Maurizio Perego

Helicobacter colonization and histopathological profile of chronic gastritis in patients with or without dyspepsia, mucosal erosion and peptic ulcer: A morphological approach to the study of ulcerogenesis in man

Helicobacter pylori colonization and the incidence, severity, activity and topography of gastritis were investigated systematically in antrum and corpus mucosal biopsies of 1177 subjects undergoing endoscopy in the absence of gastric complaints (asymptomatic, 49) or for non-ulcer dyspepsia (NUD; 631 patients, 72 of whom had gastric and/or duodenal erosions), active gastric ulcer (GU, 76 patients), active duodenal ulcer (DU, 138 patients), and healed gastric (HGU, 39 cases) or duodenal ulcer (HDU, 230 cases). In the antrum,H. pylori colonization and the incidence, severity and activity of gastritis increased progressively in the sequence asymptomatic, erosion-free NUD, erosive NUD, healed ulcer and active ulcer. The same trend was observed in the corpus as regardsH. pylori and gastritis incidence, whereas the severity and activity of gastritis were lower in active DU and erosive NUD and higher in active, proximal GU than in the remaining patients. Active DU and erosive NUD showed the highest incidence of nonatrophic gastritis and lowest type-A or AB atrophic gastritis, while active GU had lowest normal mucosa or type-A gastritis and highest type-B atrophic gastritis. In conclusion,H. pylori colonization and gastritis incidence, severity and, especially, activity of the antrum might all contribute to mucosal erosion and ulceration, whereas the same factors, at least in part and with the exception of proximal GU, seem to have a preventive role when affecting corpus mucosa.

Prevalence and impact of symptoms suggestive of gastroesophageal reflux disease.

Few studies have focused on the impact ofgastroesophageal reflux disease on general health and onwork absenteeism. Our aim was to evaluate the prevalenceand severity of symptoms suggestive of gastroesophageal reflux disease in two samples of Italianemployees. We interviewed 424 subjects of S. MatteoHospital staff and 344 subjects of the Military Factoryof Pavia regarding the frequency and severity ofheartburn and acid regurgitation during the last 12months. Subjects were specifically asked whethersymptoms interfered with the quality of work activitiesor determined work absenteeism. In all, 91% of eligible subjects responded. The prevalence rate per 100of any heartburn or regurgitation experienced at leastmonthly was 21. This value increased to 45% taking intoconsideration symptoms experienced occasionally. Mild or moderate symptoms were more frequentthan severe symptoms (P < 0.001). Only 2.6% ofsubjects answered that symptoms have a negativeinfluence on the quality of their work. No workabsenteeism was recorded. The study confirms that typicalgastroesophageal reflux symptoms are common conditions,but mainly of mild or moderate degree.

Endoscopic evaluation of gastrointestinal tract in patients with hereditary hemorrhagic telangiectasia and correlation with their genotypes.

Purpose:Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant vascular dysplasia characterized by telangiectases and arteriovenous malformations. Three causative genes are known: ENG (HHT-1), ACVRL1 (HHT-2), and SMAD4 (mutated in HHT in association with juvenile polyposis). Gastrointestinal bleeding is the most common symptom after epistaxis. The stomach and the duodenum are the main gastrointestinal sites of telangiectases. Our aim was to explore gastrointestinal tract of consecutive HHT patients to assess distribution, number, size, and type of telangiectases in relation to genotype.Methods:HHT patients underwent gastroduodenoscopy, video capsule endoscopy, and colonoscopy. Molecular analysis of ENG and ACVRL1 was performed to identify the disease-causing mutation.Results:Twenty-two patients (13 men; mean age: 59 ± 9 years) were analyzed: 7 with HHT-1, 13 with HHT-2, and 2 undefined. Gastrointestinal telangiectases were identified as follows: at gastroduodenoscopy in 86% of HHT-1 patients and in 77% of HHT-2 patients, at video capsule endoscopy in all HHT-1 patients and in 84% of HHT-2 patients, and at colonoscopy in 1 patient for each group. HHT-1 showed multiple telangiectases with a higher prevalence, more relevant in the duodenum.Conclusion:Our data demonstrate extensive involvement of the gastrointestinal tract with a more severe association in HHT-1. Gastroduodenoscopy provides significant information on gastrointestinal involvement, and video capsule endoscopy may be added in selected patients. Colonic polyps/adenomas were identified as occasional findings.Genet Med 16 1, 3–10.

Increased CD8+ intraepithelial lymphocyte infiltration and reduced surface area to volume ratio in the duodenum of patients with ulcerative colitis.

Abstract Objective. Recent evidence suggests the involvement of the upper gastrointestinal tract in ulcerative colitis (UC). By conducting a prospective controlled study, we explored the immunological abnormalities in the duodenal mucosa of UC patients. Methods. Duodenal and colonic biopsies were collected from 24 corticosteroid-free UC patients and 21 controls. Colonization by Helicobacter pylori and positivity for anti-endomysial antibodies was an exclusion criteria. The severity of duodenal and colonic inflammation was determined by endoscopic and histologic scores. Morphometry was performed to measure the surface area to volume ratio (SV). Duodenal CD3+ and CD8+ intraepithelial lymphocytes (IELs) and lamina propria mononuclear cells (LPMCs) were detected by immunohistochemistry. Results. Fifteen UC patients and 14 controls were Helicobacter pylori and anti-endomysial antibody negative and were thus included in the study. Microscopic duodenitis was reported in 4 of the 15 UC patients (26.6%), and in none of the controls. A significantly higher number of CD3+ and CD8+ IELs and LPMCs was found in UC patients than in controls. A significant positive correlation between the percentage of both CD3+ and CD8+ IELs and disease activity was found in UC patients. SV was significantly reduced in UC patients compared to controls, and inversely correlated with the percentage of CD8+ IELs. Conclusions. The duodenum of UC patients is infiltrated by a higher number of CD8+ IELs which correlates with the degree of villous flattening and disease activity, but not with extent of the colonic lesions. Further studies are needed to clarify whether the duodenum is a target organ in UC.

Defining a proper setting for endoscopy in coeliac disease

Objective As it has been demonstrated that a careful duodenal inspection during upper gastrointestinal endoscopy may be useful in predicting coeliac disease, we tried to define the usefulness of endoscopy in detecting unsuspected coeliac patients. Design and methods We considered all the first diagnoses of coeliac disease from 1992 to 2001, i.e. 110 patients with a biopsy-proven diagnosis of coeliac disease. From 1992 to 1997, neither of the endoscopists paid careful attention to the endoscopic features of coeliac disease in the course of the examinations performed for indications other than coeliac disease. From 1998 to 2001, the same endoscopists looked very carefully at these endoscopic features, regardless of the indication for the procedure. Results Over the first period, 22/16 081 patients endoscoped for the first time had a histological diagnosis of coeliac disease, with a prevalence of 1/731. In all 22 patients the indication for the examination was the suspicion of coeliac disease. The endoscopic appearance of the duodenum was indicative in 16/22 (72.7%) patients. Over the second period, the diagnosis of coeliac disease was made in 88/10 410 patients endoscoped for the first time. The prevalence of the disease was 1/118 examinations performed. The endoscopic appearance of the duodenum was indicative in 70/88 (79.5%) patients. In 13/88 patients, the diagnosis of coeliac disease was presumed because of the macroscopic appearance of duodenum, lacking a past history suggestive of coeliac disease. Conclusions Despite a still open controversy on the accuracy of endoscopic markers in the diagnosis of coeliac disease, we have found that in subjects not suspected for coeliac disease and undergoing an upper gastrointestinal endoscopy for other reasons, attention to the endoscopic pattern could facilitate the identification of a relevant number of cases.

Transvaginal laparoscopic cholecystectomy: endoscopically assisted

We read with interest the article by Bessler et al. [1], entitled ‘‘Transvaginal laparoscopic cholecystectomy, laparoscopically assisted.’’ In their technique, the authors used a 5-mm trocar for the laparoscopic grasper to retract the fundus of the gallbladder. The entire cholecystectomy was then performed using a 12-mm dual-channel therapeutic gastroscope. Aside from the title of the paper (which may convey a mistake), the authors define their operation as ‘‘transvaginal endoscopic cholecystectomy’’ which is laparoscopically assisted. Interestingly, using the same access in the pig model, we have performed a ‘‘transvaginal laparoscopic cholecystectomy, endoscopically assisted.’’ After approval from the University of Pavia Research Ethical Board and from the Italian Ministry of Health, four 30-kg Large White pigs underwent transvaginal cholecystectomy. After pneumoperitoneum induction with a Veress needle, a 5-mm laparoscopic trocar was placed in the left lower quadrant of the abdomen. Using a 5-mm optic for direct vision control, the intra-abdominal insertion of a 12-mm dual-channel gastroscope through the vagina was safely performed. Using the same vaginal access, a 43-cmlong laparoscopic grasper was inserted to retract the fundus of the gallbladder. The gastroscope was used only for video assistance and further retraction of the gallbladder. The cholecystectomy was performed using 5-mm laparoscopic instruments through the trocar. The cystic structures were dissected using a conventional laparoscopic hook cautery device and a blunt laparoscopic right-angle. The cystic duct and the cystic artery were then closed with clips using a 5mm laparoscopic clip applier and subsequently divided with laparoscopic forceps. The gallbladder was then dissected from its bed using the hook cautery as in conventional laparoscopic cholecystectomy. The laparoscopic grasper inserted through the vagina was used to remove the gallbladder from the abdomen. The trocar access was also used for additional haemostasis and for intra-abdominal washing and aspiration. The only intraoperative complication was bile leakage from the gallbladder, in two of the four cases. Operative time ranged between 65 and 95 min and was significantly less than that reported by Bessler et al. The advent of NOTES on the scene has attracted attention and enthusiasm, but also caution and recommendations for animal studies that better define the surgical technique, test new dedicated instruments, overcome potential problems, and explore applicability to clinical settings [2]. Following this recommendation, a large number of animal studies have been performed during the last 3 years [3]. The experimental techniques described by Bessler et al. and by us are good examples of this strategy for the safe development of NOTES technology. However, the two techniques are two sides of the same coin: one is endoscopically based with laparoscopic assistance; the other is laparoscopically based, with endoscopic assistance. Both of the procedures are performed with conventional endoscopic and laparoscopic devices, which are not specifically designed for this type of surgery, making necessary a hybrid approach to ensure safe M. Alessiani (&) L. Cobianchi S. Zonta P. Dionigi Hepatopancreatic Unit, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, P.le Golgi 19, 27100 Pavia, Italy e-mail: m.alessiani@unipv.it