Rinaldo Pellicano

Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures

BACKGROUND Benign, refractory esophageal strictures are an important therapeutic challenge. Metal stents occasionally have been used, but results have been disappointing. The present study assessed the safety and the efficacy of temporary placement of the new expandable polyester silicone-covered stent for management of problematic esophageal strictures. METHODS Fifteen patients with benign esophageal strictures were treated by temporary (6 weeks) placement of an expandable polyester silicone-covered stent. All patients had previously been treated, unsuccessfully, by repetitive endoscopic dilation. RESULTS Stent placement was successful in all patients. There was no procedure-related complication. Dilation with over-the-guidewire polyvinyl dilators was required before stent placement. With the stent in situ, dysphagia completely resolved in all patients. Six weeks after placement, one stent was found to have migrated into the stomach. In the remaining patients, the stent was easily removed with a foreign body forceps. The pretreatment dysphagia score was 3 (range 2-4); the post-treatment score was 1 (range 0-1) (p < 0.0005). Long-term resolution (mean follow-up 22.7 [2.6] months) of the stricture was achieved in 12 patients (80%). The treatment failed in 3 patients, all of whom continue to require periodic dilation. CONCLUSIONS In patients with benign esophageal strictures refractory to conventional dilation, temporary placement of a removable expandable polyester silicone-covered stent may lead to long-term relief of dysphagia with minimal morbidity.

Bone Mineral Density at Diagnosis of Celiac Disease and after 1 Year of Gluten-Free Diet

Atypical or silent celiac disease may go undiagnosed for many years and can frequently lead to loss of bone mineral density, with evolution to osteopenia or osteoporosis. The prevalence of the latter conditions, in case of new diagnosis of celiac disease, has been evaluated in many studies but, due to the variability of epidemiologic data and patient features, the results are contradictory. The aim of this study was to evaluate bone mineral density by dual-energy X-ray absorptiometry in 175 consecutive celiac patients at time of diagnosis (169 per-protocol, 23 males, 146 females; average age 38.9 years). Dual-energy X-ray absorptiometry was repeated after 1 year of gluten-free diet in those with T-score value <−1 at diagnosis. Stratification of patients according to sex and age showed a higher prevalence of low bone mineral density in men older than 30 years and in women of all ages. A 1-year gluten-free diet led to a significant improvement in lumbar spine and femoral neck mean T-score value. We propose that dual-energy X-ray absorptiometry should be performed at diagnosis of celiac disease in all women and in male aged >30 years, taking into account each risk factor in single patients.

Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes.

Open access endoscopy and screening programs enable detection and removal of an increased number of colon polyps in the early stages of neoplastic transformation. Unfortunately, polyps larger than 3 cm, involving more than one-third of circumference or two haustral folds, or with a flat/depressed morphology are more challenging to remove with standard polypectomy techniques. Endoscopic mucosal resection potentiates the removal, in a minimally invasive way, of certain colonic lesions that would otherwise require surgical or ablative treatment. Because the plane of resection during endoscopic mucosal resection is typically the middle to deep submucosal layer, compared with standard polypectomy, which normally provides resection at a mucosal level, endoscopic mucosal resection offers the advantage of providing en bloc resection specimens for histopathologic analysis. Indications to perform endoscopic mucosal resection are adenoma and small, well-differentiated carcinoma, confined to the mucosa or with minimal invasion to submucosa, and without any invasion to lymphatic channels or vessels. The most frequently reported major complications, such as perforation (0-5%) and bleeding (0.5-6%), may be controlled by endoscopic methods and rarely require surgical treatment. Follow-up postendoscopic mucosal resection is essential because of the risk of neoplastic recurrence.

Helicobacter species and liver diseases: association or causation?

The discovery of Helicobacter hepaticus as a causal agent of hepatitis and hepatocarcinoma in mice has stimulated interest in looking for Helicobacter spp in human liver samples. These bacteria could be a risk factor for the progression of liver disease to cirrhosis and hepatocellular carcinoma, especially among patients chronically infected with hepatitis C virus. We reviewed the studies done on this topic, and, with the exception of one, all studies reported an association between the presence of Helicobacter spp and liver disease. However, these data are weakened by the fact that Helicobacter spp DNA was detected but no bacteria could be grown, and by the difficulties in identifying the Helicobacter spp involved. More studies are therefore needed to confirm whether a causal association exits between the presence of Helicobacter spp in the liver and the development of cirrhosis and hepatocellular carcinoma.

Incidence of Type 2 Diabetes Mellitus and Glucose Abnormalities in Patients With Chronic Hepatitis C Infection by Response to Treatment: Results of a Cohort Study

BACKGROUND:Patients with chronic hepatitis C are at risk of developing type 2 diabetes mellitus (DM) and impaired fasting glucose (IFG), and this risk may increase among hepatitis C virus (HCV) patients not responding to an antiviral therapy.AIM:To compare the incidence of glucose abnormalities (IFG or DM) after an antiviral therapy between HCV+ patients with a long-term virological response (LTR) and nonresponders (NR; persistently positive HCV-RNA).METHODS:All 202 HCV+ patients without the baseline glucose abnormalities enrolled by our center in investigational trials or routinely treated with interferon (IFN)/peginterferon (Peg-IFN) (+/– ribavirin) from 1988 to 2001, with the available baseline sera stored at −80°C, were considered. The baseline data included age, sex, body mass index (BMI), viral load, genotype, liver histologic staging and steatosis, glucose, and cholesterol. The homeostatic assessment of insulin resistance (HOMA-IR) was calculated in the baseline serum. The incidence of IFG or DM at the end of follow-up was compared between patients with LTR and NR.RESULTS:After a median follow-up of 8.0 yr (range 5–16), the cumulative risk of DM (N = 7) or IFG (N = 33) among the 202 HCV+ included patients was 16.9% (95% confidence interval [CI] 11.3–22.5). The 8-yr risk was not significantly lower between LTRs (14.5%) compared to NRs (18.8%) (hazard ratio [HR] 0.60, CI 0.30–1.20, P= 0.16). The HR adjusted for the baseline risk factors for DM and the predictors of a poor response (age, sex, HOMA-IR, BMI, family history of diabetes, HCV genotype 1, high viral load, cirrhosis, and steatosis) was 0.88 (CI 0.38–2.02, P= 0.76). Among other factors, those more associated to IFG-DM were an increasing age (P= 0.017), a higher BMI (P= 0.054), and a family history of DM (P= 0.065).CONCLUSIONS:After adjustment for several baseline risk factors, the incidence of glucose abnormalities was not significantly different between LTRs and NRs. Our data suggest that HCV clearance does not significantly reduce the risk of glucose intolerance.

Helicobacters and Extragastric Diseases

For two decades, Helicobacter pylori has been considered as the culprit in many extragastric manifestations. However, for several of these supposed associations the hypothesis of an etiological role has not yet been fully investigated. This may be due to a series of factors linked to the epidemiological features of the studies and to the diseases investigated. This review attempts to highlight the main reported associations of H. pylori with extragastric manifestations during the last year. The most convincing data arise in the field of idiopathic thrombocytopenic purpura (ITP) and sideropenic anemia. Long‐term follow‐up studies have shown that 50% of subjects with ITP maintain a hematological response after H. pylori eradication. There is also growing evidence of the role of H. pylori in other diseases, including ischemic heart disease even though results are not conclusive.

Helicobacter pylori seroprevalence in hepatitis C virus positive patients with cirrhosis

BACKGROUND/AIMS Liver cirrhosis is a significant cause of death in Italy and one of the most frequent causes of hospitalization. Acute peptic ulcer and upper gastrointestinal bleeding reportedly occur in over one-third of cirrhotic patients. Since Helicobacter pylori (H. pylori) infection strongly correlates with peptic ulcer, we sought to ascertain the prevalence of H. pylori infection in cirrhotic patients. METHODS In a case-control study, we examined 254 consecutive patients (127 male and 127 female, age range 30-82 years) suffering from hepatitis C virus (HCV)-related cirrhosis and 463 sex- and age-matched patients admitted to the Department of Emergency Care of our hospital (254 male, 209 female, age range 30-79 years) resident in the same area. RESULTS Antibodies to H. pylori were present in 226/254 (89%) cirrhotic patients and in 275/463 (59%) controls (p<0.0001). The difference was significant both in males and in females. CONCLUSIONS The very high prevalence of H. pylori infection may explain the frequent occurrence of gastroduodenal ulcer in cirrhotic patients and may possibly determine the prognosis of those who are also infected with HCV.

Preliminary experience with a new cytology brush in EUS-guided FNA

BACKGROUND Despite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published. OBJECTIVE To assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion. DESIGN Case series. SETTING Tertiary care university hospital (Molinette Hospital, Turin, Italy). PATIENTS Thirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled. INTERVENTIONS The material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists. MAIN OUTCOME MEASUREMENTS Adequacy of the sample and sensitivity and specificity of the EchoBrush method. RESULTS Adequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure. LIMITATION Preliminary study. CONCLUSIONS This report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

Insulated-tip knife endoscopic mucosal resection of large colorectal polyps unsuitable for standard polypectomy

OBJECTIVES:Endoscopic mucosal resection (EMR) has been shown to be safe and effective. En bloc resection is often not achieved using conventional EMR. Insulated-tip knife (It-knife) EMR has been recently proposed for early gastric cancer dissection and removal. This study was conducted to evaluate the safety and efficacy in obtaining en bloc resection with It-knife EMR of large colonic lesions not resectable with standard endoscopic techniques.METHODS:A total of 29 patients (19 men, 10 women, mean age 67.5 yr, range 44–88) were included in the study. Lesions were considered not suitable for standard polypectomy because of large diameter (>3cm), morphology, and/or position. Lesions were located in the rectum (N = 11), sigmoid: (N = 10), descending: (N = 4), transverse: (N = 2), and hepatic flexure (N = 2). After saline injection, circumferential incision and dissection of the lesions were attempted with the aim of achieving en bloc resection.RESULTS:En bloc resection was achieved in only 55.1% of the lesions (16 out of 29 patients). In the remaining cases, resection was completed with a piecemeal technique. The median size of the en bloc resected specimen was 3 × 3.4 cm. Complications occurred in four patients (13.7%). At histopathology, 13 patients had low-grade dysplasia, 15 high-grade dysplasia. One patient had a tumor invading the submucosa and was submitted to surgery.CONCLUSIONS:It-knife EMR is a promising technique for attempting en bloc resection of large colonic polyps. Adequate training and caution are required because it can be associated with a higher complication rate than with other EMR modalities.

Helicobacter pylori: from the stomach to the heart.

A surprising number of extra-gastrointestinal diseases have been reported to be associated with Helicobacter pylori infection, including coronary heart disease and stroke. Since coronary heart disease is the principal cause of death in western countries, and since the known risk factors cannot fully explain the pathogenic mechanisms of the disease, the exploration of the role of possible causal agents has stimulated intense research. Infectious agents have been linked to coronary heart disease on epidemiological and pathogenic grounds. In 1994, H. pylori infection was reported to be one of them. Since then, a number of studies have been published with controversial results. Studies performed thus far show a high degree of heterogeneity in the selection of patients and also in the type of disease studied, i.e. coronary heart disease in general or acute myocardial infarction. Since the pathogenic development is most likely different for each of these two conditions (one chronic and the other acute) they should be studied separately. H. pylori infection can cause platelet aggregation and induces a procoagulant activity. H. pylori can also contribute to atherosclerosis, through increased concentration of homocysteine in the blood, caused by decreased levels of folic acid and cobalamin, or to an autoimmune process. Prospective cohort studies and interventional trials focusing separately on the chronic and acute phases of coronary heart disease and H. pylori infection should be performed in order to provide firm epidemiological data for a causal relationship.