Study on content of serum epidermal growth factor,gastric acid secretion and serum gastrin in duodenitis

AIM: To study whether there is EGF secreting abnormality in duodenitis and its relationship with gastric acid output and serum gastrin, so as to further explore the pathogenesis of duodenitis. METHODS: Twenty-five duodenitis patients were confirmed by electrogastroscopy and biopsy, with an average age of 35.9 ± 7.0 years (range, 24-52 years). The control group consisted of 20 healthy volunteers (10 females, 10 males), with an average age of 34.4 ± 7.6 years (range, 23-48 years). Twenty duodenal ulcer patients (10 females, 10 males), with an average age of 35.0 ± 7.6 years (range, 24-52 years), were also included. Serum EGF and gastrin were measured using radioimmunoassay. Intragastric acidity was determined by pentagastrin method. Statistical analysis was performed using Student’s t-test. RESULTS: In comparison with those in the control group, the contents of serum EGF and serum gastrin in duodenitis patients were all significantly increased. In comparison with those in the duodenal ulcer group, serum EGF was significantly increased, basal acid output and peak acid output were decreased, and serum gastrin was increased significantly in duodenitis patients. Serum EGF was negatively correlated with gastric acid output and positively correlated with serum gastrin. CONCLUSION: In duodenitis, serum EGF concentration was increased, which was positively correlated with serum gastrin content, but was negatively correlated with gastric acid output. This indicates that EGF plays a protective role in the pathogenesis of duodenitis, which provides a new clue to pathogenesis study of duodenitis.     

Peptic ulcers and abdominal aortic aneurysms

Upper gastrointestinal endoscopy was performed in 106 of 204 Chinese patients with intact abdominal aortic aneurysms, ninety-seven for screening and nine for gastrointestinal bleeding or pain. Peptic disease was discovered in 38 patients: 12 duodenal ulcers, 12 gastric ulcers, four duodenal and gastric ulcers, three duodenitis, three gastritis and four previously operated for ulcers. The eight patients who bled before aneurysmectomy all had gastric ulcers; four required emergency operation and two died. Only two patients bled from duodenal ulcers, both after aneurysmectomy and one died. Excluding gastritis and duodenitis, peptic ulcer was found in 26.4% of patients with abdominal aortic aneurysms. Half of these ulcers were gastric ulcers and 50% of them bled before aneurysmectomy. Duodenal ulcers tend to remain asymptomatic before operation and two of 12 (16.7%) bled postoperatively. The risk of bleeding for ulcers associated with aneurysms was 10 of 28 (35.7%) ulcers. The result of this uncontrolled study suggests that routine endoscopic screening should be used in all patients with aortic aneurysms and early surgery should be offered for gastric ulcers.     

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction

AIM: To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI). METHODS: Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI. RESULTS: A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6+/-1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027). CONCLUSION: EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.     

Giardia lamblia infection in patients with irritable bowel syndrome and dyspepsia： A prospective study

AIM:To evaluate the prevalence of Giardia lamblia(G.lamblia)infection in patients with irritable bowel syndrome(IBS)and dyspepsia and to establish which is the mostaccurate test to diagnose the infection in this setting.METHODS:One hundred and thirty-seven patients whoconsecutively attended the Outpatient GastroenterologyClinic for the first time between January 2002 and De-cember 2003 due to symptoms of IBS and/or dyspepsiawere recruited.All patients underwent clinical evaluation,first-step haematology and chemistry tests,serologic as-says for celiac disease,lactose-H2 breath test,abdominalultrasonography,and esophagogastroduodenoscopy.Helicobacter pylori status was evaluated.In patients withsymptoms of IBS older than 45 years,colonoscopy wasalso performed.In all patients,duodenal biopsies andstool samples were examined for trophozoites and cystsof G.lamblia by several methods.RESULTS:G.lamblia was identified in 9 patients.Thefollowing diagnoses were also made:IBS(100/137,73%),functional dyspepsia(62/137,45%),organicdyspepsia(33/137,24%),and lactose intolerance(75/137,55%).A significant association was foundbetween giardiasis and H pylori infection(X~2=6.632,OR=12.4,CI=1.5-68.1).There were no symptomsthat reliably allowed the recognition of giardiasis.Direct search of the parasite in duodenal biopsy andstool sample examinations gave concordant results inall cases while histological examination of duodenal biopsies displayed a low sensitivity(e.g.,22.2%).CONCLUSION:In this consecutive series,diagnosisof G.lamblia infection accounted for 6.5% of patientswith IBS and dyspepsia.Duodenal biopsies for diag-nosis of giardiasis may be unnecessary if stool sampleexamination is performed.     

Helicobacter pylori infection, gastric metaplasia in the duodenum and the relationship with ulcer recurrence

OBJECTIVE: To study the prevalence of Helicobacter pylori (H. pylori) infection and gastric metaplasia (GM) in the duodenum a large group of patients with duodenal ulcer was evaluated to determine whether these factors are related to the number of ulcer recurrences. METHODS: Three hundred and seven patients diagnosed by endoscopy as having active duodenal ulcers were studied. At endoscopy, all patients had gastric biopsies taken for histology, the rapid urease test and culture. Three duodenal biopsies were also taken and processed for histology (haematoxylin & eosin, Giemsa, Warthin-Starry, and PAS stain). RESULTS: GM and H. pylori in the duodenum was identified in 73% (68-78%) and 66% (60-71%) of the cases, respectively. All patients with H. pylori in the duodenum also had GM at this location, while areas with GM but without H. pylori were described. The kappa statistic for concordance between GM and H. pylori at the duodenum was 0.82. The prevalence of GM and H. pylori, depending on the number of ulcer recurrences, was: 1st episode, 34% and 27%, respectively; 2nd episode, 84% and 80%; and > or = 3rd episode, 90% and 79% (P < 0.001 when comparing 1st vs 2nd or > or = 3rd episode). In the multivariate analysis, age and number of ulcer recurrences correlated both with GM and with H. pylori in the duodenum. Chronic duodenitis was demonstrated in all duodenal biopsies, 87% being active chronic duodenitis. H. pylori in the duodenum was more frequent in patients with active duodenitis (73%) than in those with inactive duodenitis (13%) (P < 0.001). CONCLUSIONS: Patients with recurrent ulcer disease have a higher prevalence of both GM and H. pylori infection in the duodenum, suggesting that these two factors are related with the chronicity and recurrence of duodenal ulcer disease. H. pylori infection in the duodenum always appears in areas of GM, although GM is not necessarily colonized by the organism. H. pylori infection cannot be excluded based only on the results of duodenal biopsies, as false negative results at this area are frequent.     

Role of hepatitis C virus in acute non-A, non-B hepatitis in Greece: a 5-year prospective study.

The prevalence of hepatitis C virus (HCV) infection in 182 prospectively followed adult patients (110 males, 72 females) with acute non-A, non-B hepatitis and its correlation with progression to chronic hepatitis were studied. These patients were followed for a mean of 24.7 +/- 13.1 (range, 6-57) months. By using a specific enzyme immunoassay for the detection of antibodies against C100-3 polypeptide of HCV, 96 (52.7%) were found antibody positive. HCV was implicated in 64/89 (71.9%) of the cases with classical parenteral exposure but only in 18/64 (28.1%) of the community-acquired cases. Progression to chronic hepatitis was observed more frequently in antibody-positive than in antibody-negative cases (60/96 or 62.5% vs. 27/86 or 31.4%, P = 0.00002). Progression was also observed more often in males than in females (66/112 or 58.9% vs. 21/70 or 30.0% P = 0.0001), both in the antibody positive (48/68 or 70.6% vs. 12/28 or 42.9%, P = 0.01) and in the antibody negative (18/44 or 40.9% vs. 9/42 or 21.4%, P = 0.043) cases. These data indicate that (a) acute hepatitis due to HCV is characterized by a high rate of chronicity, especially in males, and (b) a non-A, non-B, non-C agent or a different strain of HCV may be responsible for the majority of the community-acquired cases of non-A, non-B hepatitis in Greece.     

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. METHODS: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). RESULTS: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. CONCLUSION: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.     

Clinical impact of upper endoscopy in the management of patients with gastroesophageal reflux disease

OBJECTIVE: Esophago-gastro-duodenoscopy (EGD) is frequently performed in patients with heartburn. However, the benefit of an EGD is unclear. The objective is to determine the clinical impact of performing an EGD in the management of GERD. METHODS: Patients with alarm symptoms or persistent heartburn from primary care and gastroenterology clinics were invited to participate. Patients with known reflux complications or an EGD procedure within 3 yr were excluded. Endpoints for EGD-improving management were prospectively defined: change in medical therapy, dilating esophageal stricture, identifying Barrett's esophagus (BE), finding severe esophagitis (Hetzel-Dent grade 3 or 4), or finding cancer. RESULTS: Two hundred and six patients (59 M/147 F; median age, 48 yr) were enrolled, in which, 124 had alarm symptoms and 82 had persistent heartburn. EGD improved the overall management in 40% of patients with alarm symptoms and 29% with persistent heartburn (p= NS). Medical therapy was altered in only 5% of patients, and no cancer was identified. EGD was more likely to improve management in males with alarm symptoms. CONCLUSIONS: It was uncommon for an EGD to alter antireflux therapy. The management was improved in approximately one-third of the patients by dilating esophageal stricture, finding BE to initiate surveillance, or finding severe esophagitis. EGD should be performed when alarm symptoms are present, especially in males.     

Duodenal erosions,a common and distinctive feature of portal hypertensive duodenopathy

OBJECTIVE: The aim of the present study was to assess the presence of duodenal erosion and its clinical characteristics on endoscopy in patients with portal hypertension who had undergone endoscopic injection sclerotherapy and/or endoscopic variceal ligation for esophagogastric varices. METHODS: The subjects were 440 patients with portal hypertension, 450 with chronic hepatitis as a related control group, and 450 who underwent upper endoscopic examination as part of their routine physical examination as the controls. The underlying hepatic disease, hepatic function, and endoscopic findings of duodenal erosion among the patients with portal hypertension were studied. RESULTS: Duodenal erosion was found in 68 patients with portal hypertension (68 of 440, 15.5%), four patients with chronic hepatitis (four of 450, 0.9%), and two controls (two of 450, 0.4%). The incidence of duodenal erosion among the patients with portal hypertension was significantly higher than that in the other two groups (p < 0.01, p < 0.01, respectively). The lesions commonly observed in duodenitis are speckle erosions mainly located in the duodenal bulb. However, the most frequently seen form of duodenal erosion among the patients with portal hypertension extended from the superior portion to the descending portion, and tended to show a circular alignment along the Kerckring's folds. The patients with portal hypertension with reduced hepatic reserve capacity had more severe duodenal erosion. Endoscopic ultrasonography revealed thickening of the duodenal wall and proliferation of vascular structures within and around the wall. The histological findings of the duodenal erosion included edema and vascular dilation in the mucosal and submucosal layers. CONCLUSIONS: The location of duodenal erosion in patients with portal hypertension differs from that in patients with ordinary duodenitis. Duodenal erosion in patients with portal hypertension is considered to be one of the lesions of portal hypertensive duodenopathy.     

Prospective evaluation of a 3.1-mm battery-powered esophagoscope in screening for esophageal varices in cirrhotic patients

OBJECTIVE: Standard esophagogastroduodenoscopy (EGD) is costly and uses conscious sedation that cirrhotic patients may tolerate poorly. This study aimed to determine the feasibility and acceptance of unsedated esophagoscopy with an ultrathin battery-powered endoscope (BPE) in cirrhotic patients for diagnosing esophageal varices (EV). METHODS: We first studied the prevalence of significant gastroduodenal pathology that could be missed if only esophagoscopy were performed in cirrhotic patients undergoing liver transplant evaluation. A prospective study was then done to evaluate a BPE in EV screening. Unsedated per-oral endoscopy was first done by a single endoscopist using a BPE, followed by EGD by a second endoscopist who was masked to the BPE result. A visual analog score was used to determine patient tolerance. Patients were asked about their preference for endoscopy in the future. A paired Student t test and the kappa statistic were used in the statistical analysis. RESULTS: In the retrospective study, 199 patients were reviewed; three patients (1.5%) had gastric ulcers, and two patients (1%) had duodenal ulcers. In the prospective study, 28 cirrhotic patients (16 women) were evaluated. EV were diagnosed in 14 patients with a BPE, and 13 were confirmed by standard EGD (sensitivity and negative predictive value 100%, specificity and positive predictive value 93%, kappa = 0.93). EV were graded as large in one and small in 13 patients with a BPE, but small varices diagnosed in one patient were not confirmed on EGD. Both procedures were well tolerated by all patients. Twenty-seven of 28 patients preferred unsedated endoscopy with a BPE over EGD. CONCLUSIONS: Unsedated endoscopy with a BPE is safe and well tolerated. The diagnostic accuracy of a BPE for diagnosing EV is the same as by EGD. Esophagoscopy with a BPE is a potential alternative to EGD for EV screening.     

Unsedated transnasal small-caliber esophagogastroduoden oscopy in elderly and bedridden patients

AIM: To evaluate the safety of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) for elderly and critically ill bedridden patients.METHODS: One prospective randomized comparative study and one crossover comparative study between transnasal small-caliber EGD and transoral conventional EGD was done (Study 1). For the comparative study,we enrolled 240 elderly patients aged > 65 years old.For the crossover analysis, we enrolled 30 bedridden patients with percutaneous endoscopic gastrostomy(PEG) (Study 2). We evaluated cardiopulmonary effects by measuring arterial oxygen saturation (SpO_2) and calculating the rate-pressure product (RPP) (pulse rate × systolic blood pressure/100) at baseline, 2 and 5 min after endoscopic intubation in Study 1. To assess the risk for endoscopy-related aspiration pneumonia during EGD, we also measured blood leukocyte counts and serum C-reactive protein (CRP) levels before and 3 d after EGD in Study 2.RESULTS: In Study 1, we observed significant decreases in SpO_2 during conventional transoral EGD,but not during transnasal small-caliber EGD (0.24% vs-0.24% after 2 min, and 0.18% vs -0.29% after 5 min,P = 0.034, P = 0.044). Significant differences of the RPP were not found between conventional transoral and transnasal small-caliber EGD. In Study 2, crossover analysis showed statistically significant increases of the RPP at 2 min after intubation and the end of endoscopy (26.8 and 34.6 vs 3.1 and 15.2, P = 0.044, P = 0.046),and decreases of SpO_2 (-0.8% vs -0.1%, P = 0.042) during EGD with transoral conventional in comparison with transnasal small-caliber endoscopy. Thus, for bedridden patients with PEG feeding, who were examined in the supine position, transoral conventional EGD more severely suppressed cardiopulmonary function than transnasal small-caliber EGD. There were also significant increases in the markers of inflammation,blood leukocyte counts and serum CRP values, in bedridden patients after transoral conventional EGD, but not after transnasal small-caliber EGD performed with the patient in the supine position. Leukocyte count increased from 6053 ± 1975/L to 6900 ± 3392/L ( P = 0.0008) and CRP values increased from 0.93 ± 0.24 to 2.49 ± 0.91 mg/dL ( P = 0.0005) at 3 d after transoral conventional EGD. Aspiration pneumonia, possibly caused by the endoscopic examination, was found subsequently in two of 30 patients after transoral conventional EGD.CONCLUSION: Transnasal small-caliber EGD is a safer method than transoral conventional EGD in critically ill,bedridden patients who are undergoing PEG feeding.     

Helicobacter Pylori and Refractory Duodenal Ulcers: Cross-over Comparison of Continued Cimetidine with Cimetidine plus Antimicrobials

Objectives: To determine the distribution of Helicobacter pylori in the antral and duodenal mucosa of patients with duodenal ulcers refractory to 12 wk of treatment with cimetidine and to evaluate the effect of adding antimicrobial agents to cimetidine on the bealing of refractory duodenal ulcers. Methods: A randomized crossover comparison of continued 800 mg of cimetidine at night for 4 wk with cimetidine plus 500 mg of amoxycillin three times a day for the first 2 wk and 250 mg of metronidazole three times a day for the second 2 wk. H. pylori status in the gastric antral and duodenal mucosa was evaluated by histology and bacterial culture before and at the end of each treatment period. Results: Forty-eight patients were studied. Upon entry to the study, all patients had antral colonization with H. pylori . In the duodenum, active chronic duodenitis was present in 66%, duodenal gastric metaplasia in 33%, and H. pylori in 50%, similar proportions to patients with nonrefractory duodenal ulcers. Healing occurred in 70% (30 of 43) of patients during treatment with cimetidine plus antimicrobials but in only 21 % (6 of 28) during treatment with cimetidine alone ( P = 0.0003). In patients who received antimicrobials, neither clearance of H. pylori from the antrum (58% of patients) or duodenum (71% of colonized patients) nor eradication of H. pylori (33%) was significantly correlated with ulcer healing. Conclusions: The distribution of H. pylori in refractory duodenal ulcers is similar to nonrefractory ulcers, and the combination of amoxycillin and metronidazole with cimetidine increases the proportion of refractory duodenal ulcers, which heals.     

Prevalence of Helicobacter pylori infection and related gastroduodenal lesions in spouses of Helicobacter pylori positive patients with duodenal ulcer.

BACKGROUND: To date, very few studies have evaluated the risk of infection among spouses of Helicobacter pylori positive patients and their results are conflicting. AIM: To assess the seroprevalence of H pylori infection in spouse of H pylori positive patients with duodenal ulcer as compared with age and sex matched volunteer blood donors, as well as the frequency of endoscopic gastroduodenal lesions in these spouses, according to the presence or absence of gastrointestinal complaints. METHODS: Some 124 spouses (48% males) of patients with duodenal ulcer consecutively seen over a 10 month period were studied. They were all screened for serum IgG anti-H pylori antibodies and asked to complete a questionnaire with particular reference to the presence of chronic or recurrent dyspepsia. Upper gastrointestinal tract endoscopy with antral and corpus biopsy specimens taken for histological examination and urease rapid test was offered to all seropositive spouses. Volunteer blood donors (248), living in Milan and matched for age, sex, north-south origins, and socioeconomic status to the cases, were used as controls. RESULTS: Spouses of patients with duodenal ulcer had a significantly higher seroprevalence of H pylori infection than controls (71% v 58%, p < 0.05); 30 of 88 (34%) H pylori positive spouses complained of dyspeptic symptoms compared with only four of 34 (12%) seronegative spouses (p < 0.02). At endoscopy, H pylori infection was confirmed in 48 of 49 (98%) seropositive spouses. The endoscopic findings in those spouses showed active duodenal ulcer in eight (17%), duodenal scar and cap deformity in two (4%), active gastric ulcer in two (4%), erosive duodenitis in three (6%), antral erosions in two (4%), antral erosions plus duodenitis in one, and peptic oesophagitis in another patient. The prevalence of major endoscopic lesions was significantly higher in symptomatic spouses than in those who had never been symptomatic. CONCLUSIONS: These findings show that being the spouse of an H pylori positive patient with duodenal ulcer may increase the risk of H pylori colonisation and perhaps of peptic ulcer disease, and raises questions as to whether serological screening of cohabiting partners of H pylori positive patients with duodenal ulcer may be indicated.     

Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection

AIM： To investigate endoscopic and histopathological findings in the duodenum of patients with Strongyloides stercoralis （S. stercoralis） hyperinfection. METHODS： Over a period of 23 years （1984-2006）, we investigated 25 patients with S. stercoralis hyperinfection who had had an esophagogastroduodenoscopy before undergoing treatment for strongyloidiasis. The clinical and endoscopic findings were analyzed retrospectively. RESULTS： Twenty-four （96%） of the patients investigated were under immunocompromised condition which was mainly due to a human T lymphotropic virus type 1 （HTLV-1） infection. The abnormal endoscopic findings, mainly edematous mucosa, white villi and erythematous mucosa, were observed in 23 （92%） patients. The degree of duodenitis including villous atrophy/destruction and inflammatory cell infiltration corresponded to the severity of the endoscopic findings. The histopathologic yield for identifying larvae was 71.4% by duodenal biopsy. The endoscopic findings of duodenitis were more severe in patients whose biopsies were positive for larvae than those whose biopsies were negative （Endoscopic severity score： 4.86 ± 2.47 vs 2.71 ±1.38, P 〈 0.05）. CONCLUSION： Our study clearly demonstrates that, in addition to stool analysis, endoscopic observation and biopsies are very important. We also emphasize that S. stercoralis and HTLV-1 infections should be ruled out before immunosuppressive therapy is administered in endemic regions.     

Upper gastrointestinal mucosal lesions in chronic renal failure.

The upper gastrointestinal mucosa was studied endoscopically in 182 patients (140 males, 42 females) with chronic renal failure prior to hemodialysis. Endoscopy revealed normal mucosa in 77 patients (42.3%), inflammatory mucosal lesions in 88 (48.4%), peptic ulcer in 16 (8.8%; duodenal 15, gastric 1) and Barrett's ulcer in one patient. Upper gastrointestinal bleeding was noted at presentation in 16 (8.8%) cases and was associated with erosive gastritis, duodenitis and duodenal ulcer in 11, 3 and 2 patients respectively. Thus patients with chronic renal failure had a high prevalence of inflammatory mucosal changes.     

Is esophagoscopy alone sufficient for patients with reflux symptoms?

BACKGROUND: Unsedated esophagoscopy with ultrathin endoscopes is a valuable screening modality for Barrett's esophagus, but the stomach and the duodenum cannot be examined completely with the smallest and best tolerated of these endoscopes. There are no data as to how often disease in the stomach and the duodenum would be missed when using this screening strategy. Our hypothesis is that patients with reflux symptoms, in the absence of daily abdominal pain, nausea, or history of ulcer, were unlikely to have clinically significant gastroduodenal disease. METHODS: Patients scheduled for upper endoscopy at a single outpatient endoscopy unit in a tertiary referral center were screened. The inclusion criterion was reflux symptoms as the primary indication for upper endoscopy. Patients with another valid indication were excluded. A detailed history was recorded and symptom questionnaire completed for each patient before endoscopy; these data were compared with the endoscopy findings. RESULTS: A total of 175 patients were included. Indications for upper endoscopy were the following: worsening symptoms (n=74), ongoing reflux despite therapy (n=27), and long-standing reflux (n=74). Major esophageal findings were discovered in 95 patients. In 10 patients, major gastric or duodenal findings were detected as follows: erosive gastritis (n=8), gastric ulcer (n=2), duodenal ulcer (n=2), erosive duodenitis (n=2), and duodenal polyp (n=1). Daily abdominal pain (p=0.014) or possibly daily nausea (p=0.028 unadjusted, 0.197 adjusted) was associated with major gastric/duodenal disease. Patients without daily abdominal pain, nausea, or a history of gastric/duodenal ulcer were much less likely to have major disease (0.9%) than patients with one of these predictors (13.2%, p=0.00097). CONCLUSIONS: Daily abdominal pain and nausea, in combination with a history of ulcer disease, are strong predictors of major gastric or duodenal disease. Patients with reflux without these predictors are highly unlikely to have a major disease involving the stomach or duodenum, and are suitable candidates for esophagoscopy alone.     

Duodenal histology, ulceration, and Helicobacter pylori in the presence or absence of non-steroidal anti-inflammatory drugs.

Duodenitis and gastric metaplasia, which is often colonised by Helicobacter pylori (H pylori), are increasingly recognised for their importance in the pathogenesis of duodenal ulcers. The situation is not clear in patients receiving non-steroidal anti-inflammatory drugs (NSAIDs), who have a higher risk of peptic ulceration. The aim of this study was to identify the duodenal histological abnormalities in the presence or absence of NSAIDs, H pylori, and duodenal ulceration. Endoscopic duodenal biopsy specimens were taken from healthy looking mucosa of 172 patients (74 took NSAIDs, and 98 did not). Duodenitis was graded according to the degree of neutrophilic and plasma cell infiltration, villus height, Brunner's gland prolapse, and gastric metaplasia. The activity of duodenitis was dependent on the neutrophilic infiltration. A global score covering all the above factors was constructed, and H pylori in both the stomach and duodenum, was also assessed. The results showed that duodenitis with varying degrees of neutrophilic infiltration and gastric metaplasia was found in 20 patients (27%) taking NSAIDs, compared with 56 patients (57%) not taking NSAIDs (chi 2 = 16.24, p < 0.001). This degree of duodenitis was also found in 20 of 25 patients (80%) with duodenal ulcers, regardless of NSAID intake (chi 2 = 15.38, p < 0.001). Gastric metaplasia was identified in 20 patients (27%) receiving NSAIDs and 38 (39%) not receiving NSAIDs. Duodenal H pylori was only seen in patients with gastric metaplasia 10 (50%) receiving NSAIDs, and 34 (89%) not receiving NSAIDs. H pylori positive gastritis, and the combination of active duodenitis and gastric metaplasia were independent predictors of duodenal ulceration. It is concluded that active duodenitis is less common in patients taking NSAIDs but is strongly associated with gastric metaplasia, H pylori positive gastritis, and duodenal ulceration. These findings are relevant to the pathogenesis and treatment of duodenal ulcers in patients taking NSAIDs.     

A Prospective Study of Bidirectional Endoscopy (Colonoscopy and Upper Endoscopy) in the Evaluation of Patients with Occult Gastrointestinal Bleeding

One hundred patients with occult gastrointestinal bleeding (OGIB) (i.e., guaiac-positive stools and/or iron deficiency anemia) were prospectively evaluated with bidirectional endoscopy [upper endoscopy (EGD) and colonoscopy] to determine the origin of occult bleeding. Predetermined criteria were used to prospectively define gastrointestinal bleeding sources. Among the 58 males and 42 females, the median age was 65 yr. Thirty-one percent of the group had gastrointestinal symptoms. Sixty-six percent of the study group were inpatients. Bidirectional endoscopy detected the source of OGIB in 53% of patients, with a positive finding on EGD of 36%, and with colonoscopy, of 26%. In only 9% of patients was a source of OGIB detected on both EGD and colonoscopy. Acid peptic disease accounted for the source of OGIB in 27%, colonic adenomas 14%, angiodysplasia 13%, colorectal carcinoma 6%, and gastric cancer in 1% of patients. The diagnostic yield was significantly higher with EGD than with colonoscopy in patients with anemia and guaiac-positive stools (45% vs. 26%, p less than 0.01). Upper endoscopy directed a change in patient management in 29 patients. In conclusion: for the patient population described in this study, bidirectional endoscopy determined the source of OGIB in 50%. As expected, colonoscopy resulted in a higher cancer detection rate than EGD--yet EGD detected the origin of OGIB in 68% (36/53) of patients found to have an occult bleeding source, and resulted in a therapeutic initiation or a change in therapy for 30% of all patients.     

Mucosal polymerase chain reaction for diagnosing Helicobacter pylori infection in patients with bleeding peptic ulcers

AIM: Helicobacter pylori (H pylon) has been linked to chronic gastritis, peptic ulcers, gastric cancer and MALT-lymphoma. Conventional invasive tests are less sensitive than non-invasive tests in diagnosing H pylori infection in patients with bleeding peptic ulcers. Polymerase chain reaction is a sensitive and accurate method for diagnosing H pylori infection. The aim of this study was to evaluate the diagnostic role of mucosai polymerase chain reaction for H pylori infection in patients with bleeding peptic ulcers. METHODS: In patients with bleeding, non-bleeding peptic ulcers and chronic gastritis, we checked rapid urease test, histology, bacterial culture and mucosai polymerase chain reaction fordetecting H pylori infection. Positive H pylori infection was defined as positive culture or both a positive histology and a positive rapid urease test. For mucosai polymerase chain reaction of H pylori, we checked vacA (s1a, s1b, s1c, s2, m1, m1T, m2), iceA1, iceA2. and cag A. RESULTS: Between October 2000 and April 2002,88 patients with bleeding peptic ulcers (males/females: 60/28, gastric ulcers/duodenal ulcers: 55/33), 81 patients with non-bleeding peptic ulcers (males/females: 54/27, gastric ulcers/duodenal ulcers: 45/36) and 37 patients with chronic gastritis (males/ females: 24/13) were enrolled in this study. In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, 45 patients (51%), 71 patients (88%) and 20 patients (54%) respectively were found to have positive H pylori infection (P<0.001). In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, polymerase chain reaction for H pylori infection was positive in 54 patients (61%), 70 patients (86%) and 20 patients (54%) respectively (P<0.001). The sensitivity, positive predictive value and diagnostic accuracy of mucosai polymerase reaction for H pylori infection were significantly lower in patients with bleeding peptic ulcers (84%, 79% and 81%) than in patients with non-bleeding peptic ulcers (99%, 99% and 98%) (P<0.001, P<0.01 and P<0.001 respectively). The sensitivity, negative predictive value and diagnostic accuracy of mucosal polymerase reaction for H py/ori were significantly lower in patients with bleeding peptic ulcers (84%, 83% and 81%) than in patients with chronic gastritis (100%, 100% and 100%) (P= 0.02, P= 0.02 and P=0.001). CONCLUSION: Mucosal polymerase chain reaction for detecting H pylori infection is not reliable in patients with bleeding peptic ulcers.