Matteo Neri

A prospective evaluation of iron deficiency anemia in the GI endoscopy setting: role of standard endoscopy, videocapsule endoscopy, and CT-enteroclysis

BACKGROUNDnIron deficiency anemia (IDA) is a frequently encountered condition in clinical practice. After conventional endoscopy, the cause of anemia remains unknown in up to 40% of patients.nnnOBJECTIVEnTo evaluate prospectively the diagnostic efficacy of a systematic endoscopic approach to IDA and to compare the diagnostic yield of videocapsule endoscopy (VCE) and CT-enteroclysis in endoscopy-negative patients.nnnDESIGNnConsecutive patients with IDA were enrolled prospectively.nnnSETTINGnOpen-access endoscopy within an academic hospital.nnnPATIENTSnThis study involved 189 patients with IDA, including 98 women and 91 men; mean (±standard deviation) age 68 years±16.6 years.nnnINTERVENTIONnPatients with IDA underwent gastroscopy and colonoscopy plus ileoscopy. Endoscopy-negative patients were further blindly evaluated by both CT-enteroclysis and VCE.nnnMAIN OUTCOME MEASUREMENTSnDiagnostic yield of conventional endoscopy; diagnostic yield of VCE versus CT-enteroclysis.nnnRESULTSnEndoscopy results were positive in 144 of 189 patients (76.2%). CT-enteroclysis and VCE allowed a diagnosis in 37 of 45 endoscopy-negative patients (82.2%). Overall, VCE was superior to CT-enteroclysis (77.8% vs 22.2%; P<.001), in particular when flat lesions were found.nnnLIMITATIONSnSingle-center study.nnnCONCLUSIONnA systematic approach to IDA, which includes standard endoscopy, VCE, and CT-enteroclysis allows an overall diagnostic rate of 95.7%; however, CT-enteroclysis should be limited to cases of nondiagnostic VCE.

Dopamine interrupts gastrointestinal fed motility pattern in humans: Effect on motilin and somatostatin blood levels

The aim of this study was to investigate the hypothesis that during the postprandial period in humans, dopamine interrupts the gastrointestinal motility pattern through a mechanism that is peptide-mediated. Fourteen normal human subjects were studied by means of intestinal manometry. After recording two consecutive migrating motor complexes a 900-kcal solid-liquid meal was given. In eight subjects 30 min after the meal, placebo or dopamine (5 μg/kg/min) was infused for 15 min and then the recording continued for 120 min. In the remaining six subjects dopamine was administered twice with a 90-min interval in between. In three subjects the first dopamine infusion after the meal was preceded by treatment with placebo, the second by domperidone (20 mg intravenous as bolus), in the other three subjects domperidone was given before the first dopamine infusion. Blood samples for the determination of somatostatin and motilin were drawn basally, during, and immediately after dopamine in seven subjects. The results show that dopamine interrupts the fed motility pattern, inhibiting the high antrat waves, and activates a duodenal phase III of migrating motor complexes. The pretreatment with domperidone completely prevented the dopamine effect. Plasma levels of motilin increased significantly during dopamine, while somatostatin blood levels did not change. These findings support the hypothesis that a dopaminergic mechanism may modulate the cycling of duodenal motor complex in humans.

Effect of cisapride on human fasting gallbladder volume: A real-time ultrasonographic study

SummaryThe effect of cisapride, a new non-antidopaminergic agent, on human gallbladder volume has been studied in nine normal subjects. In a double-blind crossover fashion, each subject was given a slow i.v. injection of cisapride and placebo after 12-h fasting. Gallbladder volume was monitored every 15 min for 90 min by real-time ultrasonography. After cisapride, gallbladder volume significantly diminished, with a mean reduction of 22.9±5%, observed 30 min after injection, whereas no significant changes were noted after placebo. A cholinergic mechanism is proposed to explain the effect of cisapride on gallbladder volume.

Dopamine-induced migrating myoelectrical complex-like activity in human duodenum

The effect of dopamine on human gastric and small intestinal interdigestive motility was investigated in 12 subjects. Intestinal motility was recorded by means of a four-lumen polyvinyl probe with four open tips located 15 cm apart, continuously perfused with distilled water. In each subject during the same study, after recording two consecutive spontaneous phase III of migrating myoelectrical complexes and when a phase II appeared, dopamine was infused intravenously twice in a dose of 5 μg/kg/min for 15 min with an interval of 20 min between each infusion. In six subjects, the second dopamine infusion was preceded by a treatment with sulpiride (10 mg, intravenously, as bolus) or domperidone (10 mg, intravenously, as bolus), each considered a highly selective dopamine antagonist. The results show that dopamine stimulates duodenal motility producing a pattern similar to that observed in phase III of spontaneously occurring migrating myoelectrical complexes. The second dopamine infusion reproduced in all cases the same pattern of motility as observed during the first infusion. Sulpiride and domperidone prevented the effect of dopamine in all cases. It is therefore suggested that dopamine-induced duodenal motility may involve specific dopaminergic receptors.

Effect of cholinergic agonists and antagonists on gallbladder volume in fasting man

SummaryThe effect of direct cholinergic stimulation and blockade on gallbladder volume, determined by real-time ultrasonography (RUS), was evaluated in twenty normal, fasting subjects. Eleven subjects received atropine sulphate or placebo and 9 subjects a series of 3 injection of prostigmine, bethanechol or placebo, randomly assigned, at intervals of 24 h.RUS was performed under basal conditions after fasting for 12 h and every 5 min after drug injection up to 45 min in the atropine study and up to 60 min after prostigmine and bethanechol.There was no significant variation from fasting gallbladder volume after placebo in either group. After atropine sulphate gallbladder volume at first decreased and then significantly increased. With bethanechol and prostigmine, the volume fell significantly to a trough after 30 to 35 min, and then it returned to the basal value within 60 min. It is suggested that cholinergic mediation is involved in maintaining fasting tone in the gallbladder and that cholinergic stimulation causes contraction of the gallbladder by a direct effect.

Detection of Helicobacter pylori by PCR on gastric biopsy specimens taken for CP test: comparison with histopathological analysis.

The aims of the present study were: (i) to assess whether H. pylori could be succesfully detected by PCR from the same biopsy sample used for CPtest; and ii) to evaluate CPtest comparatively to both PCR and histology for detection of H. pylori infection in dyspeptic patients. Three antral gastric biopsies were collected from each of 80 consecutive dyspeptic patients undergoing oesophagogastroduodenoscopy. Two biopsies were for histology (gold standard), one for CPtest, scored at 20min, 1h and 24h for the presence of urease activity. Gastric biopsy was then removed from CPtest and used for ureC-targeted PCR. Fifty-five (68.7%) patients were positive for H. pylori infection by histology. CPtest yielded an overall diagnostic accuracy of 93.8% (95% CI: 91–96.4%), regardless of observation period. No erroneous categorization of H. pylori status occurred using PCR, yielding sensitivity, specificity, positive and negative predictive values, and overall diagnostic accuracy of 100%. Our results suggest that H. pylori can be detected by PCR in gastric biopsies previously taken for CPtest, so reducing the workload of the endoscopist by saving additional biopsies for culture analysis and susceptibility tests.

Iron deficiency anemia despite effective gluten-free diet in celiac disease: Diagnostic role of small bowel capsule endoscopy

BACKGROUND & AIMnIron deficiency anemia (IDA) is associated with celiac disease (CD). Although gluten-free diet (GFD) is an efficient treatment for CD, IDA remains an occasional finding during follow-up and correlates to inadequate gluten exclusion. Little is known regarding persistent IDA despite effective GFD. We aimed to evaluate the role of small bowel capsule endoscopy (SBCE) in this setting.nnnMETHODSnWe prospectively included consecutive patients undergoing GFD for ≥24 months with persistent concomitant IDA. Patients were assessed serologically and, if negative, underwent endoscopic evaluation.nnnRESULTSnTwenty-six patients underwent esophago-gastro-duodenoscopy (EGD), colonoscopy and SBCE. Altogether, 11 patients resulted positive. EGD showed mucosal lesions in 7: erosive gastritis (n=3), erosive duodenitis (n=1), active CD (n=3). Colonoscopy showed hemorrhoids in 2. SBCE was positive in 6 cases: erosive jejunitis (n=3, 1 eventually diagnosed as refractory CD, 2 as Crohns disease), angiodysplasias (n=2), lymphangectasia (n=1). Some overlap was observed between procedures, since in 4 subjects EGD and SBCE produced significant findings. However, in 3 cases SBCE documented severe disease, not found at EGD. Hypoalbuminemia was significantly associated with a positive SBCE outcome (p<0.01).nnnCONCLUSIONnSBCE yielded significant findings in 23% of celiacs with persistent IDA despite adequate GFD. These were associated to hypoalbuminemia, indicating their occurrence at more severe stages of the disease.

Acute esophageal necrosis: possible association with terlipressin.

A 75-year-old man was admitted to our department with abdominal pain, hematemesis, and melena. His significant medical history included erosive gastritis, alcohol-related chronic liver disease, and chronic pancreatitis. He was not receiving any medication. His blood pressure was low (80/50mmHg); results of laboratory testing showed macrocytic anemia and liver dysfunction (hemoglobin 11.8g/dL, mean cell volume [MCV] 106.4 fL, international normalized ratio [INR] 1.53). After a second episode of hematemesis, his hemoglobin dropped to 8.9g/dL and he was treated by infusion of a colloidal solution, two units of packed red blood cells, a proton pump inhibitor, and terlipressin (2mg every 4 hours). Endoscopy showed a black mucosa (● Fig.1a) that started from the upper esophagus and ended abruptly at the cardia. At that level, we identified an ulcer extending circumferentially in which there was a large exposed vessel (● Fig.1b), which was treated by application of a Hemoclip.The stomach and duodenum were intact. Brushings were negative for cytomegalovirus. Broad-spectrum antibiotics, antifibrinolytic drugs, and parenteral nutrition were commenced; terlipressinwas stopped. Endoscopy at day 8 showed a clear margin between the intact proximal esophagus and its lower portion (● Fig.2a). The luminal circumference decreased craniocaudally, ending in a stricture at the cardia (● Fig.2b). At day 16, the distal esophagus appeared stenotic but was passable and enteral nutrition was resumed. The patient was discharged 25 days after admission. A month later, endoscopy revealed almost complete restoration of the mucosa. Notably, at the cardia we observed a Schatzki ring (● Fig.3). A further endoscopy 8 months later showed no abnormal esophageal findings. Acute esophageal necrosis is characterized by a circumferential mucosal blackening involving the distal esophagus and occasionally extending upstream that stops abruptly at the gastroesophageal junction [1]. Ulceration of the cardia, as in this case, is uncommon; however, similar cases have been reported [2]. Ischemia, impaired mucosal defenses, and chemical insult seem to contribute to its pathogenesis [3]. The distal esophagus has been shown to be less vascularized in angiographic studies [2,3], arguably making it susceptible to local hypoperfusion caused by low splanchnic blood flow. In the case described, such a state could have resulted from hemorrhage and hypotension. Furthermore, because of the signs of liver dysfunction and the history of alcohol abuse, which suggested variceal bleeding, the patient received terlipressin, a splanchnic vasoconstrictor that may have reduced microcirculatory perfusion, further contributing to the local ischemia [4]. Although cutaneous necrosis following terlipressin treatment has been reported [5], this is the first reported case of a possible association with acute esophageal necrosis.

Prevalence and clinical characteristics of refractoriness to optimal proton pump inhibitor therapy in non-erosive reflux disease

The real size of the gastro‐oesophageal reflux disease (GERD) population not responding to proton pump inhibitor (PPI) therapy has still not been fully elucidated. Causes of PPI refractoriness include incorrect diagnosis and lack of adherence to therapy, in terms of incorrect dosage and timing.