Aurora Bortoli

Frequency and clinical evolution of indeterminate colitis: a retrospective multi-centre study in northern Italy

OBJECTIVE: To evaluate the prevalence and the clinical evolution of patients with an initial diagnosis of indeterminate colitis. DESIGN: Retrospective, observational study. SETTING: Fifteen gastrointestinal units in northern Italy. PARTICIPANTS: Patients with an initial diagnosis of indeterminate colitis seen between 1988 and 1993. INTERVENTIONS: Patients were traced through a common database and centres were requested to update their clinical follow-up. MAIN OUTCOME MEASURES: Frequency of patients with an initial diagnosis of indeterminate colitis among those with IBD; rate of patients who subsequently had a definite diagnosis of either Crohns disease or ulcerative colitis. RESULTS: Fifty out of 1113 IBD patients (4.6%) had been diagnosed as having indeterminate colitis. During follow-up, 37 patients (72.5%) had a definite diagnosis of either Crohns disease or ulcerative colitis. The cumulative probability of having a definite diagnosis of either ulcerative colitis or Crohns disease was 80% 8 years after the first one (i.e. the first diagnosis). The probability of having a diagnosis of Crohns disease was increased in patients with fever at onset, segmental endoscopic lesions or extra-intestinal complications and in current smokers. The probability of having a diagnosis of ulcerative colitis was increased in patients who had not undergone appendectomy before diagnosis. CONCLUSIONS: In our area, indeterminate colitis accounts for about 5% of initial diagnoses of IBD. In about 80% of patients, a diagnosis of either ulcerative colitis or Crohns disease is made within 8 years. Several clinical and demographic features can help in identifying those patients more likely to have a subsequent diagnosis of Crohns disease and those more likely to have a subsequent diagnosis of ulcerative colitis.

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.

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.

Hepatocyte proliferation and risk of hepatocellular carcinoma in cirrhotic patients.

Abstract OBJECTIVES: High hepatocyte proliferation has been recently proposed as a risk factor for the development of hepatocellular carcinoma (HCC). The aim of this study was to assess whether hepatocyte proliferation is an independent risk factor for HCC when considered together with clinical and demographic characteristics. METHODS: We retrospectively evaluated 97 consecutive patients with a histological diagnosis of cirrhosis and preserved liver function, enrolled in a surveillance program for early diagnosis of HCC. Hepatocyte proliferation was evaluated by flow-cytometric analysis in liver samples collected at the time of histological diagnosis of cirrhosis. All patients were followed with abdominal US and serum α-fetoprotein (AFP) assays every 6 months. RESULTS: During a mean follow-up of 53 months (range, 12–120 months), 12 patients developed HCC, giving an annual incidence of 2.8%. The mean S-phase fraction was 2.5% ± 1.6 in patients who developed HCC and 0.9% ± 0.6 in those who did not ( p p p p p p CONCLUSIONS: Patients with high S-phase fraction and/or above-normal serum AFP are at higher risk of developing HCC and should be offered a close surveillance program.

The use of thiopurines for the treatment of inflammatory bowel diseases in clinical practice.

BACKGROUND Thiopurines are the most commonly used immunomodulatory drugs in inflammatory bowel diseases. AIM To evaluate the use, the therapeutic and safety profiles of thiopurines in a large sample of IBD patients. METHODS We reviewed 3641 case histories of IBD patients. Thiopurines were prescribed in 582 patients (16.0%); the analysis was performed on the 553 (267 ulcerative colitis, 286 Crohns disease) with exhaustive clinical data. RESULTS The main indications for treatment were steroid-dependence (328/553, 59.3%) and steroid-resistance (113/553, 20.7%). Thiopurines were started when CD were younger than UC patients (p<0.001) but earlier from diagnosis in UC than in CD patients (p=0.003). Efficacy was defined as optimal (258/553, 46.6%), partial (108/553, 19.5%), absent (85/553, 15.4%) and not assessable (102/553, 18.4%). Efficacy was independent of disease type, location/extension or duration and age at starting. Side effects were observed in 151/553 (27.3%) patients, leading to drug discontinuation in 101 (18.3%). 15 out of the 130 (11.5%) patients who took thiopurines for more than 4 years relapsed, more frequently in CD than in UC (OR=3.67 95% C.I. 0.98-13.69; p=0.053). CONCLUSIONS Thiopurines confirm their clinical usefulness and acceptable safety profile in managing complicated IBD patients. The majority of patients treated for longer than 4 years maintain response. No clinical and demographic predictive factors for efficacy and side effects were identified.

Prediction of oesophageal variceal bleeding: evaluation of the Beppu and North Italian Endoscopie Club scores by an independent group

Objective: To evaluate the prediction of variceal bleeding by the Beppu (Japanese Research Society for Portal Hypertension) and NIEC (North Italian Endoscopie Club) scores in groups of patients with different investigators. Methods: A total of 200 patients with liver cirrhosis and endoscopically proven oesophageal varices, but without any previous gastrointestinal bleeding, were enrolled and followed up for 12 months. Results: Overall, 191 patients were evaluated. The Beppu score classified patients into categories of bleeding risk (P=0.0055), but the actual bleeding rates were significantly different from those predicted by the score (P< 0.001 ). The Beppu score overestimated the risk of variceal bleeding, particularly for high-risk groups. The NIEC score also classified patients according to bleeding risk (P= 0.0260), but the expected and observed cumulative bleeding rates were not significantly different for any group (P=0.123). This score was more accurate, although it overestimated bleeding risk by a factor of 2.4, on average. Conclusion: Our data confirm that the Beppu and NIEC scores can identify groups of patients at risk of variceal bleeding. However, the latters prediction of risk is closer to the actual bleeding rate, despite some overestimation.

Is Esophageal pH Monitoring Used Appropriately in an Open-Access System? A Prospective Multicenter Study

OBJECTIVES:To evaluate the referral patterns and indications for esophageal pH monitoring in an open-access system and to determine whether these indications conform to practice guidelines of the American Gastroenterological Association (AGA).METHODS:A total of 851 consecutive patients referred for ambulatory pH monitoring to nine open-access gastrointestinal units over a 12-month period received a structured interview. The indication for the examination was decided by the physician performing the procedure, on the basis of the patients clinical history and main complaint.RESULTS:Three hundred and twenty-three (38%) examinations were for indications in accordance with the guidelines. The proportion of appropriate requests in each center ranged from 34% to 47%. This figure was not significantly different in larger gastrointestinal units (more than 150 examinations per year) and smaller ones (35% and 40%; p = 0.14). The proportion of appropriate requests was 45% for gastroenterologists, 38% for surgeons, 32% for other specialists, and 24% for primary care physicians (PCPs) (p < 0.001). The percentage of appropriateness was significantly different between gastrointestinal specialists and PCPs (p < 0.001 vs gastroenterologists, p = 0.015 vs GI surgeons), and between gastroenterologists and other specialists (p = 0.006).The underuse of an empirical trial of acid-suppression therapy in patients with suspected reflux disease and the overuse of this test to confirm a diagnosis in patients with erosive esophagitis and in endoscopy-negative cases with typical symptoms responding completely to antisecretory therapy accounted for most of the referrals, which was not in accordance with the guidelines.CONCLUSIONS:In an open-access system, a high proportion of esophageal pH studies are done for indications not consistent with published guidelines, particularly among the examinations not requested by gastrointestinal specialists. Further education is still needed on the appropriate use of esophageal pH monitoring and management of gastroesophageal reflux disease (GERD).

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,

Efficacy and tolerability of metoclopramide nasal spray in the symptomatic therapy of functional dyspepsia

Abstract A new pharmaceutical form of metoclopramide (MTC) has recently been developed as a nasal spray. The aim of the present study was to compare the clinical efficacy and tolerability of two formulations of MTC—the new nasal spray versus the more well-established tablet—in the treatment of outpatients affected with functional dyspepsia. Patients were randomly allocated to receive, following clinical ultrasound and endoscopic evaluation, either MTC nasal spray 10 mg/0.1 mL (1 puff) twice daily (n = 15) or MTC tablets 10 mg twice daily (n = 15); one patient in the MTC nasal spray group did not attend the final visit and therefore was considered a dropout. The results obtained in 29 patients at the end of a 4-week treatment period confirm the clinical efficacy of MTC in the treatment of dyspeptic symptoms of functional origin. No statistical difference was observed between the two pharmaceutical formulations of MTC. MTC nasal spray was well tolerated and no drug-related undesired effects were observed. In addition, nasal spray treatment was judged satisfactory by 100% of the patients who actually received it, and 78% of the patients treated with the oral formulation were favorable toward this new method of administration of MTC. Thus the new formulation of MTC appears to be a valid pharmacologic alternative to oral administration of MTC in the management of outpatients with functional dyspepsia.