Luigi Montalbano

Natural history of congestive gastropathy in cirrhosis

In a prospective study of the natural history of congestive gastropathy, 212 consecutive cirrhotic patients (75 treated with sclerotherapy) were included. Mean follow-up was 46 months. Mild gastropathy (mosaiclike pattern) was found in 110 patients and severe gastropathy (granular mucosa with cherry spots) was found in 20. Prevalence of Helicobacter pylori, formerly Campylobacter pylori, was 50% in patients without, 43% in those with mild, and 28% in those with severe gastropathy. Congestive gastropathy was significantly more frequent in patients treated with sclerotherapy (83% vs. 50%, P less than 10(-5)). Sixty-month actuarial proportions of patients free of anemia (in the absence of hematemesis or melena), were 17% with severe, 62% with mild, and 93% without gastropathy (P less than 10(-8]. Corresponding figures for overt bleeding were 25%, 73%, and 87% (P less than 10(-7], whereas those for survival were 46%, 72%, and 85% (P = 0.0005), respectively. A multivariate regression analysis supported the following conclusions: (a) sclerotherapy and the presence of large esophageal varices significantly increase the risk of congestive gastropathy, which (b) is a significant risk indicator of both chronic and overt bleeding but does not independently affect survival.

Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures.

AIM To evaluate prospectively the clinical efficacy and safety of endoscopic hydrostatic balloon dilation in a consecutive cohort of symptomatic intestinal Crohns disease strictures. METHODS Between September 2003 and December 2008 we performed endoscopic balloon dilations in 37 Crohns disease patients with 39 intestinal symptomatic strictures (4 naïve and 35 postoperative). Dilations were performed using a Rigiflex through-the-scope balloon. Clinical success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation, following technical success. Actuarial curves of clinical, endoscopic (redilation) and surgical recurrence were obtained by Kaplan-Meier method. Demographic and disease variables were related to the main outcomes. RESULTS After a mean follow-up of 26.3 months (range, 2-61 months), the long-term global benefit rate was 89% (33/37). The 1-2-3 years cumulative symptom-free rates were respectively: 76%, 55% and 46%. Four patients were operated upon. Technical success predicts a lower rate of surgery. There were no complications related to the endoscopic procedures. CONCLUSIONS Endoscopic balloon dilation of symptomatic Crohns disease strictures may achieve clinical benefit in many patients and is a valid alternative to surgery in the management of the disease. Dilation may be repeated in recurrent intestinal obstructions and appears safe without morbidity.

Music for colonoscopy: A single-blind randomized controlled trial

BACKGROUND Several methods have been reported to minimize patient discomfort during colonoscopy, none are currently recommended by clinical practice guidelines. We performed a single-blind randomized controlled trial to assess the efficacy of music for colonoscopy. METHODS 109 patients were randomized to music-delivering or mute headphones before and during colonoscopy. Physicians were blinded to the trial. Sedation was given on demand. Primary outcome was pain measured on linear analogue scale from 0 to 10. Secondary endpoints were the difficulty of the procedure, need of sedation, overall patient satisfaction and willingness to repeat the procedure. RESULTS Mean pain score was 5.9±2.2 in the control group vs. 3.8±1.9 in the music group (p<0.00001); correspondingly overall satisfaction and willingness to repeat the procedure were significantly improved by music and the difficulty perceived by physicians was significantly reduced. Total administered midazolam was 36mg in the control group vs. 13 in the music group (p<0.007), pethidine was 860mg vs. 465mg (p=0.07) and patients requiring sedation were 22 vs. 9, respectively (p=0.003). A multivariable analysis to adjust treatment effect for potential confounding factors confirmed the significant beneficial effect of music. CONCLUSIONS Music significantly reduces discomfort and should be routinely offered to patients undergoing colonoscopy.

Natural history of cytomegalovirus infection in a series of patients diagnosed with moderate-severe ulcerative colitis

AIM To evaluate the natural history of human cytomegalovirus (HCMV) infection in a series of 28 ulcerative colitis patients in whom the search for HCMV was positive. METHODS A series of 85 patients with moderate-severe ulcerative colitis flare-up were evaluated for a HCMV search by performing a haematoxylin and eosin stain, immunohistochemical assay and nested polymerase chain reaction on rectal biopsies. Among 85 screened patients (19 of whom were steroid resistant/dependent), 28 were positive for HCMV; after remission the patients were followed up clinically and histologically. RESULTS Among the 22 patients with complete follow-up, in 8 (36%) patients HCMV-DNA persisted in the intestinal specimens. Among the HCMV positive patients, 4 (50%) experienced at least one moderate-severe flare-up of colitis without evidence of peripheral HCMV. Among the 14 HCMV negative patients, 3 with pouches developed pouchitis and 5 out of 11 (45%) experienced a colitis flare-up. CONCLUSION Our preliminary results suggest that HCMV may remain in the colon after an acute colitis flare-up despite remission; it seems that the virus is not responsible for the disease relapse.

CA 19-9 to Rule Out Pancreatic or Biliary Cancer Among Patients with Cholestasis: An Unsuitable Test?

Carbohydrate antigen CA 19-9 was initially proposed as a serologic marker for colorectal cancer [1]. Nowadays its use is not recommended for this purpose [1] and CA 19-9 serum concentration is mostly evaluated in patients with suspected pancreatic or biliary cancer, because of its presumed higher specificity in this setting [2–5]. Unfortunately, CA 19-9 levels have also been reported in other malignancies such as gastric and ovarian cancer and in different benign conditions like cystic fibrosis, hydronephrosis, and Hashimoto thyroiditis [5–7]. Furthermore, elevated CA 19-9 serum concentration can be associated with several conditions producing reduced biliary drainage [8–10], especially in the presence of cholangitis [11]. It is generally be-

A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding

BACKGROUND Pre-endoscopic triage of patients who require an early upper endoscopy can improve management of patients with non-variceal upper gastrointestinal bleeding. AIMS To validate a new simplified clinical score (T-score) to assess the need of an early upper endoscopy in non variceal bleeding patients. Secondary outcomes were re-bleeding rate, 30-day bleeding-related mortality. METHODS In this prospective, multicentre study patients with bleeding who underwent upper endoscopy were enrolled. The accuracy for high risk endoscopic stigmata of the T-score was compared with that of the Glasgow Blatchford risk score. RESULTS Overall, 602 patients underwent early upper endoscopy, and 472 presented with non-variceal bleeding. High risk endoscopic stigmata were detected in 145 (30.7%) cases. T-score sensitivity and specificity for high risk endoscopic stigmata and bleeding-related mortality was 96% and 30%, and 80% and 71%, respectively. No statistically difference in predicting high risk endoscopic stigmata between T-score and Glasgow Blatchford risk score was observed (ROC curve: 0.72 vs. 0.69, p=0.11). The two scores were also similar in predicting re-bleeding (ROC curve: 0.64 vs. 0.63, p=0.4) and 30-day bleeding-related mortality (ROC curve: 0.78 vs. 0.76, p=0.3). CONCLUSIONS The T-score appeared to predict high risk endoscopic stigmata, re-bleeding and mortality with similar accuracy to Glasgow Blatchford risk score. Such a score may be helpful for the prediction of high-risk patients who need a very early therapeutic endoscopy.

Self-expandable metal stents for malignant colonic obstruction: Data from a retrospective regional SIED-AIGO study

BACKGROUND Self-expandable metal stents are a non-surgical option for the treatment of symptomatic malignant colorectal obstruction as palliative treatment or as a bridge to surgery. AIMS To report data from a regional study on self-expandable metal stent (SEMS) placement for malignant colorectal obstruction. METHODS Two hundred and four patients (male 54.9%, mean age of 69.5 ± 14.2) were retrospectively evaluated and data on technical and clinical success, and complications, were analyzed. RESULTS Technical and clinical success rates were 99% and 94.6% respectively, with 36.7% treated on an emergency basis and 63.3% electively. Palliative treatment was administered to 70.1%, and as a bridge to surgery for 29.9%. Complications were 17 neoplastic ingrowths, 10 stent migrations, and 4 perforations. Palliative treatment was associated with a higher risk of stent ingrowth (p=0.003), and chemotherapy with a lower risk of stent ingrowth (p=0.009). CONCLUSION This regional study, although it has certain limitations, confirms the positive role of self-expandable metal stents in the treatment of symptomatic malignant colorectal obstruction, and that chemotherapy decreases the risk of ingrowth.

Delayed-Onset Superior Mesenteric Artery Syndrome Presenting as Oesophageal Peptic Stricture

Superior mesenteric artery (SMA) syndrome is an infrequent cause of vomiting and weight loss due to compression of the third part of the duodenum by the SMA. We describe the case of a 17-year-old woman, admitted to our department for progressive dysphagia and severe weight loss due to an oesophageal peptic stricture, caused by chronic acid reflux secondary to duodenal compression by the SMA. Symptoms improved after (par)enteral nutrition and repeated oesophageal dilatation, thus supporting the role of intensive medical and endoscopic intervention as an alternative to surgery, at least in some cases.

Is Epstein-Barr virus infection associated with the pathogenesis of microscopic colitis?

BACKGROUND Epstein-Barr virus (EBV) has been associated with inflammation in the colon, particularly in patients with inflammatory bowel disease (IBD). Even if a relevant plasmocytosis, similar to IBD, is present in microscopic colitis (MC), the frequency of EBV infection in this setting is unknown. OBJECTIVES We aimed to compare the frequency of colonic EBV infection in patients with MC, ulcerative colitis (UC), and irritable bowel syndrome (IBS). STUDY DESIGN The frequency of colonic EBV infection in biopsies of 30 patients with MC, 30 patients with UC, and 30 controls with IBS was retrospectively assessed. PCR was performed to detect viral EBV DNA in colonic biopsies. In situ hybridization was also performed to identify and localize EBV-encoded small RNA1 and 2 (EBERs) within cells. RESULTS The presence of EBV DNA was detected in 27 out of 30 MC patients, in 20 out of 30 UC cases, and in none of IBS group. The frequency of EBV DNA in MC was significantly higher compared with that reported in UC (90.0% vs. 66.7%, p=0.03). EBERs+ cells were observed in 18 out of 30 MC patients, in only 3 out of 30 UC patients (60.0% vs. 10.0%, p<0.001), and in none of IBS group. CONCLUSIONS EBV infection is almost always detectable in the colonic mucosa of patients with MC. Further studies are necessary to confirm this association and to clarify the role of EBV in MC and, more generally, in colonic inflammation.

JC Virus, Helicobacter pylori, and oesophageal achalasia: preliminary results from a retrospective case-control study.

To the Editor: JC virus (JCV) is a member of the polyomavirus family. It infects humans worldwide, and 90 % of the population carry antibodies to the virus by adult life [1]. The initial infection is asymptomatic, but it may become persistent. JCV DNA is frequently present in the upper and lower gastrointestinal tract of healthy adults [2, 3]. Several studies have suggested the involvement of certain DNA viruses in chronic gastrointestinal motility disorders such as chronic intestinal pseudo-obstruction [4–7]. Although a close causal relationship between neurotropic viruses and enteric neuromuscular lesion is not easily demonstrated, the identification of neurotropic viruses and/ or molecular components associated with them may help to clarify their role in the highly severe gastrointestinal disease. The aim of our study was to assess the prevalence of JC virus in a cohort of patients with oesophageal achalasia, comparing it with a cohort of healthy subjects, in order to evaluate whether JC virus could be play a role in this disease; we evaluated also the relationship between JC virus and Helicobacter pylori (HP). In the cohort of patients with achalasia, 12 out of 15 (80 %) had a positive JC-PCR, while in the cohort of healthy controls, ten out of 15 (66.7 %) had a positive JC-PCR (chi-square 0.68, odds ratio 2, p = 0.409). In the cohort of patients with achalasia, 13 out of 15 (86.7 %) had a positive hystologic HP test, while in the cohort of healthy controls, eight out of 15 (53.3 %) had a positive hystologic HP test. Curiously, in the entire cohort of patients, JC virus infection proved to be protective against HP infection (chisquare 11.35, odds ratio 0.09, p = 0.0008). The prevalence of HP and JC virus infection in the entire cohort is shown in Table 1. Because of the known neuropathic capability of JC virus, and its frequent presence in the upper gastrointestinal tract, as well as in the gut, we proposed that JCV might be detectable in tissues of patients with oesophageal achalasia, and possibly be involved in the pathogenesis of this disease. However, in this study the difference between the prevalence of JC virus in achalasia patients and in healthy controls was not statistically significant, probably due to the small number of cases and control subjects. Few data are available about the relationship between JC virus and HP. Selgrad and coworkers, in their case–control study, showed that JC virus is present in HP induced gastritis and gastric cancer [9]. By contrast, the findings of our case–control study show that JC virus could be a protective factor against HP infection, though the biological and pathophysiological reasons for this microbiological interference are not yet known. Electronic supplementary material The online version of this article (doi:10.1007/s10620-012-2485-9) contains supplementary material, which is available to authorized users.