Treatment of diverticular disease: an update on latest evidence and clinical implications

Background: Diverticular disease (DD) is a common condition, especially in Western countries. In about 80% of patients, colonic diverticula remain asymptomatic (diverticulosis), while approximately 20% of patients may develop abdominal symptoms (symptomatic uncomplicated diverticular disease, SUDD) and, eventually complications as acute diverticulitis (AD). The management of this condition has been improved, and in the last five years European countries and the USA have published guidelines and recommendations. Scope: To summarize the latest evidence and clinical implication in treatment of DD focusing the attention either on the treatment of diverticulosis, SUDD and AD together with the primary and secondary prevention of diverticulitis. Findings: The present review was based on the latest evidence in the treatment of DD in the last 10 years. In the last 5 years, six countries issued guidelines on DD with differences regarding covered topics and recommendations regarding treatments. At present there is a lack of rationale for drug use in patients with asymptomatic diverticulosis, but there are limited indications to suggest an increase in dietary fibre to reduce risk of DD. To achieve symptomatic relief in SUDD patients, several therapeutic strategies with fibre, probiotics, rifaximin and mesalazine have been proposed even if a standard therapeutic approach remained to be defined. Agreement has been reached for the management of AD, since recent guidelines showed that antibiotics can be used selectively, rather than routinely in uncomplicated AD, although use of antibiotics remained crucial in the management of complicated cases. With regard to treatment for the primary and secondary prevention of AD, the efficacy of rifaximin and mesalazine has been proposed although with discordant recommendations among guidelines. Conclusion: Treatment of DD represented an important challenge in clinical practice, especially concerning management of SUDD and the primary and secondary prevention of AD

Treatment of helicobacter pylori infection in atrophic gastritis

Helicobacter pylori (Hp) is a major human pathogen causing chronic, progressive gastric mucosal damage and is linked to gastric atrophy and cancer. Hp-positive individuals constitute the major reservoir for transmission of infection. There is no ideal treatment for Hp. Hp infection is not cured by a single antibiotic, and sometimes, a combined treatment with three or more antibiotics is ineffective. Atrophic gastritis (AG) is a chronic disease whose main features are atrophy and/or intestinal metaplasia of the gastric glands, which arise from long-standing Hp infection. AG is reportedly linked to an increased risk for gastric cancer, particularly when extensive intestinal metaplasia is present. Active or past Hp infection may be detected by conventional methods in about two-thirds of AG patients. By immunoblotting of sera against Hp whole-cell protein lysates, a previous exposure to Hp infection is detected in all AG patients. According to guidelines, AG patients with Hp positivity should receive eradication treatment. The goals of treatment are as follows: (1) Cure of infection, resolution of inflammation and normalization of gastric functions; (2) possible reversal of atrophic and metaplastic changes of the gastric mucosa; and (3) prevention of gastric cancer. An ideal antibiotic regimen for Hp should achieve eradication rates of approximately 90%, and complex multidrug regimens are required to reach this goal. Amongst the factors associated with treatment failure are high bacterial load, high gastric acidity, Hp strain, smoking, low compliance, overweight, and increasing antibiotic resistance. AG, when involving the corporal mucosa, is linked to reduced gastric acid secretion. At a non-acidic intra-gastric pH, the efficacy of the common treatment regimens combining proton pump inhibitors with one or more antibiotics may not be the same as that observed in patients with Hp gastritis in an acid-producing stomach. Although the efficacy of these therapeutic regimens has been thoroughly tested in subjects with Hp infection, there is a paucity of evidence in the subgroup of patients with AG. Bismuth-based therapy may be an attractive treatment in the specific setting of AG, and specific studies on the efficacy of bismuth-based therapies are needed in patients with AG

Pressure-induced coordination change of Ti in silicate glass: a XANES study

The effect of pressure on titanium coordination in glasses, with composition K2TiSi4O11, quenched isobarically from liquids equilibrated at high pressure (5, 10, 15, 20, 25, 30 kbar respectively) and T=1600° C has been investigated by X-ray absorption spectroscopy (XAS). The XANES spectra collected at the Ti K-edge clearly show a variation with pressure that is related to changes in the geometrical environment around the Ti atoms. By comparison with spectra of standard materials, the XANES spectra of the glasses suggest a relatively low average coordination number (near 5) in samples quenched at low pressure and a higher coordination number (near 6) in samples quenched from the highest pressure. The combination of XANES data with density and compressibility measurements supports the idea that a mixture of 6- and lower coordinated (4- and/ or 5-coordinated) Ti geometries are present in the 1 bar glass, and an increasing proportion of 6-coordinated Ti occurs in the glasses synthesized at progressively higher pressures

X-ray absorption study of Ti-bearing silicate glasses

Ti K-edge XANES spectra have been collected on a series of Ti-bearing silicate glasses with metasilicate and tetrasilicate compositions. The intensity of the preedge feature in these spectra has been found to change with glass composition and varies from 29 to 58% (normalized intensity) suggesting a variation in structural environent around the absorbing atom. The pre-edge peak intensity increases for the alkali titanium tetrasilicate glasses from 35% to 58% in the order Li < Na < K < Rb, Cs whereas for the metasilicate compositions there is a maximum for the K-bearing glass. The pre-edge peak intensity remains constant for the alkaline earth titanium metasilicate glasses, Ca and Sr (34%) but increases slightly for Ba (41%). As the intensity of this feature is inversely correlated with coordination number, a comparison of the pre-edge intensity data for the investigated glasses with those of materials of known coordination number leads us to establish a regression equation and to infer that the average coordination number of Ti in these glasses ranges from 4.8 to 5.8. Large alkali cations appear to stabilize a relatively low average coordination number for Ti in silicate melts. The Ti structural environment results appear also to vary as a function of SiO2 content within the K2O-TiO2-SiO2 system. A number of physical properties of the melts from which these glasses were quenched and of other Ti-bearing silicate melts, have been determined in recent years. Clear evidence of a variable coordination number of Ti, consistent with the interpretation of the present XANES data is available from density measurements. These and other property determinations are compared with the present spectroscopic observations in an attempt to relate structure and properties in these melts which contain a major component with variable coordination number

The role of initial conditions in the ageing of the long-range spherical model

The kinetics of the long-range spherical model evolving from various initial states is studied. In particular, the large-time auto-correlation and -response functions are obtained, for classes of long-range correlated initial states, and for magnetized initial states. The ageing exponents can depend on certain qualitative features of initial states. We explicitly find the conditions for the system to cross over from ageing classes that depend on initial conditions to those that do not.Comment: 15 pages; corrected some typo

Common Pitfalls in the Management of Patients with Micronutrient Deficiency. Keep in Mind the Stomach

Micronutrient deficiencies are relatively common, in particular iron and cobalamin deficiency, and may potentially lead to life-threatening clinical consequences when not promptly recognized and treated, especially in elderly patients. The stomach plays an important role in the homeostasis of some important hematopoietic micronutrients like iron and cobalamin, and probably in others equally important such as ascorbic acid, calcium, and magnesium. A key role is played by the corpus oxyntic mucosa composed of parietal cells whose main function is gastric acid secretion and intrinsic factor production. Gastric acid secretion is necessary for the digestion and absorption of cobalamin and the absorption of iron, calcium, and probably magnesium, and is also essential for the absorption, secretion, and activation of ascorbic acid. Several pathological conditions such as Helicobacter pylori-related gastritis, corpus atrophic gastritis, as well as antisecretory drugs, and gastric surgery may interfere with the normal functioning of gastric oxyntic mucosa and micronutrients homeostasis. Investigation of the stomach by gastroscopy plus biopsies should always be considered in the management of patients with micronutrient deficiencies. The current review focuses on the physiological and pathophysiological aspects of gastric acid secretion and the role of the stomach in iron, cobalamin, calcium, and magnesium deficiency and ascorbate homeostasis

High concordance between trained nurses and gastroenterologists in evaluating recordings of small bowel video capsule endoscopy (VCE)

Background & Aims: The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming. A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations. Methods: This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as “thumbnails” and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded. Results: A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 ± 12 years, range: 27−86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients. There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference:-79.6%). Conclusions: Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure

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