Severe metabolic alkalosis

In the rat, hypergastrinaemia induced by drug treatment with omeprazole or potent H2-receptor antagonists leads to the development of gastric enterochromaffin-like cell carcinoids. In man, gastric carcinoids induced by hypergastrinaemia have been described only in patients with chronic atrophic gastritis type A and in patients with the multiple endocrine neoplasia syndrome type 1. This patient with Zollinger-Ellison syndrome without gastric mucosal atrophy and without evidence of the multiple endocrine neoplasia syndrome developed an argyrophil gastric carcinoid tumour. This observation indicates that hypergastrinaemia in the sporadic Zollinger-Ellison-syndrome may induce gastric carcinoids.     

Protein patterns of Pasteurella multocida strains in relation to the animal host and the geographic site of isolation]

AIM: Our objective was to document the clinical and pathological findings in eight patients with gastric carcinoids seen in our institution over a 16-year period (1980-96). METHODS: All cases reported during this period as microcarcinoids, atypical carcinoids and mixed carcinoid-carcinoma of the stomach were retrieved from pathology records. Eight cases with typical histologic features of carcinoid were studied. RESULTS: Seven cases were men (median age 53 years, range 35-55). Four patients presented with upper abdominal pain. Serum gastrin level was elevated in two cases. The endoscopic appearances and the endoscopic biopsy histology were not diagnostic. Surgical treatment ranged from simple nodule excision to partial, subtotal or extended gastrectomy and Whipple's pancreatico-duodenectomy. Lymph node and liver metastasis were seen in four patients each. The median duration of follow-up was one year. CONCLUSION: Gastric carcinoids have varied etiopathogenesis. These may arise in a background of hypergastrinemic conditions or may be sporadic. Most appear to be slow growing but aggressive neoplasms are capable of distant metastasis.     

Carcinoid tumors of the colon and rectum

The article gives a review of the literature concerning carcinoid tumours of the colon and rectum. Carcinoid tumours of the rectum are more common than of the colon, although these tumours are rarities. The carcinoid tumour grows slowly and the patients can survive for years with the disease. Treatment of the rectal carcinoid depends on the size and invasiveness of the primary tumour, as a non-invasive tumour less than 2 cm in diameter can be locally excised. For carcinoids of the colon, the treatment of tumours of less than 2 cm and without invasion will be local excision. For larger and/or invasive tumours in both colon and rectum the treatment is resection. The prognosis for colonic carcinoids is worse than for rectal carcinoids. Adjuvant treatment forms are briefly described. Follow-up programmes for these patients are generally long (over five years) and include recto-/colonoscopy, and search for metastatic spread.     

Aggressive forms of gastric neuroendocrine tumors in multiple endocrine neoplasia type I

In recent classifications of gastric endocrine tumors, tumors arising in patients with multiple endocrine neoplasia type 1 (MEN-1) are regarded to be regulated by the concomitant hypergastrinemia resulting from to pancreatic or, most commonly, duodenal gastrinomas and to have a benign behavior. In this article, we report on two cases of MEN-1 gastric neuroendocrine tumors having a fatal course. Case 1 was a young male with hyperparathyroidism and Zollinger-Ellison syndrome and with florid development of multiple gastric carcinoids and multiple duodenal gastrinomas. Metastases occurred in the liver, of exclusive gastric origin, in periduodenal lymph nodes, of exclusive duodenal origin, and in perigastric lymph nodes, of mixed origin. The patient died 48 months after diagnosis. Case 2 was an adult female patient with hyperparathyroidism, adrenocortical disorders, and gastric tumors but no hypergastrinemia. The patient died 3 months after tumor diagnosis. At autopsy, the stomach showed multiple benign carcinoids and two independent neuroendocrine carcinomas not reported before in MEN-1 and massively metastatizing to lymph nodes, liver, and peritoneum. Multiple islet cell tumors mostly producing pancreatic polypeptide were found, whereas gastrinomas were seen in neither the pancreas nor the duodenum. Allelic losses at the MEN-1 gene locus in chromosome 11q13, the mechanism responsible for tumor development in MEN-1 syndrome, were demonstrated in the carcinoid tumors of case 1 and in the neuroendocrine carcinoma of case 2. We conclude that gastric neuroendocrine tumors in patients with MEN-1 may have a poor outcome, they have the same genetic mechanism as MEN-1 tumors in other organs, and they may be independent of the trophic effect of hypergastrinemia.     

Summary of the updated guideline 'Gastric Complaints' of the Dutch College of General Practitioners

The Dutch College of General Practitioners recently updated its guideline 'Gastric complaints'. The main change concerns Helicobacter pylori infection diagnosis and treatment. In cases of functional dyspepsia with Helicobacter infection antibiotic eradication treatment is not advised. In patients with gastric complaints, three working diagnoses are presented: aspecific gastric complaints, ulcer complaints, reflux complaints. Endoscopy is given a more prominent role than in the previous version of the guideline. Criteria are given for discontinuation of unmotivated long-term use of antacid medication.     

Effect of polyethylene on osteocalcin, alkaline phosphatase and procollagen secretion by human osteoblastic cells

BACKGROUND AND STUDY AIMS: Anastomotic leakage is a severe complication in gastric surgery and it is associated with a high rate of mortality. Conservative treatment sometimes is not sufficient to stem the leakages and, even when it is sufficient, it takes a long time. The present study describes the first experience in the treatment of anastomotic leakages with endoscopic clipping. PATIENTS AND METHODS: From May 1995 to December 1996, seven patients with postoperative anastomotic leakages after gastric surgery were prospectively treated in our Endoscopy Service. Metallic endoclips (MD 850, Olympus Corp., Tokyo, Japan) with prongs 12 mm long and 6 mm wide were applied, controlling the closure of the leakage by endoscopy, using radiographs to confirm the closure 24 hours later. RESULTS: Complete closure of the leakage was obtained in all seven cases. A single session of endoscopic clipping was needed for five patients while two other required, respectively, two and three sessions. The median time of leakage closure after endoscopic clipping was 2.3 days (range 1-5 days). The clips spontaneously dislodged within 1 month in five patients and within the second month in the other two patients. CONCLUSION: Endoscopic treatment of anastomotic leakages by metallic clips represents a safe and easily repeated method and, compared to conservative treatment, it seems to offer several time and cost advantages. Further studies involving a larger number of patients are needed to verify this finding.     

Carcinoid tumor associated with vascular malformation as a cause of massive gastric bleeding

Massive gastric bleeding in a 28-yr-old woman requiring emergency surgical treatment was found to originate from a polypoid carcinoid tumor 1.3 cm in diameter. Histologically, the tumor was found to be associated with a complex vascular malformation apparently originating from the underlying submucosa, crossing the tumor and ending in large mucosal sinusoids that opened on the mucosal surface. A similar clinical presentation was reported in three previous cases of small gastric carcinoids, one of which revealed an anomalous intratumoral bleeding artery. We recommend that in the absence of more common causative lesions of gastric bleeding, gastric carcinoid be considered in cases of focal massive hemorrhage requiring emergency treatment.     

Multiple gastric carcinoid, its diagnosis in gastric polyposis (author's transl)

Carcinoid of the stomach, hormonally inactive, is diagnosed with MDP, gastroscopy and biopsy. Solitary carcinoids are treated with excision in toto with immediate histology of the edges. Multiple gastric carcinoids require gastrectomy.     

Sensorineural hearing loss in patients reaching chronic renal failure in childhood

An analysis of 25 patients with carcinoids of the colon (1,94% of the amount of patients with cancer of the colon) was made. In the recent decade this disease has become 2 times more frequent. Sixteen patients had carcinoids of the rectum, 9 patients had carcinoids of the right half of the colon. Malignant carcinoids were diagnosed in 16 cases, 8 of them being located in the right half. Radical operations are recommended for all carcinoids of the right half of the colon and for tumors of the rectum if more than 2 cm.     

Effect of Helicobacter pylori eradication on subsequent development of cancer after endoscopic resection of early gastric cancer

Although epidemiological studies strongly suggest an association between gastric cancer and Helicobacter pylori infection, there has been no clinical report indicating that cure of the infection prevents cancer. We conducted a nonrandomized H. pylori eradication trial in patients whose gastric cancer was removed by endoscopic resection (ER). We investigated the effect of treatment on the histopathology of the gastric mucosa, as well as on the incidence of metachronous gastric cancer during the long-term clinical and endoscopic follow-up. One hundred and thirty-two patients with early gastric cancer underwent ER and had H. pylori infection. Sixty-five (group A) were treated with omeprazole and antibiotics to eradicate the infection, and 67 (group B) were not. All patients were followed for 2 years post ER. After eradication treatment in group A, the disappearance of neutrophil infiltration in the antrum and body of the stomach was observed as was a decrease of the severity of intestinal metaplasia. Endoscopy after ER detected no new gastric cancers in these patients. After 3 years of follow-up, 6 (9%) of the 67 patients in group B had a new early-stage, intestinal-type gastric cancer endoscopically diagnosed. The above results suggest that H. pylori eradication may improve neutrophil infiltration and intestinal metaplasia in the gastric mucosa and inhibit the development of new carcinomas. This finding should be confirmed in a randomized, controlled trial.     

Efficacy of famotidine in the healing of active benign gastric ulceration: comparison of nonsteroidal anti-inflammatory- or aspirin-induced gastric ulcer and idiopathic gastric ulceration. Long Island Jewish Medical Center Acid-Peptic Study Group

Seventy-one of 85 consecutive patients with endoscopically confirmed active benign gastric ulcers completed an 8-week study to evaluate the effects on healing of famotidine 40 mg given as a single dose at night. The healing rate in the 48 patients in whom the ulcers were associated with nonsteroidal anti-inflammatory drug (NSAID) or aspirin (ASA) use was compared with that in the 23 patients with idiopathic ulcers. Endoscopy, symptom assessments, antacid use, hematology, and serum chemistry were performed at weeks 4 and 8 of treatment. Famotidine 40 mg at bedtime healed 63 (89%) of the 71 ulcers at 8 weeks; the healing rate for NSAID/ASA-associated ulcers was 46 (96%) of 48, which was significantly greater than that for idiopathic ulcers (17 of 23; 74%) (P = 0.0119). Of the 54 patients who returned a questionnaire 1 to 2 years after completing the study, 20% were still taking an NSAID/ASA (mainly for cardiovascular prophylaxis). About half of the patients surveyed were taking anti-ulcer medication. None of these patients had experienced any serious ulcer complication. The results of this study suggest that differentiating NSAID/ASA-induced ulcers from idiopathic ulcers may be important with regard to healing rates and duration of therapy.     

Gastrointestinal leishmaniasis in human immunodeficiency virus-infected patients: report of five cases and review

We describe five cases of gastrointestinal leishmaniasis in patients with human immunodeficiency virus infection and review 10 additional cases reported in the literature. All of the patients had CD4+ cell counts of < 200/mm3, and AIDS had been previously diagnosed for 12 patients. Fever and splenomegaly were present in 46% of cases. Thirteen patients had digestive symptoms; these symptoms included diarrhea (6), dysphagia and/or odynophagia (6), abdominal pain (2), epigastric pain (2), gastrointestinal hemorrhage (1), and rectal discomfort (1). The regions of the digestive tract most frequently affected by Leishmania organisms were the duodenal mucosa (90%) and the gastric mucosa (75%). Endoscopy showed normal-appearing mucosa in 45% of cases. In 10 cases the diagnosis of visceral leishmaniasis was first made by biopsy of the gastrointestinal mucosa. In most cases treatment with antimonial agents was not effective.     

Comparison of 24-h control of gastric acidity by three different dosages of pantoprazole in patients with duodenal ulcer

BACKGROUND: It is now clear that the extent to which gastric acid secretion must be suppressed varies with the clinical condition being treated. AIM: To assess the 24-h control of gastric acidity and the individual response variability of three different doses of pantoprazole. METHODS: Sixty-four duodenal ulcer patients were recruited for this prospective, randomized, multicentre, double-blind, parallel-group study. They were subdivided into three well-matched groups treated with 20 mg o.m., 40 mg o.m. and 40 mg b.d. of pantoprazole, respectively. Endoscopy and intragastric pH monitoring were performed in each patient before and after 14 days of treatment. RESULTS: Fifty-five patients were eligible for final analysis (17 treated with 20 mg o.m., 18 with 40 mg o.m. and 20 with 40 mg b.d. pantoprazole). The ulcer crater healed in 94, 88 and 95% of cases, respectively. The three dosages of pantoprazole produced significant increases in gastric pH compared to basal levels (P < 0.0001). There was also a clear dose-dependent pharmacodynamic effect, which augmented on moving from the lowest dosage of 20 mg o.m. pantoprazole to the highest dosage of 40 mg b.d. (P < 0.01-0.001). The inter-individual response variability within the three treatment groups was more marked with the dose of 20 mg than with the two higher doses of pantoprazole. CONCLUSIONS: All three doses of pantoprazole we tested are highly effective in decreasing gastric acidity and there is a clear dose-dependent pharmacodynamic effect on moving from the lowest to the highest dosage. The greatest inter individual variation in the degree of acid inhibition was seen with pantoprazole 20 mg o.m., while the majority of patients responded adequately to the two higher doses of the drug.     

Gastric intramucosal pH: an indicator of weaning outcome from mechanical ventilation in COPD patients

The aim of this study was to determine whether gastric intramucosal pH (pHim) and/or gastric intramucosal carbon dioxide tension (PCO2,im) measured by tonometry can be used to predict the success of weaning in chronic obstructive pulmonary disease (COPD) patients. Twenty six consecutive COPD patients, undergoing mechanical ventilation for acute respiratory failure and satisfying the criteria of weaning from mechanical ventilation with nasogastric tonometer in place, were studied. Arterial blood gas values and PCO2,im were measured 24 h before (H-24), just before (H0), and after 20 min of a weaning trial on T-piece (H20min). Weaning failure was defined as the development of respiratory distress and/or arterial blood gas impairments during the first 2 h of spontaneous breathing on T-piece, or reintubation within 24 h after extubation. Between the weaning failure (n = 6) and weaning success (n = 20) groups, there were no differences in blood gas analysis readings at H-24 and H0 before the weaning period, age, Simplified Acute Physiology Score (SAPS) on admission, SAPS on the day of weaning trial, and duration of ventilation. Clinical status, tonometric and arterial gasometric data were similar at H-24 and H0 in all patients. During mechanical ventilation, pHim was < or = 7.30 in patients who failed weaning and > 7.30 in patients who were successfully weaned (p < 0.001; 100% sensitivity and specificity). The threshold value for PCO2,im of 8.0 kPa (60 mmHg) represents a clear demarcation with respect to outcome before the weaning trial. PCO2,im values during mechanical ventilation are significantly different (p < 0.001) between patients who were successfully weaned and those who were not (6.9 +/- 0.9 vs 9.9 +/- 1.1 kPa (51.9 +/- 6.7 vs 74.3 +/- 8.0 mmHg, respectively)). At H20min, pHim and PCO2,im were still statistically different between the weaning failure and the weaning success group. We conclude that measurement of gastric intramucosal pH (or gastric intramucosal carbon dioxide tension) represents a simple and accurate index to predict weaning outcome in chronic obstructive pulmonary disease patients before attempting weaning.     

Acute gastritis associated with infection of large spiral-shaped bacteria

We report a case of gastric colonization of large spiral-shaped bacteria in a patient with acute gastritis. Endoscopy showed an acute erosive and hemorrhagic gastroduodenitis. Histopathological examination of antral biopsies revealed intense neutrophil infiltrates with microabscesses. Numerous large spiral-shaped bacteria were seen in the Gram-stained smear of the gastric biopsy. The patient was treated with colloidal bismuth subcitrate and cimetidine. Biopsy taken after treatment showed resolution of infection and histological gastritis. The results provide further evidence that large spiral-shaped bacteria are another infective cause of acute neutrophilic gastritis in humans.     

Gastric pacing improves emptying and symptoms in patients with gastroparesis

BACKGROUND & AIMS: No effective treatment is available for patients with gastroparesis refractory to standard medical therapy. The aim of this study was to investigate the effects of gastric pacing on gastric electrical activity, gastric emptying, and symptoms in patients with gastroparesis. METHODS: Nine patients with gastroparesis participated in this study. Four pairs of cardiac pacing wires were implanted on the serosa of the stomach. The protocol consisted of two portions: a temporary inpatient study period and an outpatient study for a period of 1 month or more. RESULTS: Gastric pacing entrained the gastric slow wave in all subjects and converted tachygastria in 2 patients into regular 3-cpm slow waves. Gastric emptying was significantly improved after the outpatient treatment with gastric pacing. The gastric retention at 2 hours was reduced from 77.0% +/- 3.3% to 56.6% +/- 8.6% (P < 0.05). Symptoms of gastroparesis were substantially reduced at the end of the outpatient treatment (1.51 +/- 0.46 vs. 2.84 +/- 0.61; P < 0.04). Eight of 9 patients no longer relied on jejunostomy tube feeding, and no adverse events were noted related to the pacing unit. CONCLUSIONS: Gastric pacing seems to be able to improve symptoms of gastroparesis and to accelerate gastric emptying in patients with gastroparesis. More controlled studies are necessary to further investigate the role of gastric pacing in clinical practice.     

One-day therapy for treatment of Helicobacter pylori infection

The present study evaluated the effect of a one-day high-dose combined therapy on Helicobacter pylori infection. Thirty-two consecutive patients (suffering from either peptic ulcer or nonulcer dyspepsia) with Helicobacter pylori infection received omeprazole (40 mg) + bismuth subcitrate (240 mg x 4) + amoxicillin suspension (2000 mg x 4) + metronidazole (500 mg x 4), for only one day. Endoscopy, histology, culture, and susceptibility studies were done at entry and 30 and 90 days after the treatment day. Successful eradication was obtained in 23/32 (72%) patients and gastritis had resolved in 95% of these. Side effects were induced by the treatment in 6/32 (19%) patients, but these were all self-limiting, short-lasting, and did not require any specific treatment. Development of bacterial resistance to metronidazole occurred in 6/9 (67%) non-eradicated patients. These data suggest that one-day treatment with high doses of amoxicillin, metronidazole, bismuth, and omeprazole represents an effective, safe, and inexpensive therapeutic approach for the treatment of H. pylori infection.     

Somatostatin receptor subtypes, octreotide scintigraphy, and clinical response to octreotide treatment in patients with neuroendocrine tumors

Several types of neuroendocrine tumor express high numbers of somatostatin receptors (sstr). We have compared the expression of sstr subtypes with the outcome of octreotide scintigraphy in patients with carcinoids and medullary thyroid carcinoma (MTC) in comparison with Hürthle cell tumors. The effect of sstr activation (octreotide treatment) on tumor markers was also studied in patients with disseminated carcinoid tumors. Six patients with carcinoid tumors (four midgut and two foregut), and three patients with thyroid tumors (one MTC, one Hürthle cell carcinoma, and one Hürthle cell adenoma) were studied. Octreotide scintigraphy visualized tumor sites in all nine patients. Macroscopic tumor was verified at these sites at subsequent surgical exploration. Using Northern blotting and subtype-specific riboprobes, sstr could be detected in all tumors examined. All five sstr subtypes were detected in most of the carcinoid tumors. All six carcinoids expressed sstr2. This was in contrast to the findings for the thyroid tumors analyzed, which also expressed several sstr subtypes but in some cases lacked expression of sstr2. This was also the case for normal thyroid tissue. Clinically, octreotide treatment of the patients with midgut carcinoid tumors resulted in palliation of hormonal symptoms accompanied by a significant reduction of urinary 5-HIAA levels (28-71%). These results indicate that carcinoid tumors frequently express all five sstr subtypes. The thyroid tumors also expressed multiple sstr but could lack expression of sstr2. Nevertheless, these tumors were visualized by octreotide scintigraphy, indicating that sstr2 expression is not a prerequisite for tumor imaging.     

Characterization of the neurochemical effects of N-[2-(1-azabicyclo[3,3,0]octan-5-yl)ethyl]2-nitroaniline fumarate (SK-946) as a cognition activator

BACKGROUND: This study characterized the phenotypic subsets of isolated gastric lymphocytes and the cellular immune response in cultured gastric biopsy specimens. METHODS: Endoscopy specimens from 40 Helicobacter pylori-positive and 40 H. pylori-negative patients were studied. a) Isolated gastric lymphocytes were analysed for CD4+, CD8+ T-lymphocyte subsets, activated T cells, and natural killer cells on a fluorescence-activated cell sorter, using monoclonal antibodies. b) The supernatant of cultured gastric biopsy specimens were assayed for interleukin (IL)-2, IL-4, and IL-6 levels. RESULTS: In H. pylori-positive patients there was (a) a decrease in CD4+/CD8+ T cells, no change in activated T cells, and an increase in natural killer cells, and (b) no change in IL-2 levels and a significant increase in IL-4 and IL-6 levels. CONCLUSIONS: There is an increase in CD8+ lymphocytes and natural killer cells, and the observed increase in IL-4 and IL-6 might be important in H. pylori-associated gastritis.     

The hidden illness of endoscopy patients: mental health disorders, Part I

Because nearly half of all adults experience some mental health disorders in their lifetime, many endoscopy patients must have psychiatric problems along with their gastrointestinal (GI) illnesses. In addition, all patients undergoing an endoscopic procedure experiences some degree of apprehension and worry; anxiety itself is a major factor in most mental illnesses. Endoscopy nurses are very good at establishing rapport quickly with patients and learning about the patient's health history from all the available sources of information. These nurses spend much of their time teaching, listening, reassuring, and caring for people undergoing GI procedure, and these same skills are an important part of the care in mental health disorders. A series of case studies of GI patients in a busy endoscopy department document and summarize the mental health disorder each experienced and the pertinent care given by the GI nurse during an endoscopy or gastric laboratory procedure. Although it is inappropriate for endoscopy nurses to attempt to diagnose major psychiatric disease or provide psychiatric interventions for these patients, their nursing care and reassurance enable the patients to successfully complete their GI procedures.