Brendan J. Collins

Long-term follow-up of gastric histology after Helicobacter pylori eradication.

Helicobacter pylori causes chronic active gastritis and is thought to be associated with the development of gastric atrophy, intestinal metaplasia and carcinoma. As the effect of H. pylori eradication on this process is poorly understood, we sought to determine the long‐term effects of H. pylori eradication on gastric histology. Fifty‐four patients with duodenal ulceration associated with H. pylori infection received H. pylori eradication therapy in 1985/86 and either remained infected (n= 22) or had the infection eradicated (n= 32); patients were followed up by endoscopy with gastric antral biopsy for 7.1 years (mean). Histopathological analysis of gastric antral mucosa from patients rendered H. pylori‐negative revealed a marked decrease in both inflammatory cells within the lamina propria and intraepithelial neutrophils and an increase in epithelial mucinogenesis. Gland atrophy remained unchanged in both H. pylori‐positive and ‐negative patients. When examined for the presence and severity of intestinal metaplasia, there was neither a difference between the two patient groups nor a change with time. These data demonstrate that significant long‐term improvements in gastric histology accompany H. pylori eradication when compared with histology in patients with persistent infection. Whether this confers a protective effect by reducing the risk of gastric carcinoma remains unknown.

Nitrous oxide for colonoscopy: a randomized controlled study

BACKGROUND Intravenous sedation/analgesia for colonoscopy is accompanied with certain risks and postprocedure drowsiness. We sought to determine whether inhaled nitrous oxide (Entonox: 50% nitrous oxide, 50% oxygen) provides adequate analgesia for colonoscopy and the impact of this agent on recovery. METHODS All patients undergoing outpatient colonoscopy were considered for the study (n = 248) except those with previous colonic resection. Data for patients unsuitable for randomization (n = 58) and those who declined to participate (n = 88) were also analyzed. RESULTS One hundred two patients were randomized to receive inhaled Entonox alone (n = 56) or intravenous midazolam and meperidine (n = 46). Forty-nine (88%) patients randomized to Entonox underwent complete colonoscopy without conversion to intravenous medications. Entonox patients reported more pain (p < 0.0001), tolerated colonoscopy less well (p < 0.0001), were less satisfied (p = 0.01), and less willing to undergo colonoscopy again under the same circumstances (p = 0.04). Of patients receiving intravenous medication, 91% found colonoscopy less unpleasant and 9% as unpleasant as anticipated; this compares with 52% and 21% Entonox patients, respectively, and an additional 27% Entonox patients who found colonoscopy more unpleasant than anticipated. Recovery was faster among Entonox patients (median 30 versus 60 minutes, p < 0.0001). CONCLUSION Entonox is less effective than midazolam with meperidine for colonoscopy but is acceptable in many patients and allows faster recovery.

Liver disease complicating bone marrow transplantation: A clinical audit

Abstract Hepatic dysfunction following bone marrow transplantation (BMT) may present complex management issues. The incidence and aetiology of abnormal liver function following allogeneic and autologous BMT was reviewed over a 2 year period in Royal Perth Hospital and these findings were related to management decisions and patient outcome. Abnormal serum liver biochemistry during the first 12 post‐transplant months occurred in all allogeneic (n= 31) and 14 of 23 (61%) autologous transplant patients; 13 (41%) allogeneic and three (13%) autologous patients developed severe hepatic dysfunction. In allogeneic transplants, the most common causes of liver disease were graft‐versus‐host disease (33%), drug hepatotoxicity (19%) and post‐transplant viral hepatitis (15%); in autologous patients, disease recurrence (28%) and sepsis (17%) were the most frequent identifiable cause of abnormal liver function. The aetiology of abnormal liver biochemistry was not determined in 13 instances, but this did not adversely affect patient outcome. Percutaneous liver biopsy or endoscopic cholangiography were only required in three patients. Liver disease contributed to death in two allogeneic patients with multiple causes for liver dysfunction, and in one patient with refractory severe hepatic graft‐versus‐host disease. It was concluded that hepatic dysfunction is common after BMT, the cause of which can be determined in many cases with simple non‐invasive tests used in conjunction with the clinical setting. Specific treatment, where necessary, is then able to be commenced in a majority of patients without the need for invasive investigation.

Perendoscopic pneumatic dilatation in achalasia: Assessment of outcome using esophageal scintigraphy

Sixteen patients (nine male) underwent perendoscopic pneumatic dilatation for achalasia. The Witzel dilator was chosen as it allows placement of the balloon under endoscopic vision. Its efficacy was assessed using esophageal scintigraphy. Symptom score and esophageal transit values at 100 s and after a drink of water all improved significantly (P less than or equal to 0.014) after dilatation and there was a significant correlation between the improved symptom score and the change in transit values after 100 s (r = 0.586, P = 0.017). At follow-up at 8 (3-16) months [mean (range)], 15 of 16 patients (94%) are symptom free. The Witzel dilator is effective in the treatment of achalasia. Esophageal scintigraphy offers a quantitative assessment of esophageal function, helping the clinical investigator evaluate new forms of therapy.Sixteen patients (nine male) underwent perendoscopic pneumatic dilatation for achalasia. The Witzel dilator was chosen as it allows placement of the balloon under endoscopic vision. Its efficacy was assessed using esophageal scintigraphy. Symptom score and esophageal transit values at 100 s and after a drink of water all improved significantly (P≤0.014) after dilatation and there was a significant correlation between the improved symptom score and the change in transit values after 100 s (r=0.586,P=0.017). At follow-up at 8 (3–16) months [mean (range)], 15 of 16 patients (94%) are symptom free. The Witzel dilator is effective in the treatment of achalasia. Esophageal scintigraphy offers a quantitative assessment of esophageal function, helping the clinical investigator evaluate new forms of therapy.

Ultrastructural evidence of intestinal mucosal macrophage activation after bone marrow transplantation

&NA; Previous studies have demonstrated upregulation of intestinal mucosal macrophage CD16 (an FC receptor for IgG) in bone marrow transplant (BMT) recipients with graft‐versus‐host disease (GVHD). We sought to determine whether there was ultrastructural evidence of mucosal macrophage activation in allogeneic BMT recipients and relate appearances to those seen in autologous BMT patients and to immunohistological findings. Sigmoid colonic mucosal biopsies from five allogeneic and three autologous BMT patients were taken prior to, 30 days after transplant and, in three of the allogeneic patients, 120 days after transplant. These were examined by immunohistochemistry and electron microscopy. Immunohistological analysis revealed upregulation of lamina propria macrophage CD16 after transplant in all patients except one autologous BMT recipient; there were no such changes in total macrophage numbers. Ultrastructural evidence of lamina propria macrophage activation was prominent after both allogeneic and autologous BMT. There was an increase in nuclear size accompanied by increased euchromatin and larger nucleoli. In the cytoplasm there were increased numbers of lysosomes, many of which were small and cylindrical, and cytoplasmic flaps were prominent. Phagosomes were less numerous after transplant. These data confirm that after BMT intestinal mucosal macrophages become activated. However changes in macrophage ultrastructure specific to patients at risk of developing clinical GVHD are lacking.

Assessment of different histological variables in gastro-oesophageal reflux disease using oesophageal pH monitoring

Objective: To assess the relationship between acid reflux and histological damage of the oesophageal mucosa. Design: In the assessment of gastro-oesophageal reflux disease, there is a poor correlation between the presence of endoscopic oesophagitis and abnormal oesophageal acid exposure as measured by oesophageal pH monitoring. Assessment of oesophagitis by histology provides a more objective examination of the relationship between oesophageal acid exposure and mucosal damage. In this study, the results of oesophageal pH monitoring and histological assessment of the oesophageal mucosa were compared in 73 patients, presenting to their local hospital for the first time with heartburn. Methods: Endoscopic findings, histological variables and results of pH monitoring were each recorded by authors blinded to the results of the other two measures. Results: Oesophageal acid exposure was significantly higher in patients with histological oesophagitis (total time pH<4: 6.6 compared with 3.5%, P <0.05). However, when individual histological parameters were examined, the most specific (basal zone hyperplasia and papillary elongation, 80% specificity) were insensitive (<35%) for abnormal oesophageal acid exposure. Neutrophil infiltration was more sensitive (63%), but relatively non-specific (56%). Conclusion: The value of histology in the assessment of reflux disease appears to be limited.