Dimitrios Polymeros

Hypergastrinemia Is Associated with Increased Risk of Distal Colon Adenomas

Background/Aims:Helicobacter pylori infection is a recognized cause of hypergastrinemia, but the association of blood gastrin levels with colonic adenomas (CAs) is controversial. The aim of this study is to investigate if hypergastrinemia, H. pylori infection and/or cagA protein are risk factors for CAs. Methods: In this prospective case-control study, fasting serum samples from 78 consecutive patients with CAs and 78 demographically matched colonoscopy-negative controls were assayed for anti-H. pylori immunoglobulin G, cagA protein and serum gastrin levels. Multivariate analysis was performed to identify risk factors for colon adenomas. Results: Though prevalence of H. pylori antibodies was not significantly different, the prevalence of cagA protein was significantly higher in patients with adenomas (42.3%) as compared with controls (25.6%, p < 0.03). Mediangastrin levels were significantly higher in patients with CAs (55, 20–975 pg/ml) than in controls (45.2, 23–529 pg/ml) (p < 0.001). Hypergastrinemia (>110 pg/ml) was commoner in patients with CAs than in controls (29.5 vs. 11.5%, p = 0.006) and was the only independent risk factor for adenomas (odds ratio 3.2, 95% CI 1.4–7.5) by multivariate analysis, but not H. pylori infection or cagA positivity. There was a significant association of hypergastrinemia and distal distribution of adenomas (p < 0.002). Conclusions: Our study shows that hypergastrinemia is a risk factor for CAs, especially of the distal colon.

Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis

BACKGROUND AND STUDY AIMS The optimal treatment of bleeding due to radiation proctitis is still controversial. Although argon plasma coagulation (APC) has been recently reported as an effective treatment, its efficacy in relation to disease severity is unknown. The study aims were to prospectively evaluate (i) the efficacy of APC in endoscopically mild and severe radiation proctitis, and (ii) the recurrence rate following successful treatment. PATIENTS AND METHODS 56 patients (mean age 68.4 years) with radiation proctitis after radiotherapy for prostate cancer were studied. All presented with rectal bleeding, occurring a median 21.5 months after radiotherapy. Using an established scoring system, patients were classified into two groups, with mild or severe disease. We also examined the correlation between endoscopic severity and hemoglobin level as a more objective measure of bleeding activity. Success was defined either as cessation of bleeding or a significant reduction so that further treatment was not required. RESULTS Proctitis was classified as mild in 27 patients (48%) and severe in 29 (52%). Endoscopically judged severity and hemoglobin level showed good correlation (R = 0.58). All patients with mild proctitis and 23/29 (79%) with severe disease were successfully treated (P < 0.05). During a follow-up of a mean of 17.9 months (range 6-33), 34/38 patients (89.5%) remained in clinical remission. Recurrence was higher in those using anticoagulant or aspirin (P = 0.02). CONCLUSIONS APC is highly effective in all patients with mild radiation proctitis and in the majority of those with severe disease, providing long-lasting clinical remission.

Symptomatic eosinophilic gastritis cured with Helicobacter pylori eradication

Eosinophilic gastroenteritis is a disorder of unknown aetiology, characterised by eosinophilic infiltration of the gastric and intestinal mucosa and peripheral eosinophilia. To date, only two cases have reported the coexistence of Helicobacter pylori gastritis and eosinophilic gastroenteritis. In none of these cases was a causal association between these two entities documented.1,2 We present a case of eosinophilic gastritis cured with H pylori eradication therapy. A 44 year old woman presented with a two month history of vomiting, nausea, and crampy abdominal pain. Her past medical history included idiopathic thrombocytopenic purpura, splenectomy at the age of 11 years, hyperlipidaemia, hypertension, diabetes mellitus type II, and depression. Her medication included valsartan, atenolol, …

Comparative performance of novel solutions for submucosal injection in porcine stomachs: An ex vivo study

BACKGROUND Submucosal injection of normal saline (NS) is commonly used during endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) but is quickly absorbed. Sodium hyaluronate (SH) produces longer lasting mucosal elevation but is expensive. AIMS To evaluate the performance of novel solutions for submucosal injection in comparison with NS and SH. METHODS One ml of the following solutions was injected in the submucosa of fresh specimens of porcine stomachs: NaCl 0.9%, SH 0.4%, human albumin 25%, two artificial tears solutions, namely, hydroxypropyl methylcellulose (HPMC) 0.3%/dextran 70.1% and polyvinyl alcohol (PVA) 1.4%, hydroxyethyl starch (HES) 6% and polyethylene glycol (PEG) 50%. The time until the disappearance of the mucosal elevation was recorded in a blind manner. RESULTS The median duration of mucosal elevation was significantly longer with HPMC/dextran, PVA, HES, PEG and SH (29, 26, 38, 31.5, and 41.5min, respectively) compared with NS (12min) (p<0.05 for each comparison). There were no significant time differences between SH and HPMC/dextran, HES and PEG (p>0.05). CONCLUSIONS Novel viscous or hypertonic solutions for submucosal injection, perform better than normal saline and equally well as sodium hyaluronate in porcine stomachs in vitro.

Functional symptoms in inflammatory bowel disease and their potential influence in misclassification of clinical status

Background : Functional symptoms occur in inflammatory bowel disease probably more than in the general population. Existing disease indices rely heavily on symptoms that may be organic or functional. This may explain inconsistencies between recent therapeutic trials in inflammatory bowel disease. Clinically, misinterpretation can lead to over‐treatment of functional symptoms with potent agents, and to under‐treatment of inflammatory bowel disease when inflammatory features are more subtle.

Anti-Helicobacter pylori antibody responses specific for VacA do not trigger primary biliary cirrhosis-specific antimitochondrial antibodies

Andreas Koutsoumpas, Maria Mytilinaiou, Dimitrios Polymeros, George N. Dalekos and Dimitrios Petrou Bogdanos, Liver Immunopathology, Institute of Liver Studies, King’s College London School of Medicine, King’s College Hospital, London, UK, 2nd Department of Medicine, Hepatogastroenterology Unit, Attikon University General Hospital, Athens, Department of Medicine, Academic Liver Unit and Research Laboratory of Internal Medicine, Medical School, University of Thessaly and Research Group of Investigational Medicine, Institute of Biomedical Research and Technology, Centre for Research and Technology – Thessaly (CE.RE.TE.TH), Larissa, Greece

Prevalence and Characteristics of Extra-intestinal Manifestations in a Large Cohort of Greek Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS Extraintestinal manifestations [EIMs] are common in inflammatory bowel disease [IBD]. Data on epidemiology and risk factors of EIMs in IBD patients are limited. The aim of this study was to investigate the prevalence of EIMs in a large cohort of Greek IBD patients and identify risk factors for their development. METHODS The study population consisted of IBD patients, who were followed in eight tertiary Greek hospitals. Demographic and clinical characteristics of patients were analysed. The diagnosis of EIMs was based on standard criteria and on specialist consultation. RESULTS In total, 1860 IBD patients (1001 with Crohns disease [CD], 859 with ulcerative colitis [UC]) were registered. Among them 615 [33.1%] exhibited at least one EIM; 238 patients [38.6%] developed an EIM before IBD diagnosis. An association between active IBD and presence of an EIM was established in 61.1% of the patients. Arthritic [peripheral arthritis], mucocutaneous [erythema nodosum], and ocular [episcleritis] were the most common manifestations. EIMs were more prevalent in females, patients with CD, smokers [for all p <0.0001], patients with extensive UC [p = 0.007], and patients with a previous appendectomy [p < 0.0001] or a major IBD-related surgery [p = 0.012]. CONCLUSIONS About one-third of Greek IBD patients developed at least one EIM. Of those, more than one-third had their EIM diagnosed before IBD, and in about two-thirds it was related to disease activity. EIMs were more frequently present in females and patients with extensive UC in multivariate analysis.

Effect of sleep on excessive belching: a 24-hour impedance-pH study.

In patients with repetitive and troublesome belching an organic cause is seldom found, indicating the presence of an acquired abnormal behavior. The aim of our study was to investigate the incidence and pattern of belching during a 24-hour period. Methods Combined 24-hour pH and intraluminal impedance monitoring was performed in 14 patients (9 female; mean age: 43 y) with excessive belching and 10 patients (6 women, mean age 42 y; range 28 to 56) with noncardiac chest pain. Thereafter, we counted the number of belching events and differentiated the number of supragastric and gastric belches. Results During the 24-hour study, the hourly rate of belching was 38.7±6.0; rate of supragastric belches were significantly higher compared to gastric belches (37.7±6.0 vs 1.0±0.5, P<0.001). Patients with noncardiac chest pain showed a lower average hourly rate of belching (3.1±0.6, P<0.001). Dividing the recording into 2 periods (daily-upright and night-supine), there was a significant decrease in the hourly rate at night (37.8±6.1 vs. 0.9±0.5, respectively, P<0.001); mostly due to decrease in supragastric belches, where as the rate of gastric belches remained unchanged. None of the patients showed pathological acid reflux and none of the supragastric belches was associated with acid or nonacid reflux events. Conclusions Supragastric belch is the prominent belching pattern in patients with excessive belching. Supragastric belches almost ceased at night suggesting the presence of a behavioral disorder. There were no diurnal changes in the rate of gastric belches.

Yield of Combined Impedance-pH Monitoring for Refractory Reflux Symptoms in Clinical Practice

Background/Aims In patients with gastroesophageal reflux disease, persistent symptoms on proton pump inhibitor (PPI) therapy may be due to residual acid or non-acid reflux. Combined impedance-pH has been suggested to be superior to pH alone in the management of refractory patients to PPI. The utility of implementation of this technique in every day clinical practice is still unknown. The aim of this study was to investigate the outcomes of patients studied with combined impedance-pH and to evaluate the yield of additional impedance monitoring over pH alone in patients with persistent gastroesophageal reflux disease symptoms. Methods Seventy-one patients (31 men; mean age, 49.1 ± 15.5 years) on PPI therapy underwent combined impedance-pH for persistent typical (76%) or atypical (49%) symptoms. Results During impedance-pH study, 44 (62%) patients reported symptoms. A positive symptom index (SI) was found in 21 (48%) patients: 8 (18.2%) had a positive SI for acid reflux, 9 (20.5%) for non-acid reflux and 4 (9.1%) for mixed reflux. Addition of impedance allowed association between reflux and symptoms in 20.5% of patients who would have been missed by pH study alone. Heartburn was the most prevalent symptom associated with acid reflux, whereas regurgitation and ear, nose and throat symptoms were associated with non-acid reflux. Conclusions The use of combined impedance-pH monitoring substantially increased the diagnostic yield compared to pH alone. With SI analysis, 20.5% of patients received a diagnosis that could not have been achieved with pH testing alone.

Peculiar antibody reactivity to human connexin 37 and its microbial mimics in patients with Crohn's disease

BACKGROUND/AIMS We found that pooled Crohns disease (CD) sera strongly react with a human gap-junction connexin 37 (Cx37) peptide and tested for anti-Cx37 antibody reactivity in sera from CD patients and controls. We also investigated whether peptide-recognition is due to Cx37/microbial molecular mimicry. METHODS The PSI-BLAST program was used for Cx37(121-135)/microbial alignment. Reactivity to biotinylated human Cx37(121-135) and its microbial mimics was determined by ELISA using sera from 44 CD, 30 ulcerative colitis and 28 healthy individuals. RESULTS Anti-Cx37(121-135) reactivity (1/200 dilution) was present in 30/44 (68%) CD cases and persisted at 1/1000 dilution. Database search shows that Cx37(121-135) contains the -ALTAV- motif which is cross-recognized by diabetes-specific phogrin and enteroviral immunity. Testing of 9 Cx37(121-135)-microbial mimics revealed 57-68% reactivity against human enterovirus C, Lactococcus lactis, coxsackie virus A24 and B4. Anti-Cx37(121-135) was inhibited by itself or the microbial mimics. No reactivity was found against the poliovirus, rubella, and Mycobacterium tuberculosis mimics, or the beta cell phogrin autoantigen. Microbial/Cx37 reactivity was not able to differentiate CD patients from UC or healthy controls, in terms of overall prevalence and antibody titres, but microbial mimics were unable to inhibit reactivity to human Cx37 in the majority of the controls. CONCLUSIONS Sera from CD patients react with connexin 37 and cross-react with specific Cx37-mimicking enteroviral peptides. Microbial/self reactivity can be seen in UC and healthy controls. The lack of responses to other Cx37(121-135) microbial mimics and the inability of the reactive microbes to inhibit reactivity to self is intriguing and warrants further investigation.