Alberto Prada

Complications of Diagnostic and therapeutic ERCP : A prospective multicenter study

Abstract OBJECTIVES: Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study. METHODS: One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists. RESULTS: Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (≤60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater. CONCLUSIONS: The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.

Familial aggregation of inflammatory bowel disease in northern Italy: A multicenter study

To assess the familial aggregation of inflammatory bowel disease (IBD) in Italy, the family pedigrees of 411 patients with ulcerative colitis (UC) and 241 patients with Crohns disease (CD) seen at 14 participating hospitals were studied. Sufficient information was obtained on 97% of 3752 first-degree relatives, 80% of 8869 second-degree relatives, and 74% of 5791 cousins. Thirty-six propositi (5.52%) had a total of 44 affected relatives (16 CD, 28 UC). The prevalence of IBD was higher in first- than in second-degree relatives and cousins (791, 112, and 163 in 100,000, respectively). A strong intrafamilial disease concordance was observed, with 26 cases of UC and 6 of CD among relatives of UC patients and 10 cases of CD and 2 of UC among relatives of CD patients. The prevalence of UC among first-degree relatives of UC patients and that of CD among first-degree relatives of CD patients was 680 and 531 in 100,000, respectively. In conclusion, there is a high degree of familial aggregation for IBD in Italy, with a strong intrafamilial disease concordance.

The natural history of ulcerative proctitis: a multicenter, retrospective study

Abstract OBJECTIVE: The aim of this study was to evaluate the clinical features and the long term evolution of patients with a well defined initial diagnosis of ulcerative proctitis. METHODS: Patients with an original diagnosis of ulcerative proctitis who had been seen at any of 13 institutions from 1989 to 1994 were identified. Data on disease onset and subsequent evolution were recorded. In addition, 575 patients with more extensive disease, treated in the same centers, were used as controls. RESULTS: A total of 341 patients satisfied the inclusion criteria. The percentage of smokers in these patients was slightly lower than in controls; no differences were found in the other clinical/demographic variables evaluated. A total of 273 patients entered long term follow-up (mean, 52 months). Proximal extension of the disease occurred in 74 of them (27.1%). The cumulative rate of proximal extension and of extension beyond the splenic flexure was 20% and 4% at 5 yr and 54% and 10% at 10 yr, respectively. The risk of proximal extension was higher in nonsmokers, in patients with >3 relapses/yr, and in patients needing systemic steroid or immunosuppressive treatment. Refractory disease was confirmed as an independent prognostic factor at multivariate analysis. CONCLUSIONS: Proximal extension of ulcerative proctitis is frequent and may occur even late after the original diagnosis. However, the risk of extension beyond the splenic flexure appears to be quite low. Smoking seems to be a protective factor against proximal extension, whereas refractoriness is a risk factor for proximal extension of the disease.

Pregnancy before and after the diagnosis of inflammatory bowel diseases: Retrospective case–control study

Background and Aim:  Inflammatory bowel diseases (IBD) commonly affect women during the reproductive years. The aim of the present study was to evaluate the reproductive histories of patients with ulcerative colitis (UC) and Crohns disease (CD) considering pregnancies occurring before and after the diagnosis.

Octreotide 24‐h prophylaxis in patients at high risk for post‐ERCP pancreatitis: results of a multicenter, randomized, controlled trial

Pharmacological prophylaxis of post‐ERCP pancreatitis is costly and not useful in most non‐selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost‐effective, in patients at high risk for this complication, where the post‐procedure pancreatitis rate is 10% and more.

Controlled trial of oral 5‐aminosalicylic acid for the prevention of early relapse in Crohn's disease

Recent data indicate that 5‐aminosalicylic acid (5‐ASA) is most effective in preventing relapse of Crohns disease in patients with a short duration of remission before enrolment.

Prevalence and risk factors of Helicobacter pylori-negative peptic ulcer: a multicenter study.

Peptic ulcer disease (PUD) has been described in the absence of Helicobacter pylori (Hp) infection, suggesting that different factors are involved in its etiopathogenesis. We investigated prevalence and characteristics of Hp-negative (Hp-) PUD in an area of Northern Italy and calculated the rate of Hp-positive (Hp+) patients with PUD in whom Hp might be coincidental and not causal. Four hundred nine consecutive patients with endoscopically diagnosed PUD were enrolled in seven hospitals. Hp infection was assessed by rapid urease test and histologic examination. The attributable risk percentages in different age groups were calculated by appropriate formulas. Of 409 patients, 31 (7.6%) were Hp- (gastric, 8.3%; duodenal, 7.6%). Age, nonsteroidal antiinflammatory drug (NSAID) consumption, and complication rates were significantly higher in Hp-than Hp+ patients with duodenal ulcers (DUs). Of the Hp-patients with DU, 58% did not use NSAIDs. In patients with Hp+ DU, the attributable risk percentage for Hp infection in patients aged <40 years, 40-60 years, or >60 years was 98%, 88%, and 66%, respectively. The prevalence of Hp- PUD was about 8%, mainly unrelated to any known etiologic factor. In about one-third of Hp+ patients with PUD aged over 60 years, Hp infection might be coincidental and not causal.

A simplified urea breath test for the diagnosis of Helicobacter pylori infection using the LARA System

Helicobacter pylori, one of the most prevalent human pathogens, is associated with chronic gastritis, peptic ulcer disease, and possibly gastric cancer and primary gastric lymphoma. The need to treat these patients has necessitated the development of improved methods to diagnose H. pylori infection. We present the preliminary assessment of a 13C-urea breath test (UBT) in which the expired 13CO2 is detected in a rapid, simple, inexpensive way by the LARA (Laser Assisted Ratio Analyzer) System (Alimenterics, Inc., Morris Plains, NJ). Eighty-seven consecutive patients, examined for upper gastrointestinal symptoms, underwent endoscopy. H. pylori infection was established by antral biopsies and a rapid urease test (CLOtest). The UBT was performed between 2 and 24 hours after endoscopy. Of the 84 analyzable patients, 70 were found to be H. pylori-positive either by histology or by CLOtest. All 70 were positive by the LARA UBT, yielding a sensitivity of 100%. Fourteen patients were negative for H. pylori by histology and the CLOtest. Of these, 12 were negative by the LARA UBT and 2 were positive, yielding a specificity of 85.7%; because of the limitations of H. pylori detection by histology or urease assays, however, the specificity of the UBT may have been underestimated. Our study demonstrates the feasibility of a nonradioactive, rapid UBT based on the LARA system and suggests the need for its more detailed evaluation.

Parietal cell hyperplasia with deep cystic dilations: a lesion closely mimicking fundic gland polyps

Parietal cell hyperplasia with deep cystic dilations: a lesion closely mimicking fundic gland polyps

Fundic gland polyps and proton pump inhibitors: an obvious link, or an open question?

To the Editor, We read with great interest the article by Kumar et al [1] that recently appeared in HUMAN PATHOLOGY. The authors reported the predictive value of parietal cell changes (PCC) associated with proton pump inhibitors (PPI), with or without Helicobacter pylori colonization. They found that only in H pylori–negative PCC does PPI use seem to have a significant positive predictive value (86.9%), whereas in H pylori–positive patients the predictive value fell to a dismal 55.8%. However, maybe it is too early to dismiss altogether PCC as a characteristic effect of PPI, at least in H pylori– negative patients. Fiocca et al [2], in their report of the LOTUS trial (5-year follow-up of 288 patients treated for gastroesophageal reflux disease with laparoscopic antireflux surgery [LARS] versus 266 patients treated with esomeprazole [ESO]) found that in the ESO arm of the trial, PCC increased in H pylori–negative patients from 39.5% at the baseline to 60.2% at 5 years (in the LARS group, it decreased from 37.4% to 6.9%), whereas the trend was also observed in the H pylori–positive cases with lower prevalence (18.9% at the baseline to 47.4% at 3 years). So H pylori positivity seemed to inhibit PCC. Interesting as these results are, the article raised a question. On one hand, the authors seems cautious to take PCC as a characteristic lesion associated with PPI therapy; on the other hand, after exclusion of polyps from their present study, they seem to take for granted that fundic gland polyps (FGPs) represent a (more) advanced manifestation of the PPI effect, and they found FGPs in 7 of the PPI users (5.0%). Some authors, including us [3], have denied an association between fundic gland polyps and PPI. Torbenson et al [4] stated clearly that “most patients on PPI therapy do not develop fundic gland polyps” and that the control tissue of one of their cases showing PCC did not show β-catenin (CTNNB1) mutations. Even Aprile et al [5], in their article on 101 patients with FGPs associated with Zollinger-Ellison syndrome, found a statistical relationship between gastrin levels and cysts/FGPs formation and no statistical relationship with PPI dose or duration. Vieth and Stolte [6], comparing 2251 and 28096H pylori–negative patients,