Time trend occurrence of duodenal intraepithelial lymphocytosis and celiac disease in an open access endoscopic population

Background: Duodenal intraepithelial lymphocytosis (DIL) is a histological finding characterized by the increase of intraepithelial CD3T-lymphocytes over the normal value without villous atrophy, mostly associated to coeliac disease (CD), Helicobacter pylori (Hp) gastritis and autoimmune diseases. Objective: To assess the occurrence of DIL, CD and Hp gastritis in an endoscopic population over a 13 year period. Methods: From 2003 to 2015 we included adult patients who consecutively underwent oesophago-gastro-duodenoscopy (OGD) with duodenal biopsies assessing the overall and annual occurrence of DIL and CD and the prevalence of Hp gastritis. Results: 160 (2.3%) patients with DIL and 275 (3.9%) with CD were detected among 7001 patients. CD occurrence was higher from 2003 to 2011, while since 2012 DIL occurrence gradually increased significantly compared to CD (p = 0.03). DIL patients were more frequently female (p = 0.0006) and underwent OGD more frequently for dyspepsia (p = 0.002) and for indications not related to gastrointestinal symptoms than CD patients (p = 0.0003). Hp gastritis occurred similarly in CD and DIL patients but the latter had higher frequency of atrophic body gastritis (p = 0.005). Conclusions: DIL is a condition increasing in the general endoscopic population mainly diagnosed by chance. Concomitant gastric histological evaluation is able in one third of DIL patients to identify associated possible causes of DIL, such as Hp and atrophic gastritis

Helicobacter pylori virulence factors in duodenal ulceration: A primary cause or a secondary infection causing chronicity

Reports from countries with a high prevalence of Helicobacter pylori. (H pylori) infection do not show a proportionately high prevalence of duodenal ulceration, suggesting the possibility that H pylori cannot be a primary cause of duodenal ulceration. It has been mooted that this discrepancy might be explained by variations in the prevalence of virulence factors in different populations. The aim of this paper is to determine whether the published literature gives support to this possibility. The relevant literature was reviewed and analyzed separately for countries with a high and low prevalence of H pylori infection and virulence factors. Although virulent strains of H pylori were significantly more often present in patients with duodenal ulcer than without the disease in countries with a low prevalence of H pylori infection in the population, there was no difference in the prevalence of virulence factors between duodenal ulcer, non - ulcer dyspepsia or normal subjects in many countries, where the prevalence of both H pylori infection and of virulence factors was high. In these countries, the presence of virulence factors was not predictive the clinical outcome. To explain the association between virulence factors and duodenal ulcer in countries where H pylori prevalence is low, only two papers were found that give little support to the usual model proposed, namely that organisms with the virulence factors are more likely than those without them to initiate a duodenal ulcer. We offer an alternative hypothesis that suggests virulence factors are more likely to interfere with the healing of a previously produced ulcer. The presence of virulence factors only correlates with the prevalence of duodenal ulcer in countries where the prevalence of H pylori is low. There is very little evidence that virulence factors initiate duodenal ulceration, but they may be related to failure of the ulcer to heal

Risk factors associated with the occurrence of autoimmune diseases in adult coeliac patients

Objectives. Autoimmune diseases (AD) may be associated with coeliac disease (CD), but specific risk factors have been poorly investigated. The aim of this study was to assess the spectrum of AD and its specific risk factors associated in a series of adult coeliac patients. Materials and Methods. We performed a single-center case-control study including adult newly diagnosed CD patients. To evaluate the risk factors of the association between AD and CD, 341 coeliac patients included were categorized on the basis of AD presence: 91 cases with at least one AD and 250 controls without AD were compared for clinical, serological, and histological features. Eighty-seven cases were age-gender-matched with 87 controls. Results. Among 341 CD patients, 26.6% of CD patients had at least one AD. Endocrine and dermatological diseases were the most prevalent AD encountered: autoimmune thyroiditis was present in 48.4% of cases, psoriasis in 17.6%, and type I diabetes and dermatitis herpetiformis in 11%, respectively. At logistic regression, factors associated with AD were a positive 1st-degree family history of AD (OR 3.7, 95% CI 1.93–7), a body mass index ≥ 25 kg/m2 at CD diagnosis (OR 2.95%, CI 1.1–3.8), and long standing presentation signs/symptoms before CD diagnosis (>10 years) (OR 2.1, 95% CI 1.1–3.7). Analysis on age-gender-matched patients confirmed these results. Conclusions. CD patients with family history of AD, overweight at CD diagnosis, and a delay of CD diagnosis had an increased risk of having another AD. The benefit of CD screening in these specific subsets of patients with AD awaits further investigation

Improving basic skills in celiac-like disease diagnosis. A case report

Background: The diagnosis of Coeliac disease (CD) requires a combination of sign/symptoms, positivity of specific antibodies and duodenal histological evidence of villous atrophy. Duodenal villous atrophy, despite representing the CD landmark, is not specific since it is found in many gastrointestinal disorders. Giardiasis is one of the most common human intestinal protozoan infestations in industrialized countries whose histological duodenal mucosa damage could mimic that of CD. The present report shows how a wise clinical and laboratory assessment led us shortly to a correct diagnosis. Case presentation: A 42-year-old outpatient woman without previous significant gastrointestinal diseases, was referred with dyspeptic symptoms, fatigue and mild diarrhea from 4 months. Her first investigations including immunoglobulin A (IgA) anti-tissue transglutaminase antibodies (anti-tTG) and stool parasitological and cultural analysis were negative. An esophagogastroduodenoscopy (EGDS) showed no mucosal alteration. But histology demonstrated a Helicobacter Pylori (HP) pan-gastritis while duodenal mucosa showed villous atrophy consistent with a diagnosis of CD Marsh type 3b. While on gluten-free diet (GFD) the patient didn't experience any improvement of symptoms. Duodenal biopsies were then reviewed showing the presence of trophozoites of Giardia on the luminal surface of the duodenal wall and at the same time, a second stool examination revealed the presence of trophozoites and cysts of Giardia. Treated with metronidazole, 500 mg twice daily for 6 days the patient reduced diarrhea after few days. After about 2 months of GFD she was invited to discontinue it. At the same time stool examination was repeated with negative results. She subsequently performed eradication for Hp with triple therapy (Pylera®). Around 6 months later, the patient did not complain any gastrointestinal symptoms. Serological tests were normal and at a follow-up EGDS, duodenal mucosa had normal histology with normal finger-like villi and absence of Giardia trophozoites. Conclusion: This case report shows how CD diagnosis can sometimes be manifold. Intestinal villous atrophy alone may not automatically establish a diagnosis of CD. In the present case the clinical scenario could be fully explained by giardiasis. Indeed, different diagnostic tools and a multi-step approaches have been used to determine the final correct diagnosis

Epidemiology of Peptic Ulcer Disease: Endoscopic Results of a Systematic Investigation in Iran

BACKGROUND Peptic ulcer disease is a multifactorial health problem affecting almost all populations worldwide. Large scale population-based studies are crucial to understanding its scope and specifications in various nations. We aimed to explore environmental risk factors of peptic ulcer disease in the first population based study in Ardabil, Northwest Iran. METHODS This study was a part of a larger survey on upper gastrointestinal tract health conducted in Ardabil and Meshkinshahr with a total catchment area population of 600,000 persons during 2000-01. Using a random sampling proportional to place of residence, 1122 persons aged 40 or elder were selected. 1011 (90.1%) accepted participation and underwent a comprehensive medical examination and a systematic upper gastrointestinal endoscopy. Point prevalence of peptic ulcers was correlated to various life style risk factors. RESULTS Gastric and duodenal ulcers were identified in 33 (3.26%) and 50 (4.94%) participants, making an overall prevalence of 8.20%. Based on multivariable logistic regression analyses, H.pylori infection (OR 3.1, 95% CI: 2.1-4.7), Smoking (OR 1.8, 95% CI: 1.1-6.8), and chronic intake of NSAIDs (OR 2.8, 95% CI: 1.3-4.4) were main risk factors of gastric ulcer. For duodenal ulcer, in addition to H.pylori infection (OR 5.6, 95% CI: 1.9-8.8) and Smoking (OR 2.3, 95% CI: 1.4-6.5), male gender (OR 3.6, 95% CI: 1.2-5.8) and living in an urban area (OR 1.9, 95% CI: 1.1-5.2) were among significant risk factors. CONCLUSION This is the first population-based endoscopic study in North West of Iran reporting accurate point prevalence of peptic ulcer disease. The rate of 3.3% for gastric ulcer and 4.9% for duodenal ulcers are substantially lower than the estimates reported in Asian population-based endoscopic studies but higher than European reports

A Fibreoptic Endoscopic Study of Upper Gastrointestinal Bleeding at Bugando Medical Centre in Northwestern Tanzania: a Retrospective Review of 240 Cases.

Upper gastrointestinal (GI) bleeding is recognized as a common and potentially life-threatening abdominal emergency that needs a prompt assessment and aggressive emergency treatment. A retrospective study was undertaken at Bugando Medical Centre in northwestern Tanzania between March 2010 and September 2011 to describe our own experiences with fibreoptic upper GI endoscopy in the management of patients with upper gastrointestinal bleeding in our setting and compare our results with those from other centers in the world. A total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients. Diagnostic accuracy was greater within the first 24 h of the bleeding onset, and in the presence of haematemesis. Oesophageal varices were the most frequent cause of upper GI bleeding (51.3%) followed by peptic ulcers in 25.0% of cases. The majority of patients (60.8%) were treated conservatively. Endoscopic and surgical treatments were performed in 30.8% and 5.8% of cases respectively. 140 (58.3%) patients received blood transfusion. The median length of hospitalization was 8 days and it was significantly longer in patients who underwent surgical treatment and those with higher Rockall scores (P < 0.001). Rebleeding was reported in 3.3% of the patients. The overall mortality rate of 11.7% was significantly higher in patients with variceal bleeding, shock, hepatic decompensation, HIV infection, comorbidities, malignancy, age > 60 years and in patients with higher Rockall scores and those who underwent surgery (P < 0.001). Oesophageal varices are the commonest cause of upper gastrointestinal bleeding in our environment and it is associated with high morbidity and mortality. The diagnostic accuracy of fibreoptic endoscopy was related to the time interval between the onset of bleeding and endoscopy. Therefore, it is recommended that early endoscopy should be performed within 24 h of the onset of bleeding

Gastrointestinal stromal tumor (GIST) of the Treitz’s angle– a very rare cause of high bowel obstruction

Gastrointestinal stromal tumors (GIST) are somewhat rare gastrointestinal tumors - approximately 1% to 3% incidence, but they are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs are usually found in the stomach or small intestine but can occur anywhere within the gastrointestinal tract, even in extremely uncommon locations like duodeno-jejunal flexure. Only 3% – 5% of GISTs are located in the duodenum and tumors occurring in the angle of Treitz are even rarer, most published studies being case reports. These tumors have a size ranging from small lesions to large masses and can cause digestive bleeding or high bowel obstruction. This paper is a case presentation illustrating an emergency situation involving a high bowel obstruction caused by a small tumor with an unusual location in the Treitz’s angle. A large percentage of duodenal GISTs are localized in the third and fourth part of the duodenum and may not be found through standard upper endoscopy; only the barium study of the upper gastrointestinal tract highlights the obstruction point. Preoperative diagnosis is difficult but non-invasive imaging techniques like ultrasonography and computed tomography of the abdomen can be helpful. Recently, targeted therapy with inhibitors of tyrosine kinase receptors (IMATINIB) has been introduced for the management of advanced and metastatic tumors. In our opinion the surgical resection with curative intent is the treatment of choice

Differential inflammatory response to Helicobacter pylori infection: etiology and clinical outcomes

The bacterial pathogen Helicobacter pylori commonly colonizes the human gastric mucosa during early childhood and persists throughout life. The organism has evolved multiple mechanisms for evading clearance by the immune system and, despite inducing inflammation in the stomach, the majority of infections are asymptomatic. H. pylori is the leading cause of peptic ulcer disease and gastric cancer. However, disease outcomes are related to the pattern and severity of chronic inflammation in the gastric mucosa, which in turn is influenced by both bacterial and host factors. Despite over 2 decades of intensive research, there remains an incomplete understanding of the circumstances leading to disease development, due to the fascinating complexity of the host-pathogen interactions. There is accumulating data concerning the virulence factors associated with increased risk of disease, and the majority of these have pro-inflammatory activities. Despite this, only a small proportion of those infected with virulent strains develop disease. Several H. pylori virulence factors have multiple effects on different cell types, including the induction of pro- and anti-inflammatory, immune stimulatory, and immune modulatory responses. The expression of multiple virulence factors is also often linked, making it difficult to assess the meaning of their effects in isolation. Overall, H. pylori is thought to usually modulate inflammation and limit acute damage to the mucosa, enabling the bacteria to persist. If this delicate balance is disturbed, disease may then develop

The Modern Approach To The Complex Therapy Of Demodicosis

Demodicosis is one of the most common diseases of the skin. Despite the large number of scientific publications on this issue the question of the etiology and pathogenesis of this disease still remains unresolved and the development of more effective methods of treatment and prevention has not only medical but also social significance as patients preserving the working ability have actually long enough to be on outpatient and even inpatient treatment. In addition the long existence of the rash on the face that is the "business card" leads to the secondary sometimes severe neurotic disorders that results in reducing abilities, isolation, unwillingness to be in a team, family, etc.We investigated the effect of complex therapy which had been conducted by means of antiparasitic, immunomodulatory, anti-inflammatory and desensitizing drugs in patients with demodicosis, as well as mandatory adjustment of changes in the hepato- panсreato-duodenal system. We examined 109 patients with demodicosis from 18 to 39 years old and 10 healthy individuals of the corresponding age and sex. It was established that the effectiveness of treatment of demodicosis based on the application of albendazole in the complex treatment along with immune-modulating therapy and hepatoprotection increased significantly. There has been a reliable rapid regression of clinical symptoms in most patients with demodicosis

Cause-specific hospital admission and mortality among working men: association with socioeconomic circumstances in childhood and adult life, and the mediating role of daily stress

BACKGROUND: The aim of this study was to investigate the association of childhood and adulthood social class with the occurrence of specific diseases, including those not associated with a high mortality rate, and to investigate daily stress as the mechanism for that part of any association which cannot be accounted for by established risk factors. METHODS: This was a prospective cohort study with 25 years of follow-up for cause-specific morbidity and mortality. A total of 5577 Scottish men were recruited from 27 workplaces in the West of Scotland. Childhood social class was determined from the occupation held by the individual's father, and adulthood social class from the individual's occupation at enrolment. Daily stress was measured at enrolment using the Reeder Stress Inventory. RESULTS: Health differentials were found for cardiovascular diseases, lung cancer, peptic ulcer, asthma, accidents and violence, alcohol-related diseases, and perhaps psychiatric illness. Adulthood circumstances were associated with the incidence of most diseases in adulthood, the exception being stroke, which was strongly associated with less privileged circumstances in childhood. Both childhood and adulthood circumstances contributed to the incidence of coronary heart disease. Daily stress did not underlie any of these associations once the influence of established risk factors had been taken into account. CONCLUSIONS: Socioeconomic circumstances in childhood and adulthood both contribute to health differentials in adulthood, the relative contributions depending upon the particular disease. Where known risk factors explained only part of the excess of a disease among individuals raised or living in less-privileged circumstances, there was no evidence to suggest that daily stress was the reason for the unexplained excess