30(10.1%)had a followup endoscopy with a mean duration of 26±16.3 mo.Interval development of cancer was not noted in any of the patients during follow up period.CONCLUSi ON:Gastric hyperplastic polyps were significantly associated with positive H.pylori status and portal hypertensive gastropathy as compared with fundic gland polyps.

Normal aspects of colorectal motility and abnormalities in slow transit constipation

Human colonic motility is a relatively difficult topic to investigate. However, the refinement of manometric techniques in recent years enabled us to study both the proximal and distal segments of the viscus. The present paper reviews our knowledge about normal aspects of colorectal motility in man and the abnormalities found in slow transit constipation (STC), one of the most frequent and difficult to treat subtypes of constipation. An internetbased search strategy of the Medline and Science Citation Index was performed using the keywords colon, colonic,colorectal, constipation, slow transit, motility, recal, rectum in various combinations with the Boolean operators AND, OR and NOT. Only articles related to human studies were used, and manual cross-referencing was also performed.Most of colonic motor activity is represented by single nonpropagated contractions, rarely organized in bursts; this activity is maximal during the day, especially after waking and following meals. In addition, a specialized propagated activity with propulsive features is detectable, represented by high- and low-amplitude propagated contractions. In the severe form of constipation represented by the slow transit type, the above motor activity is completely deranged. In fact, both basal segmental activity (especially in response to meals) and propagated activity (especially that of high amplitude) are usually decreased, and this may represent a physiologic marker of this disorder. Human colonic motor activity is quite a complex issue, still only partly understood and investigated, due to anatomic and physiological difficulties. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, althoughonly in part, some pathophysiological mechanisms of chronic constipation, and especially of the STC subtype.

Incidence and mortality of primary liver cancer in England and Wales: Changing patterns and ethnic variations

AIM: To explore recent trends, modes of diagnosis, ethnic distribution and the mortality to incidence ratio of primary liver cancer by subtypes in England and Wales. METHODS: We obtained incidence(1979-2008) and mortality(1968-2008) data for primary liver cancer for England and Wales and calculated age-standardised incidence and mortality rates. Trends in age-standardised mortality(ASMR) and incidence(ASIR) rates and basis of diagnosis of primary liver cancer and subcategories: hepatocellular carcinoma, intrahepatic bile duct and unspecified liver tumours, were analysed over the study period. Changes in guidelines for the diagnosis of primary liver cancer(PLC) may impact changing trends in the rates that may be obtained. We thus explored changes in the mode of diagnosis as reported to cancer registries. Furthermore, we examined the distribution of these tumours by ethnicity. Most of the statistical manipulations of these data was carried out in Microsoft excel(Seattle, Washington, United Sttaes). Additional epidemiological statistics were done in Epi Info software(Atlanta, GA, United Sttaes). To define patterns of change over time, we evaluated trends in ASMR and ASIR of PLC and intrahepatic bile duct carcinoma(IHBD) using a least squares regression line fitted to the natural logarithm of the mortality and incidence rates. We estimated the patterns of survival over subsequent 5 and 10 years using complement of mortality to incidence ratio(1-MIR). RESULTS: Age-standardised mortality rate of primary liver cancer increased in both sexes: from 2.56 and 1.29/100000 in 1968 to 5.10 and 2.63/100000 in 2008 for men and women respectively. The use of histology for diagnostic confirmation of primary liver cancer increased from 35.7% of registered cases in 1993 to plateau at about 50% during 2005 to 2008. Reliance on cytology as a basis of diagnosis has maintained a downward trend throughout the study period. Although approximately 30% of the PLC registrations had information on ethnicity, there was a relatively higher registration of the major tumour subtypes in patients whose ethnic backgrounds were from high incident regions of the world. Survival from PLC is estimated to get poorer in 10 years(2018) relative to 2008, particularly as a result of IHBD. CONCLUSION: Incidence and mortality of PLC, and particularly IHBD, have continued to rise in England and Wales. Changes in the modes of diagnosis may be contributing.

Enteric glial cells and their role in gastrointestinal motor abnormalities: Introducing the neuro-gliopathies

The role of enteric glial cells has somewhat changed from that of mere mechanical support elements, gluing together the various components of the enteric nervous system, to that of active participants in the complex interrelationships of the gut motor and inflammatory events. Due to their multiple functions, spanning from supporting elements in the myenteric plexuses to neurotransmitters, to neuronal homeostasis, to antigen presenting cells, this cell population has probably more intriguing abilities than previously thought. Recently, some evidence has been accumulating that shows how these cells may be involved in the pathophysiological aspects of some diseases. This review will deal with the properties of the enteric glial cells more strictly related to gastrointestinal motor function and the human pathological conditions in which these cells may play a role, suggesting the possibility of enteric neuro- gliopathies.

Understanding and treating refractory constipation

Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful reevaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.

Cellular and molecular basis of chronic constipation: Taking the functional/idiopathic label out

In recent years, the improvement of technology and the increase in knowledge have shifted several strongly held paradigms. This is particularly true in gastroenterology, and specifically in the field of the so-called "functional" or "idiopathic" disease, where conditions thought for decades to be based mainly on alterations of visceral perception or aberrant psychosomatic mechanisms have, in fact, be reconducted to an organic basis (or, at the very least, have shown one or more demonstrable abnormalities). This is particularly true, for instance, for irritable bowel syndrome, the prototype entity of "functional" gastrointestinal disorders, where low-grade inflammation of both mucosa and myenteric plexus has been repeatedly demonstrated. Thus, researchers have also investigated other functional/idiopathic gastrointestinal disorders, and found that some organic ground is present, such as abnormal neurotransmission and myenteric plexitis in esophageal achalasia and mucosal immune activation and mild eosinophilia in functional dyspepsia. Here we show evidence, based on our own and other authors' work, that chronic constipation has several abnormalities reconductable to alterations in the enteric nervous system, abnormalities mainly characterized by a constant decrease of enteric glial cells and interstitial cells of Cajal (and, sometimes, of enteric neurons). Thus, we feel that (at least some forms of) chronic constipation should no more be considered as a functional/idiopathic gastrointestinal disorder, but instead as a true enteric neuropathic abnormality.

Bio-feedback treatment of fecal incontinence: Where are we, and where are we going?

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects,and scarce invasiveness. Well-designed randomized,controlled trial are eagerly awaited to solve this therapeutic dilemma.

Appropriateness of colonoscopy: Diagnostic yield and safety in guidelines

AIM: To evaluate if the guidelines for the appro-priateness of performing colonoscopy by American Society for Gastrointestinal Endoscopy (AGSE) and Italian Society of Digestive Endoscopy (SIED) yield a good diagnostic efficacy and do not present risks of missing important colonic pathologies in an Italian population sample.METHODS: A total of 1017 consecutive patients (560 men and 457 women; mean age 64.4 ± 16 years) referred to an open-access endoscopy unit for colonoscopy from July 2004 to May 2006 were evaluated according to ASGE and SIED guidelines for appropriateness of performing the procedure. Diagnostic yield was defined as the percentage of relevant colonic pathologies of the total number of colonoscopies performed.RESULTS: About 85.2% patients underwent colono-scopy that was considered appropriate based on at least one ASGE or SIED criterion, while it was considered inappropriate for 14.8% of patients. The diagnostic yield of colonoscopy was significantly higher for appropriate colonoscopies (26.94% vs 10.6%, P < 0.001) than for inappropriate colonoscopies (5.3%). There was no missed colorectal cancer following the ASGE/SIED criteria.CONCLUSION: ASGE/SIED guidelines have shown a good diagnostic yield and the rate of missing relevant colonic pathologies seems very low. Unfortunately, the percentage of inappropriate referrals for colonoscopy in an open-access endoscopy system is still high, despite the number of papers published on the issue and the definition of international guidelines. Further steps are required to update and standardize the guidelines to increase their diffusion and to promote educational programs for general practitioners.

Inflammatory bowel disease in the dog:Differences and similarities with humans

Inflammatory bowel diseases (IBD) represent important chronic conditions affecting the gastrointestinal tract in man.However,similar disorders are found in several animal species and the IBD affecting dogs are particularly important.These are encompassed by an umbrella of probably several different entities with common symptoms,some of which seem to share striking similarities with human conditions.This review will focus on the actual knowledge of IBD in dogs,and attempt to identify differences and similarities with human IBD conditions.

Persistent diarrhea with petechial rash-unusual pattern of light chain amyloidosis deposition on skin and gastrointestinal biopsies:A case report

BACKGROUND Amyloidosis is a rare disease characterized by extracellular deposition of misfolded protein aggregated into insoluble fibrils.Gastrointestinal involvement in systemic amyloidosis is common,but is often subclinical or presents as vague and nonspecific symptoms.It is rare for gastrointestinal symptoms to be the main presenting symptom in patients with systemic amyloidosis,causing it to be undiagnosed until late-stage disease.CASE SUMMARY A 53 year-old man with diarrhea,hematochezia,and weight loss presented to a community hospital.Colonoscopy with biopsy at that time was suspicious for Crohn disease.Due to worsening symptoms including nausea,vomiting,and a new petechial rash,an abdominal fat pad biopsy was done.The biopsy showed papillary and adnexal dermal amyloid deposition,in a pattern usually seen with cutaneous amyloidosis.However,Cytokeratin 5/6 was negative,excluding cutaneous amyloidosis.The patterns of nodular amyloidosis,subcutaneous amyloid deposits and perivascular amyloid were not seen.Periodic Acid-Schiff stain was negative for lipoid proteinosis,Congo red was positive for apple green birefringence on polarization and amyloid typing confirmed amyloid light chain amyloidosis.Repeat endoscopic biopsies of the gastrointestinal tract showed amyloid deposition from the esophagus to the rectum,in a pattern usually seen in serum amyloid A in the setting of chronic inflammatory diseases,including severe inflammatory bowel disease.Bone marrow biopsy showed kappa-restricted plasma cell neoplasm.CONCLUSION Described is an unusual presentation of primary systemic amyloidosis,highlighting the risk of misdiagnosis with subsequent significant organ dysfunction and high mortality.

Clinical and economic impact of infliximab one-hour infusion protocol in patients with inflammatory bowel diseases:A multicenter study

AIM To assess the impact of short infliximab(IFX) infusion on hospital resource utilization and costs.METHODS All inflammatory bowel diseases(IBD) patients who received IFX 1 h infusion from March 2007 to September 2014 in eight centers from Southern Italy were included in the analysis. Demographic, clinical and infusion related data were collected. The potential benefits related to the short infusion protocol were assessed both in terms of time saving and increased infusion unit capacity. In addition, indirect patient-related cost savings were evaluated.RESULTS One hundred and twenty-five patients were recruited(64 with ulcerative colitis and 61 with Crohn's disease). Median duration of disease was of 53 mo and mean age of pts at diagnosis was of 34 years(SD: ± 13). Adverse infusion reactions were reported in less than 4% both before and after short infusion. The total number of infusions across the selected centers was of 2501(30.5% short infusions). In the analyzed cohort, 1143 h were saved(762 in the infusion and 381 in observation phases) through the rapid IFX infusion protocol. This time saving(-15% compared to the standard protocol in infusion phase) represents, from the hospital perspective, an opportunity to optimize infusion unit capacity by allocating the saved time in alternative cost-effective treatments. This is the case of opportunity cost that represents the value of forgone benefit which could be obtained from a resource in its next-best alternative use. Hence, an extra hour of infusion in the case of standard 2-h IFX represents a loss in opportunity to provide other cost effective services. The analysis showed that the short infusion increased the infusion units capacity up to 50% on days when the IFX infusions were scheduled(infusion phase). Furthermore, the analysis showed that the short IFX infusion protocol leads to time savings also in the post-infusion phase(observation) leading to a time saving of 10% on average among the analyzed centers. Finally, the short infusion protocol has been demonstrated to lead to indirect cost savings of €138/patient(average-€17.300 on the whole cohort).CONCLUSION A short IFX infusion protocol can be considered time and cost saving in comparison to the standard infusion protocol both from the hospital's perspective, as it contributes to increase infusion units capacity, and the patients' perspective, as it reduces indirect costs and the impact of treatment on everyday life and work productivity.

Slow transit constipation: A functional disorder becomes an enteric neuropathy

慢运输便秘传统地被看作了并且分类机能紊乱。然而，临床、压力计的证据一直在积累那建议大多数在 STC 的活动性改变怎么可能神经病的类型被考虑。另外，进一步的调查显示出那伤寒神经系统的微妙的改变，不是对常规组织学的检查明显，可能在这些病人在场。在现在的文章，我们将讨论这些证据，并且将试着与处于这个病理学的条件记录的大肠的反常运动机能把他们放在关系。

Gastrointestinal motility disorders in inflammatory bowel diseases

The relationship between motility and inflammatory gastrointestinal disorders is at the same time complex and intriguing since these conditions might share some genetic,environmental,immunological and microbial predisposing factors.In addition,significant symptom overlapping may occur,muddling the waters within the clinical context.Although on one hand this represents a challenge for the clinician for a potential under-or over-treatment and diagnostic delay,on the other hand it possibly represents an opportunity for the researcher to better disclose the intimate relationship between chronic(often low-grade)inflammation,motor disorders and deranged sensory function.The best example is probably represented by Crohn’s disease and ulcerative colitis.In fact,a number of gastrointestinal motor disorders have been described in association with these diseases,disorders which span from the esophagus to the anorectum,and which will be extensively covered in this review.It is conceivable that at least part of this derangement is strictly related to inflammatory cytokine trafficking and neuromuscular changes;however,given the high prevalence of functional gastrointestinal disorders in the general population,this overlap might also be serendipitous.However,it is worth noting that literature data on this topic are relatively scarce,sometimes quite outdated,and mostly focused on the interplay between irritable bowel syndrome and inflammatory bowel disease.Nevertheless,both researchers and clinicians must be aware that symptoms related to gastrointestinal motility disorders may be highly prevalent in both active and inactive inflammatory bowel disease,correlate with greater psychological comorbidity and poorer quality of life,and may negatively influence the therapeutic approaches.

Gastroparesis:New insights into an old disease

Gastroparesis(Gp)is a chronic disease characterized by a delayed gastric emptying in the absence of mechanical obstruction.Although this condition has been reported in the literature since the mid-1900s,only recently has there been renewed clinical and scientific interest in this disease,which has a potentially great impact on the quality of life.The aim of this review is to explore the pathophysiological,diagnostic and therapeutical aspects of Gp according to the most recent evidence.A comprehensive online search for Gp was carried out using MEDLINE and EMBASE.Gp is the result of neuromuscular abnormalities of the gastric motor function.There is evidence that patients with idiopathic and diabetic Gp may display a reduction in nitrergic inhibitory neurons and in interstitial cells of Cajal and/or telocytes.As regards diagnostic approach,99-Technetium scintigraphy is currently considered to be the gold standard for Gp.Its limits are a lack of standardization and a mild risk of radiation exposure.The C13 breath testing is a valid and safe alternative method.13C acid octanoic and the 13C Spirulina platensis recently approved by the Food and Drug Administration are the most commonly used diagnostic kits.The wireless motility capsule is a promising technique,but its use is limited by costs and scarce availability in many countries.Finally,therapeutic strategies are related to the clinical severity of Gp.In mild and moderate Gp,dietary modification and prokinetic agents are generally sufficient.Metoclopramide is the only drug approved by the Food and Drug Administration for Gp.However,other older and new prokinetics and antiemetics can be considered.As a second-line therapy,tricyclic antidepressants and cannabinoids have been proposed.In severe cases the normal nutritional approach can be compromised and artificial nutrition may be needed.In drug-unresponsive Gp patients some alternative strategies(endoscopic,electric stimulation or surgery)are available.

Novel oral-targeted therapies for mucosal healing in ulcerative colitis

Ulcerative colitis(UC), a chronic, relapsing, remitting disease of the colon and rectum, is characterized by inflammatory ulceration of the mucosa. Current UC therapy relies on controlling acute episodes and preventing relapse. To predict modifications in the natural course of UC, mucosal healing(MH) has emerged as a major treatment goal. Endoscopic evaluation is considered the gold standard for assessing MH, which can be achieved by conventional drugs and biologics in many, but not all, patients. Consequently, interest is focusing on the development of new substances for UC therapy, and new oral agents are in the pipeline. This review will focus on the ability of newly developed oral drugs to induce and maintain MH in UC patients.

Toward a definition of colonic inertia

Chronic constipation is a relatively frequent symptom; among its subtypes, the so called-colonic inertia represents a disease condition that is often considered for surgery. However, to date, there has been no agreement on definition of colonic inertia, and a literature review showed that this definition was given to numerous entities that differ from each other.In this paper these concepts are reviewed and a more stringent definition of colonic inertia is proposed.

Antibiotics resistance rate of Helicobacter pylori in Bhutan

AIM:To survey the antibiotic resistance pattern of Helicobacter pylori(H.pylori)strains isolated from Bhutanese population.METHODS:We isolated 111 H.pylori strains from the gastric mucosa of H.pylori-infected patients in Bhutan in 2010.The Epsilometer test was used to determine the minimum inhibitory concentrations(MICs)of amoxicillin(AMX),clarithromycin(CLR),metronidazole(MNZ),levofloxacin(LVX),ciprofloxacin(CIP),and tetracycline(TET).RESULTS:Nineteen of the isolated H.pylori strains were susceptible to all antibiotics tested.The isolated strains showed the highest rate of antibiotic resistance to MNZ(92/111,82.9%).Among the 92 MNZresistant strains,74 strains(80.4%)showed high-level resistance(MIC≥256 g/mL).Three strains were resistance to LVX(2.7%).These strains were also resistance to CIP.None of the strains showed resistance to CLR,AMX and TET.CONCLUSION:CLR-based triple therapy is a more effective treatment approach over MNZ-based triple therapy for H.pylori infection in Bhutan.

Linear endoscopic ultrasonography vs magnetic resonance imaging in ampullary tumors

AIM:To assess linear endoscopic ultrasound (L-EUS) and magnetic resonance imaging (MRI) in biliary tract dilation and suspect small ampullary tumor.METHODS:L-EUS and MRI data were compared in 24 patients with small ampullary tumors;all with subsequent histological confirmation.Data were collected prospectively and the accuracy of detection,histological characterization and N staging were assessed retrospectivelyusing the results of surgical or endoscopic treatment as a benchmark.RESULTS:A suspicion of ampullary tumor was present in 75% of MRI and all L-EUS examinations,with 80% agreement between EUS and histological findings at endoscopy.However,L-EUS and histological TN staging at surgery showed moderate agreement (κ=0.54).CONCLUSION:L-EUS could be a useful adjunct as a diagnostic tool in the evaluation of patients with sus-pected ampullary tumors.

Histological healing in inflammatory bowel disease:A still unfulfilled promise

Treatment of inflammatory bowel disease(IBD) is traditionally based on several drugs,including salicylates,corticosteroids,and antibiotics;in addition,the therapeutic armamentarium has considerably evolved with the advent of newer,effective therapeutic measures(such as the biological agents) that are able to improve in a considerable manner both the clinical and endoscopic variables.Thus,mucosal healing,at least considered from an endoscopic point of view,is today regarded as the ultimate endpoint for treatment of these conditions.However,it is also increasingly clear that endoscopic healing is not necessarily paralleled by histological healing;There are few doubts that the latter should be considered as a true,objective healing and the ultimate goal to reach when treating patients with IBD.Unfortunately,and surprisingly,only a few,incomplete,and somewhat conflicting data exist on this topic,especially because there is still the need to standardize both histological assessment and the severity grading of these disorders;Issues that have not been yet been resolved for clinical practice and therapeutic trials.Hopefully,with the help of an increased awareness on the clinical researchers' side,and the availability of dedicated pathologists on the other side,this matter will be effectively faced and resolved in the near future.

Is hyperhomocysteinemia relevant in patients with celiac disease?

AIM:To investigate whether this might be related to the presence of hyperhomocysteinemia.RESULTS:Hyperhomocysteinemia was evident in 32 patients(19.3%),although most of them had moderate levels(mean value 25 mcg/ml;range 15-30).Only one patient had a history of myocardial infarction(heterozygosis for N5-N10-metil tetrahydrofolate reductase mutation).CONCLUSION:The systematic assessment of hyperhomocysteinemia seems,at present,unjustified in CD patients.