Methanobrevibacter smithii Is the Predominant Methanogen in Patients with Constipation-Predominant IBS and Methane on Breath

Purpose

Among irritable bowel syndrome (IBS) patients, breath methane producers overwhelmingly have constipation predominance (C-IBS). Although the most common methanogen in humans is Methanobrevibacter smithii, incidence and type of methanogenic bacteria in C-IBS patients are unknown.

Methods

By use of a questionnaire and lactulose breath testing, subjects with Rome II C-IBS and methane (>3?ppm) were selected (n?=?9). The control group included subjects with IBS who had no breath methane (n?=?10). Presence of bacterial DNA was assessed in a stool sample of each subject by quantitative-PCR using universal 16S rDNA primer. M. smithii was quantified by use of a specific rpoB gene primer.

Results

M. smithii was detected in both methane and non-methane subjects. However, counts and relative proportion of M. smithii were significantly higher for methane-positive than for methane-negative subjects (1.8?×?10⁷?±?3.0?×?10⁷ vs 3.2?×?10⁵?±?7.6?×?10⁵?copies/g wet stool, P?<?0.001; and 7.1?±?6.3?% vs 0.24?±?0.47?%, P?=?0.02 respectively). The minimum threshold of M. smithii resulting in positive lactulose breath testing for methane was 4.2?×?10⁵?copies/g wet stool or 1.2?% of total stool bacteria. Finally, area-under-curve for breath methane correlated significantly with both absolute quantity and percentage of M. smithii in stool (R?=?0.76; P?<?0.001 and R?=?0.77; P?<?0.001 respectively).

Conclusions

M. smithii is the predominant methanogen in C-IBS patients with methane on breath testing. The number and proportion of M. smithii in stool correlate well with amount of breath methane.     

Neomycin Improves Constipation-Predominant Irritable Bowel Syndrome in a Fashion That Is Dependent on the Presence of Methane Gas: Subanalysis of a Double-Blind Randomized Controlled Study

Recent studies have shown that normalization of the lactulose breath test (LBT) with neomycin leads to a significant reduction in irritable bowel syndrome (IBS) symptoms. This subanalysis was done on the constipation-predominant IBS subgroup of patients (C-IBS) to test the ability of neomycin to improve constipation and its correlation with the elimination of methane on breath test. IBS subjects underwent LBT in a blinded fashion. They were then randomly allocated to neomycin or placebo groups. For the purpose of this analysis, only the C-IBS subjects were identified. They were then evaluated for global improvement, abdominal pain, and constipation severity. The ability of neomycin to eliminate methane and its associated improvement in constipation was also determined. One hundred eleven subjects meeting Rome I criteria for IBS were included in the study. Thirty-nine of these had C-IBS. Of these, 20 received placebo and 19 received neomycin. With neomycin, a global improvement of 36.7±7.9% was seen, compared to 5.0±3.2% for placebo (P < .001) in the intention-to-treat analysis. Constipation was improved by 32.6±9.9% with neomycin compared to 18.7±7.2% for placebo (P=.26). Of the original 111 subjects, 12 demonstrated methane on breath test. All 12 of these patients were constipation predominant. In the methane producers receiving neomycin or placebo, improvement in constipation was significantly greater in those receiving neomycin (44.0±12.3%) compared to placebo (5.0±5.1%) (P < .05). Treatment with neomycin improves constipation in C-IBS. This improvement depends on the presence and elimination of methane on breath test.     

Management of chronic constipation in general practice

Background

Chronic constipation is often diagnosed and treated by general practitioners (GPs). The aim of the study was to evaluate the management of constipation by a cohort of Italian GPs.

Methods

Over the course of 1 month, 41 GPs recorded tests and therapies suggested to patients complaining of chronic constipation. They were classified according to the Rome III criteria as constipated irritable bowel syndrome (C-IBS), functional constipation (FC), or “self-perceived constipation” (SPC) (not consistent with the Rome criteria).

Results

The most frequently prescribed tests for the 229 patients (147 FC, 50 C-IBS, 32 SPC) were routine blood tests (59.3 %), abdominal ultrasounds (37.2 %), thyroid function (36.7 %), fecal occult blood tests (36.7 %), and tumor markers (35 %). Patient sex and age, GP age, and whether the diagnosis was new influenced the GP’s request, but FC, C-IBS, or SPC status did not. Dietary suggestions (81.9 %), fiber supplements (59.7 %), reassurance (50.9 %), and laxatives (30.5 %) were the most frequently prescribed treatments. Antispasmodics were more frequently suggested for C-IBS patients; dietary suggestions, fiber, and enemas were more frequently prescribed in SPC patients. Patient and GP age and whether the diagnosis was new influenced the GP’s choice of treatment.

Conclusions

The Rome III criteria do not influence diagnostic strategies and only slightly influence therapeutic strategies of GPs. Other factors (age, gender, new or old diagnosis) have more influence on GPs choice of investigations and treatment.     

Small Intestinal Bacterial Overgrowth in Gastroparesis

Objective

To determine symptoms of small intestinal bacterial overgrowth (SIBO) in gastroparesis patients.

Methods

Patients undergoing LBT (lactulose breath test) for evaluation of SIBO were included. LBT was considered positive on the basis of three conventional criteria: (1) hydrogen level increase >20 ppm above baseline by 90 min (H2@90min); (2) dual hydrogen peaks (>10 ppm increase over baseline before second peak >20 ppm (DPHBT); and (3) breath methane increase of >20 ppm above baseline by 90 min. Results of gastric emptying scintigraphy (GES) were recorded. Patients completed the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index.

Results

Of 740 patients who underwent LBT from December 2009 to August 2011, 471 underwent GES, with 201 having delayed GES. Of patients with delayed GES who underwent LBT 87 % were female, 23 % diabetic, 49 % used gastric acid suppressants, 29 % used opiate analgesics, 35 % used pro-motility medications, and 27 % had a history of gastrointestinal surgery. Overall, 79 (39 %) patients with gastroparesis had evidence of SIBO by LBT: 30 (15 %) had positive H2@90min, 53 (26 %) positive DPHBT, and 6 (3 %) positive breath methane test. In gastroparesis patients with positive H2@90min, there was increased severity of bloating (3.80 ± 0.20 vs 3.29 ± 0.12; P = 0.02), early satiety (3.57 ± 0.27 vs 3.05 ± 0.13; P = 0.045), and postprandial fullness (4.20 ± 0.18 vs 3.52 ± 0.12; P < 0.01) compared with negative H2@90min patients. No significant difference in symptom severity was seen between positive and negative DPHBT gastroparesis patients.

Conclusion

In our cohort, 39 % of gastroparesis patients tested positive for SIBO by LBT. Positive H2@90min testing by LBT was associated with increased symptoms of bloating and excessive fullness during and after meals.     

The Effect of Rifaximin on Gut Flora and Staphylococcus Resistance

Aim

Rifaximin is a non-absorbed antibiotic relative of rifampicin. The location of effect and staphylococcal resistance are two recent potential concerns with rifaximin. In this study we evaluate the location of effect of rifaximin as well as the development of staphylococcal rifampicin resistance.

Methods

Rats were divided into three groups. Group 1 gavaged for 10 days with PBS, group 2 gavaged with rifaximin for 10 days, and group 3 gavaged with rifaximin for 10 days and housed for 30 days. In each group, stool was collected daily for quantitative culture of Staphylococcus spp. and coliforms. After euthanasia luminal bacterial counts were determined at multiple gut locations by qPCR. Rifampicin susceptibility was tested on Staphylococcus pre and post rifaximin.

Results

At baseline, rats had a median of 2.90 × 10⁶ cfu/ml Staphylococcus spp. in stool. After 10 days of rifaximin, this dropped to 1.20 × 10⁵ cfu/ml (P < 0.01). With coliform counts, rats had a median of 1.86 × 10⁴ cfu/ml at baseline which dropped to 2.2 × 10³ cfu/ml (P < 0.01) after rifaximin. After cessation of rifaximin, coliform counts recovered within 3 days. When examining the total bacterial counts by qPCR, rifaximin reduced small bowel bacterial levels, but not colon. This reduction was sustained for 30 days. No colonies of Staphylococcus became resistant and only one colony was intermediate. The mean inhibitory concentration for rifampicin was not different before and after rifaximin.

Conclusion

Staphylococcal spp. fail to demonstrate resistance to rifampicin after rifaximin. The transient reductions in stool coliform counts recover while rifaximin appears to produce durable reductions in duodenal bacteria.     

Morphological Abnormalities of the Recto-Anal Inhibitory Reflex Reflects Symptom Pattern in Neurogenic Bowel

Background

Bowel dysfunction amongst multiple sclerosis (MS) and spinal cord injury (SCI) patients often manifests as fecal incontinence (FI) or constipation, but the pathophysiology is poorly understood. Anorectal physiology provides an objective assessment of lower bowel functions and is increasingly being used in clinical practice.

Aim

The purpose of this study was to correlate symptoms of bowel dysfunction in patients with spinal cord disease with findings in anorectal physiology. We hypothesized that specific abnormalities will correlate with symptoms: prolonged recto-anal inhibitory reflex in patients with incontinence and decreased rectal mucosal blood flow in patients with constipation.

Methods

Forty-nine patients with MS (35 with predominant FI and 14 constipation), 46 supraconal SCI (mixed symptom load), and 21 healthy volunteers matched for age and sex were studied. Subjects completed validated constipation and FI symptom questionnaires. Patients underwent standard anorectal physiology, including assessment of rectal mucosal blood flow and recto-anal inhibitory reflex (RAIR).

Results

Severity of constipation correlates significantly with distension sensitivity (urge volume [r = 0.68, p = 0.002] and maximal volume [r = 0.39, p = 0.03]). Severity of constipation also correlated with diminished rectal mucosal blood flow in both patient groups (r = ?0.51, p = 0.006). In both groups, constipation correlated with diminished relaxation of the sphincters in the RAIR whilst fecal incontinence correlated with a prolonged duration of RAIR (r = 0.33, p = 0.009) and recovery phase (r = 0.37, p = 0.05).

Conclusion

Bowel symptoms in patients with MS and SCI correlate with specific alterations of anorectal physiology. This provides objective assessment of bowel symptoms and may allow tailored treatment to individual patients.     

Clinical and Virological Characteristics Post HBsAg Seroclearance in Hepatitis B Virus Carriers With Hepatic Steatosis Versus Those Without

Background

It has been suggested hepatic steatosis contributes to seroclearance of hepatitis B surface antigen (HBsAg) in chronic hepatitis B virus (HBV) infection. Although HBsAg seroclearance generally confers favorable outcome, hepatic steatosis may account for progressive liver fibrosis and cirrhosis. Further studies are needed to compare clinical and virological characteristics post HBsAg seroclearance between subjects with hepatic steatosis and those without.

Methods

One-hundred and fifty-five HBsAg carriers with HBsAg seroclearance were enrolled. Subjects with moderate–severe hepatic steatosis as diagnosed by ultrasonography were designated as having hepatic steatosis.

Results

There were 69 subjects with hepatic steatosis and 86 without. Subjects with hepatic steatosis had significantly higher body mass index (BMI; 27.8 ± 3.5 vs. 23.0 ± 3.1, P < 0.001), were more likely to be male (78.3 vs. 63.9 %, P = 0.05), and were significantly younger at HBsAg seroclearance (48.7 ± 8.9 years vs. 53.4 ± 8.9 years, P = 0.001), than those without. The frequency of anti-HBsAg seroconversion (56.5 vs. 59.3 %, P = 0.72) and HBV viremia (20.3 vs. 15.1 %, P = 0.40) was not significantly different between subjects with and without hepatic steatosis, but the incidence of abnormal AST and ALT was significantly higher in the former (23.2 vs. 0 %, P < 0.0001; and 30.4 vs. 0 %, P < 0.0001, respectively), and progression to liver cirrhosis tended to be more likely in the former than in the latter (10.1 vs. 3.5 %, P = 0.09).

Conclusions

In HBsAg carriers with increased body mass index, hepatic steatosis can accelerate HBsAg seroclearance by approximately 5 years. However, the beneficial effects of HBsAg seroclearance should be balanced against the harmful effects of hepatic steatosis.     

Colorectal motor and sensory function after hysterectomy

Purpose

Women may develop constipation after hysterectomy. The pathophysiology and underlying mechanisms are poorly understood. They may originate from either neural damage of rectum and colon or changes in anatomical constellation of the remaining pelvic organs. The aim of this study is to evaluate sensory and motor functions of rectum and colon in women with newly developed constipation after hysterectomy in comparison with women without constipation and healthy controls after hysterectomy .

Methods

Barostat measurements were performed in posthysterectomy women with constipation (PH-C), without constipation (PH-NC), and healthy controls (n?=?10, every group). Outcome measures were rectal and colonic compliance (millilitre per millimetre of mercury), rectocolonic perception in reaction to mechanical distension (millimetre; VAS scores) and rectocolonic reflex (millilitre per millimetre of mercury).

Results

No differences in rectal or colonic compliance were observed. Urge perception due to rectal distension increased significantly in controls (from 7?±?5 to 41?±?10 mm; p?<?0.05) and PH-NC group (from 3?±?1 to 24?±?9 mm; p?<?0.05), but not in PH-C patients (1?±?1 to 11?±?5 mm; ns). In healthy controls and the PN-NC group, respectively, 100 and 70 % of subjects reached the minimal threshold value for urge of 10 mm during the isobaric distension sequence. In the PH-C group, only two subjects (20 %) reached this threshold (p?<?0.05). Rectal pain perception, phasic colonic motility and the rectocolonic reflex were intact in all three groups.

Conclusions

Colorectal motor and sensory function is generally well preserved in women with constipation after hysterectomy. It is unlikely that the symptom of constipation after hysterectomy has been caused by iatrogenic neuronal damage in these patients.     

Partially Hydrolyzed Guar Gum Accelerates Colonic Transit Time and Improves Symptoms in Adults with Chronic Constipation

Background and Aim

Partially hydrolyzed guar gum (PHGG) is a water-soluble, non-gelling dietary fiber with a wide range of uses in clinical nutrition. The aim of this prospective study was to investigate the effect of guar gum on colonic transit time (CTT) and symptoms of chronic constipation.

Methods

We enrolled patients fulfilling Rome III criteria for chronic constipation. CTT was measured before and at the end of treatment. After a 2-week run-in period, patients received 5 mg PHGG daily for 4 weeks. During study period, patients kept daily symptoms, stool and laxative usage diaries. They also recorded their symptom-related satisfaction weekly and treatment adverse events.

Results

Forty-nine patients received treatment; 39 (80 %) completed the study. Treatment significantly reduced colon transit time, from 57.28 ± 39.25 to 45.63 ± 37.27 h (p = 0.026), a reduction more prominent in slow transit patients (from 85.50 ± 27.75 to 63.65 ± 38.11 h, p = 0.016). Overall, the weekly number of complete spontaneous and spontaneous bowel movements increased significantly (p < 0.001); the latter correlated significantly with the acceleration of CTT in the overall population and in slow transit patients (B = 0.382; p = 0.016 and B = 0.483; p = 0.023, respectively). In addition, the number of bowel movements with straining decreased (p < 0.001) and stool form improved (p < 0.001), while days with laxative intake and days with abdominal pain decreased (p = 0.001 and p = 0.027, respectively).

Conclusion

Four-week PHGG use accelerates colon transit time in patients with chronic constipation, especially in those with slow transit, and improves many of their symptoms including frequency of bowel movements.     

Increased Platelet Binding to Circulating Monocytes in Idiopathic Pulmonary Fibrosis

Purpose

Idiopathic pulmonary fibrosis (IPF) is the most common idiopathic interstitial pneumonia and its prognosis is poor. Epidemiological evidence suggests an association of IPF with vascular disease and thrombotic tendency, which may be related to platelet activation.

Methods

Platelet–monocyte adhesion in peripheral blood was examined by flow cytometry in patients with IPF (n = 19), interstitial lung disease (ILD) other than IPF (n = 9), and control subjects without pulmonary fibrosis (n = 14). Expression of platelet activation markers P-selectin (CD62P), PSGL-1 (CD162), and CD40 ligand (CD40L) on leukocytes and platelets were studied. Plasma concentrations of soluble P-selectin and CD40L were measured by ELISA.

Results

Significantly elevated levels of platelet–monocyte binding were found in patients with IPF (35.6 ± 4.34 % [mean ± SEM]) compared with patients with non-IPF ILD (23.5 ± 3.68 %) and non-ILD control subjects (16.5 ± 2.26 %; P < 0.01). There was a trend towards increased divalent cation-independent platelet–monocyte binding in IPF (6.0 ± 0.77 % [mean ± SEM]) compared with non-IPF ILD (4.3 ± 1.38 %) and control subjects without ILD (3.1 ± 1.75 %; P = 0.058). There was no differential surface expression of platelet activation markers on subsets of leukocytes or platelets. Plasma concentrations of CD40L and soluble P-selectin did not differ between IPF and control subjects. Platelet–monocyte binding had no significant correlation with percent predicted TLco or FVC.

Conclusions

Platelet–monocyte binding is increased in IPF, suggesting increased platelet activation. This conjugation is predominantly calcium-dependent, but there may be more calcium-independent adhesion in IPF. These findings support further research into the role of platelet activation in IPF.     

Exercise Capacity and Ventilatory Response During Exercise in COPD Patients With and Without β Blockade

Background

Although β blockade (BB) in patients with chronic obstructive pulmonary disease (COPD) does not show signs of worsening pulmonary function or respiratory symptoms, the effects on cardiopulmonary exercise testing (CPET) remain unclear. The aim of this study was to determine whether BB affects exercise capacity, gas exchange, and hemodynamic responses in patients with COPD.

Methods

Twenty-four COPD subjects on BB were matched to 24 COPD subjects without BB according to age, gender, body mass index, and severity of COPD. All subjects underwent resting pulmonary function and symptom-limited CPET.

Results

Comparing COPD patients with and without BB revealed that percent peak oxygen consumption and VE/VCO₂ nadir were not significantly different (45 ± 16 vs. 51 ± 23 %, p = 0.30, and 35.1 ± 8.5 vs. 36.2 ± 11.6 %, p = 0.69). Systolic blood pressure and heart rate at peak exercise were significantly decreased in COPD patients with BB (168 ± 16 vs. 185 ± 20 mmHg, and 109 ± 16 vs. 122 ± 14 bpm, respectively, p < 0.05).

Conclusion

Exercise capacity and gas exchange remain unaffected in patients with COPD in the presence of BB, although heart rate and blood pressure are lower. These findings imply that BB does not adversely affect functional capacity in patients with COPD.     

Decreased Prohepcidin Levels in Patients with HBV-Related Liver Disease: Relation with Ferritin Levels

Background

Levels of prohepcidin, a homeostatic regulator of iron absorption, are altered in chronic hepatitis C and liver cirrhosis. However, data on the potential alterations of prohepcidin in patients with HBV-related liver disease are scarce. We investigated whether serum prohepcidin is related to iron overload and perenchymal dysfuction in HBV-related liver disease.

Methods

Three groups of subjects were studied: 66 patients with chronic hepatitis B, 32 patients with HBV-related cirrhosis, and 42 healthy controls without evidence of liver disease. Serum levels of prohepcidin were determined by enzyme-linked immunosorbent assay.

Results

Serum prohepcidin levels were significantly lower in patients with HBV-related cirrhosis (175.85 ± 71.5 ng/ml) than in patients with chronic hepatitis B (209.02 ± 62.7 ng/ml P < 0.05) and controls (222.4 ± 128.4 ng/ml, P < 0.05). After adjustment for potential confounders, prohepcidin was found to be an independent predictor of ferritin levels in multiple linear regression analysis (β = ?1.10, t = ?3.11, P < 0.01).

Conclusion

These results demonstrate that prohepcidin levels are reduced in patients with HBV-related cirrhosis and are an independent correlate of serum ferritin.     

No Significant Association Between Vitamin D and Nonalcoholic Fatty Liver Disease in a Chinese Population

Background

Some research evidence from Western populations suggests that lower vitamin D is associated with the prevalence and histologically assessed severity of nonalcoholic fatty liver disease (NAFLD).

Aims

To investigate the associations of serum 25-hydroxyvitamin D [25(OH)D] concentrations and vitamin D status (deficiency <20 ng/ml; insufficiency 20–30 ng/ml; sufficiency >30 ng/ml) with the prevalence of NAFLD in study population of Chinese.

Methods

Serum 25(OH)D, parathyroid hormone, lipids, liver enzymes, and anthropometric characteristics were measured in 1,248 subjects aged ≥20 years. NAFLD was diagnosed using abdominal ultrasound examination.

Results

The prevalence of NAFLD was 30.3 % in the total study population, 37.9 % in the male subjects, and 20.8 % in the female subjects (P < 0.0001). Subjects with NAFLD had a significantly higher body mass index, higher levels of fasting blood glucose and liver enzymes, and a more atherogenic lipid profile. However, serum 25(OH)D concentrations were not significantly different between subjects with and without NAFLD (22.1 vs. 22.8 ng/ml, respectively; P = 0.21). In addition, a 10 ng/ml higher serum 25(OH)D concentrations [odds ratio (OR) 1.02, 95 % confidence interval (CI) 0.84–1.25, P = 0.82] or vitamin D status (vs. sufficiency: deficiency OR 0.86, 95 % CI 0.54–1.37, P = 0.52; insufficiency OR 0.96, 95 % CI 0.61–1.52, P = 0.87) were not significantly associated with the presence of NAFLD in the multivariate logistic regression analyses.

Conclusions

Serum 25(OH)D concentrations or vitamin D status were not significantly associated with the presence of NAFLD. More studies are needed to elucidate the relationship between vitamin D and the occurrence of NAFLD in Chinese.     

Portal hemodynamics and clinical outcomes of patients with gastric varices after balloon-occluded retrograde transvenous obliteration

Background

Long-term hemodynamic effects and clinical outcomes after balloon-occluded retrograde transvenous obliteration (B-RTO) remain unclear. The purpose of this study was to evaluate long-term clinical results and effects on portal hemodynamics after B-RTO for the treatment of gastric varices with spontaneous gastrorenal shunt.

Methods

A total of 21 patients with cirrhosis and gastric varices treated by B-RTO were evaluated. The cumulative survival rate was calculated, portal blood flow was measured by Doppler ultrasonography, and liver function was estimated on the basis of Child-Pugh classification before and 1 year after B-RTO.

Results

Gastric varices disappeared or decreased markedly in size in all patients. Overall cumulative survival rates at 1, 3 and 5 years were 90.48, 71.11 and 53.71%, respectively. Portal blood flow increased significantly from 681.9 ± 294.9 to 837.0 ± 279.1 ml/min (P = 0.0125) after B-RTO. Child-Pugh score was not significantly changed (P = 0.755) after obliteration, but serum albumin was elevated significantly from 3.49 ± 0.49 to 3.75 ± 0.53 g/dl (P = 0.0459). The ascites score was significantly increased (P = 0.0455) after B-RTO, but all cases of ascites could be controlled with medication.

Conclusions

Balloon-occluded retrograde transvenous obliteration is a safe and effective treatment for gastric varices with gastrorenal shunt. Portal blood flow and serum albumin parameters are increased, and liver function is unchanged after B-RTO.     

Combined multichannel intraluminal impedance and pH monitoring assists the diagnosis of sliding hiatal hernia in children with gastroesophageal reflux disease

Background

The role of combined multichannel intraluminal impedance and pH monitoring (MII-pH) in diagnosing sliding hiatal hernia in gastroesophageal reflux disease (GERD) children remains unclear. We aimed to explore the clinical efficacy of MII-pH as a supplement diagnostic method for sliding hiatal hernia.

Methods

A total of 104 symptomatic GERD children [mean ± standard deviation (SD) age = 4.5 ± 5.5 years] were recruited. All of them were diagnosed as GERD with and without sliding hiatal hernia by barium and/or esophagogastroduodenoscopy study. All subjects received 24 h MII-pH monitoring to test the efficacy of this new modality.

Results

Sixteen children were diagnosed to have sliding hiatal hernia, and nine (56.3 %) of them received fundoplication. None of non-hiatal hernia children were indicated for fundoplication [risk difference (RD) 0.56; P < 0.001]. Impedance probes detected more reflux episodes than pH-probe in the whole study population (mean ± SD = 62.1 ± 47.8 vs. 47.8 ± 48.1 episodes; P = 0.02, paired t test). Due to the presence of pH-only reflux, the reflux episodes detected by impedance probes is less than that by pH probe in sliding hiatal hernia children (mean ± SD = 49.2 ± 78.9 vs. 103.7 ± 60.4 episodes; P = 0.01, paired t test). Ratio of reflux episodes detected by pH-probe to that by impedance probes >1 was more frequently noted in sliding hiatal hernia children than non-sliding hiatal hernia children (Odds ratio 58.33, P < 0.001). The sensitivity and specificity of this diagnostic tool to predict sliding hiatal hernia in GERD children are 93.8 and 79.6 %, respectively.

Conclusions

Ratio of reflux episodes detected by pH-probe to that by impedance probes >1 demonstrated by MII-pH study is a good screening test of sliding hiatal hernia in GERD children.     

Regulatory Role of CD4+CD25+Foxp3+ Regulatory T Cells on IL-17-Secreting T Cells in Chronic Hepatitis B Patients

Background

Both interleukin (IL)-17-secreting CD4⁺ T (Th17) and CD4⁺CD25⁺Foxp3⁺ T regulatory (Treg) cells have been shown to be associated with disease progression or liver damage in chronic hepatitis B (CHB) patients. However, the relationship between Treg cells and IL-17-secreting T cells in hepatitis B virus (HBV) infections is unclear.

Methods

The frequencies of Treg cells and IL-17-secreting T cells in hepatitis B e antigen (HBeAg)-positive CHB patients and healthy subjects were measured by flow cytometric analysis. The role of Treg cells on the differentiation of Ag-specific IL-17-secreting T cells was determined by removing the Treg cells from peripheral blood mononuclear cells (PBMCs) in HBeAg-positive CHB patients.

Results

The frequencies of both Th17 (1.71 ± 0.58 vs. 1.08 ± 0.36 %; P < 0.01) and Treg cells (8.92 ± 4.11 vs. 6.45 ± 1.56 %; P < 0.01) were increased in the peripheral blood of HBeAg-positive CHB patients compared with healthy controls, but in not the IL-17-secreting CD8⁺ T (Tc17) cells. The frequency of Treg cells was significantly associated with that of Th17 cells (r = 0.625, P = 0.001) in CHB patients. Spearman analysis showed a positive correlation between the frequency of Treg cells and HBV DNA load (r = 0.508, P = 0.008), as well as between the frequency of Th17 cells and serum alanine aminotransferase level (r = 0.516, P = 0.007). The deletion of Treg cells significantly enhanced both Th17 and Tc17 cell development in PBMCs following recombinant HBV core antigen stimulation.

Conclusions

Our data indicate a clear inverse relationship between Th17 cells and Treg cells and that Treg cells can inhibit Th17 cell development in CHB patients.     

Role of serum dehydroepiandrosterone sulfate level on the clearance of chronic hepatitis B virus infection

Background

The natural course of chronic hepatitis B virus (HBV) infection and relevant host factors remain unclear. This study aims to investigate the impact of dehydroepiandrosterone sulfate (DHEAS) on the clearance of chronic HBV infection.

Methods

Two hundred and one hepatitis B e antigen (HBeAg)-positive chronic HBV-infected children (101 females) were recruited. Serum DHEAS levels were determined in all subjects at 15 years of age. Serum alanine aminotransferase (ALT) levels, DHEAS levels, HBV seromarkers, genotypes, and viral loads were included for analysis.

Results

Subjects with serum DHEAS levels >3.6 μmol/L at midpuberty had earlier HBeAg seroconversion (median age, 14.7 vs. 18.2 years; HR, 1.9; P = 0.03), and the impact persisted even after adjusting for gender, HBV genotype, peak ALT levels, and viral load. Subjects with DHEAS levels >3.6 μmol/L at 15 years of age had more HBV viral titers decrement from 15 to 20 years of age (mean ± SD, 3.5 ± 2.5 vs. 1.2 ± 2.2 log10 copies/mL; P = 0.05) and shorter duration for HBeAg seroconversion than others (mean ± SD, 5.6 ± 4.4 vs. 9.2 ± 4.9 years; P = 0.02). Higher serum DHEAS levels at 15 years of age are also associated with greater hepatitis B surface antigen (HBsAg) titer decrement from 15 to 20 years of age (correlation coefficient = 0.45, P = 0.04).

Conclusions

Higher serum DHEAS levels at midpuberty predicts more HBV viral load and HBsAg titer decrement from midpuberty to young adulthood. Higher serum DHEAS levels at midpuberty also correlate with younger age of spontaneous HBeAg seroconversion in chronic genotype B and C HBV-infected patients.     

Laparoscopic ventral rectopexy: a prospective long-term evaluation of functional results and quality of life

Background

Laparoscopic ventral rectopexy for rectal prolapse combines the advantages of a minimally invasive approach with the low recurrence rate observed after abdominal procedures. To date, only a few long-term functional studies and no quality of life assessment are available. The aim of this study was to assess long-term functional outcomes and quality of life after laparoscopic ventral rectopexy.

Methods

Between January 2007 and December 2008, patients who underwent laparoscopic ventral rectopexy for full-thickness external rectal prolapse and/or rectocele were prospectively included. Fecal incontinence and constipation were scored (Wexner score and Rome II criteria). Quality of life was assessed using the gastrointestinal quality of life form (GIQLI).

Results

Thirty-three patients were included and 30 (91 %) completed all the questionnaires. There was no morbidity or mortality. The mean length of hospital stay was 5 ± 1 days (range 3–7 days). After a mean follow-up of 42 ± 7 months (range 32–52 months), recurrence of rectocele was observed in two patients (6 %). At the end of follow-up, constipation was improved in 13/18 patients (72 %) and two patients (7 %) presented de novo constipation. The patients’ Wexner score improved between preoperative status and end of follow-up (12 ± 7 vs. 4 ± 3, p = 0.002). Compared to the preoperative score, quality of life significantly improved over time: 77 ± 21 preoperatively versus 107 ± 17 at 1 year versus 109 ± 18 at the end of follow-up (p < 0.001).

Conclusions

This prospective study showed that laparoscopic ventral rectopexy was associated with excellent postoperative outcomes and a low long-term recurrence rate. Long-term functional results were excellent in terms of continence, with significant improvement of quality of life and without worsening constipation.     

Incidence,Risk Factors and Clinical Course of Pancreatic Fluid Collections in Acute Pancreatitis

Background

Acute pancreatitis is an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems. Acute fluid collections and pseudocyst formation are the most frequent complications of acute pancreatitis.

Aims

The aims of this study were to evaluate the incidence, risk factors, and clinical course of pancreatic fluid collections and pseudocyst formation following acute pancreatitis.

Methods

A prospective multicenter study was conducted in five participating centers with 302 patients diagnosed with acute pancreatitis from January 2011 to July 2012.

Results

The incidence of pancreatic fluid collections and pseudocyst was 42.7 and 6.3 %, respectively. Patients with fluid collections were significantly younger, compared to those without fluid collections (51.5 ± 15.9 vs. 60.4 ± 16.5 years, P = 0.000). The proportion of alcoholic etiology (54.3 %) in patients with fluid collections was significantly higher compared to other etiologies (P = 0.000). C-reactive protein (CRP) (48 h) was significantly higher in patients with fluid collections, compared to patients without fluid collections (39.2 ± 77.4 vs. 15.1 ± 36.2 mg/dL, P = 0.016). LDH (48 h) was significantly higher in patients with pseudocyst formation, compared to patients with complete resolution (1,317.6 ± 706.4 vs. 478.7 ± 190.5 IU/L, P = 0.000). Pancreatic fluid collections showed spontaneous resolution in 69.8 % (90/129) and 84.2 % of the pseudocysts disappeared or decreased in size during follow up.

Conclusions

Age, CRP (48 h), and alcohol etiology are risk factors for pancreatic fluid collections. LDH (48 h) appears to be a risk factor for pseudocyst formation. Most pseudocysts showed a decrease in size or spontaneous resolution with conservative management.     

Non-Erosive Reflux Disease (NERD), Symptomatic and Asymptomatic Erosive Reflux Disease (ERD): From Hypersensitive to Hyposensitive Esophagus

Aims

To compare the esophageal sensitivity to acid and saline in patients with symptomatic and asymptomatic erosive reflux disease (ERD), non-erosive reflux disease (NERD) and controls, and to assess the response to proton-pump inhibitors in patients with symptomatic ERD and NERD.

Methodology

Patients with GERD and a control group of healthy asymptomatic volunteers were recruited. All subjects underwent esophagogastroduodenoscopy and the acid-saline perfusion test. Symptomatic ERD and NERD patients were given rabeprazole 20 mg twice daily for 2 weeks and their response to treatment assessed.

Results

A total of 105 subjects were recruited: ERD = 37 (symptomatic = 24, asymptomatic = 13), NERD = 34 and controls = 34. During saline perfusion, only the NERD group recorded a significantly higher sensitivity score compared to controls (2.74 ± 7.28 vs. 0) (p = 0.035). During acid perfusion, symptomatic ERD (15.42 ± 13.42) and NERD (16.71 ± 15.04) had significantly higher scores versus controls and asymptomatic ERD patients (both p < 0.001). The mean %? reflux symptom score following treatment was significantly higher in symptomatic ERD patients compared to NERD patients (89.08 ± 21.67 vs. 58.53 ± 32.54; p < 0.001).

Conclusions

Patients with NERD were a generally hypersensitive group while asymptomatic ERD patients represent a hyposensitive group of patients which merits further study.