A case of Barrett's oesophagus in pernicious anaemia: acid is not the only culprit!

A 46-year-old female presented at our department with the onset of episodic dyspeptic symptoms, mainly postprandial fullness and bloating, as well as paresthesia. A blood test revealed the presence of mild macrocytic anaemia (haemoglobin 11.3 g/dl; mean corpuscular volume 119 fl), a reduced level of vitamin B12 (60 pmol/l; normal 200–750 pmol/l), hypergastrinaemia (1363 pg/ml; normal for female <100 pg/ml), a low level of pepsinogen I (<2.6 pg/ml; normal 30–100 pg/ml), and positivity for antibodies against parietal cells (>1:100). The upper endoscopy showed in oesophagus a single linear erosion (grade A according to Los Angeles Classification), with an absence of macroscopic gastric abnormalities. At histology, mucosal severe atrophy with moderate intestinal metaplasia was found in fundus and gastric corpus with spared antrum, in the absence of Helicobacter pylori infection. A diagnosis of autoimmune gastritis with pernicious anaemia was therefore made, and the patient started vitamin B12 intramuscular injections. Due to the absence of specific symptoms such as heartburn and/or regurgitation and to the presence of autoimmune gastritis, the erosive oesophagitis was not treated. After 4 weeks of treatment with vitamin B12, the haemoglobin, mean corpuscular volume and vitamin B12 values were restored, paresthesia improved, while dyspepsia remained stable, with sporadic symptoms about once a week

Recent advances in understanding and managing diverticulitis.

In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single ‘causa prima’ will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies

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

Endocrine cells distribution in human proximal small intestine: an immunohistochemical and morphometrical study

Atrophy of the pancreatic remnant after pancreaticoduodenectomy might be consequent to deregulation of pancreatic endocrine stimuli after duodenal removal. Relative technical surgical solution could be the anastomosis of the 1st jejunal loop to the stomach and the 2nd to the pancreatic stump. Data on the distribution of endocrine cells within the proximal intestine might represent the lacking tile of the problem. Our aims were to investigate the distribution pattern of serotonin, cholecystokinin and secretin cells in the duodenum, the 1st and 2nd jejunal loops of humans. Bowel specimens of ten patients submitted to pancreaticoduodenectomy were collected; immunohistochemical reactions and morphometric analyses were performed. A general ab-oral decrease of enteroendocrine cells was found. The rate of serotonin cells showed a significant 30.67±8.13% reduction starting from the 1st jejunal loop versus duodenum. The rate of both cholecystokinin and secretin cells in the duodenum was superimposable to that in the 1st jejunal loop, with a significant 62.88±4.80% loss of cholecystokinin and 39.5±9.31% of secretin cells in the 2nd loop. After removal of duodenum, preservation of the 1st jejunal loop could impact the function of pancreatic remnant maintaining the physiological enteroendocrine stimulus for pancreatic secretion that can compensate, at least in part for the abolished duodenal hormonal release

Upper gastrointestinal symptoms in autoimmune gastritis. A cross-sectional study

Autoimmune gastritis is often suspected for its hematologic findings, and rarely the diagnosis is made for the presence of gastrointestinal symptoms. Aims of this cross-sectional study were to assess in a large cohort of patients affected by autoimmune gastritis the occurrence and the pattern of gastrointestinal symptoms and to evaluate whether symptomatic patients are characterized by specific clinical features. Gastrointestinal symptoms of 379 consecutive autoimmune gastritis patients were systematically assessed and classified following Rome III Criteria. Association between symptoms and anemia pattern, positivity to gastric autoantibodies, Helicobacter pylori infection, and concomitant autoimmune disease were evaluated. In total, 70.2% of patients were female, median age 55 years (range 17-83). Pernicious anemia (53.6%), iron deficiency anemia (34.8%), gastric autoantibodies (68.8%), and autoimmune disorders (41.7%) were present. However, 56.7% of patients complained of gastrointestinal symptoms, 69.8% of them had exclusively upper symptoms, 15.8% only lower and 14.4% concomitant upper and lower symptoms. Dyspepsia, subtype postprandial distress syndrome was the most represented, being present in 60.2% of symptomatic patients. Univariate and multivariate analyses showed that age <55 years (OR 1.6 [CI:1-2.5]), absence of smoking habit (OR 2.2 [CI:1.2-4]), and absence of anemia (OR 3.1 [CI:1.5-6.4]) were independent factors associated to dyspepsia. Autoimmune gastritis is associated in almost 60% of cases with gastrointestinal symptoms, in particular dyspepsia. Dyspepsia is strictly related to younger age, no smoking, and absence of anemia. © 2017 the Author(s). Published by Wolters Kluwer Health, Inc

Occurrence of acute oesophageal necrosis (black oesophagus) in a single tertiary centre

Acute oesophageal necrosis (AON) is a rare condition characterised by the endoscopic finding of diffuse, circumferential, black mucosal pigmentation of the oesophagus, which typically stops at the gastro-oesophageal junction. This observational study aimed to assess the occurrence, clinical characteristics and outcomes of AON in a consecutive endoscopic cohort in a single tertiary university centre. A retrospective analysis of endoscopic data of upper gastrointestinal endoscopy (UGE) was carried out from 2008 to 2018. Out of 25,970 UGE, 16 patients (0.06%) had AON; 75.0% were men with a median age of 75 years. Almost all patients underwent diagnosis during emergency UGE performed for gastrointestinal bleeding, but one patient was diagnosed during elective UGE for persistent vomiting and diarrhoea. All patients reported one or more pre-existing comorbidities and concomitant acute events. Two patients had AON as the first presentation of Zollinger-Ellison syndrome (ZES). One patient developed an oesophageal stenosis, and another patient presented a relapse of AON. Mortality was 50%, but no patient died as a direct consequence of AON. AON is a rare cause of gastrointestinal bleeding diagnosed mainly during emergency UGE. Our study showed that ZES might manifest with this critical presentation, and endoscopists must be aware of this evidence

Upper Gastrointestinal Diseases Before and After Bariatric Surgery.

Obesity represents an important risk factor for the development of gastrointestinal (GI) disorders, most notably gastroesophageal reflux disease (GERD), but also dyspepsia, as well as other symptoms such as nausea, vomiting, and upper abdominal pain. However, the prevalence of proximal abdominal diseases and their relative complications are difficult to assess just on clinical evaluation; the presence of motor and endoscopic alterations are often asymptomatic, probably due to a dysfunction of the autonomic nervous system, which determines an impaired visceral sensation [1,2]. The preoperative GI setting is dramatically changed after bariatric surgery, affecting both gut anatomy and physiology, and influencing the outcomes of GI diseases

Mesalamine (5-ASA) for the Prevention of Recurrent Diverticulitis (Review)

Background Mesalamine, or 5-aminosalicylic acid (5-ASA) has been studied for the prevention of recurrent diverticulitis. Objectives To evaluate the efficacy of mesalamine (5-ASA) for the prevention of recurrent diverticulitis. Search methods We searched databases from 2010 to September 2017. In addition, we scanned reference lists from eligible publications, and we contacted corresponding authors to ask about additional trials. Selection criteria We included randomized controlled clinical trials comparing the efficacy of 5-ASA versus placebo or another active drug for the prevention of recurrent diverticulitis. Main results We included in this review seven studies with a total of 1805 participants. We judged all seven studies to have unclear or high risk of bias. Investigators found no evidence of an effect when comparing 5-ASA versus control for the prevention of recurrent diverticulitis (31.3% vs 29.8%; RR 0.69, 95% confidence interval (CI) 0.43–1.09); very low quality of evidence). Five of the seven studies provided data on adverse events of 5-ASA therapy. The most commonly reported side effects were gastrointestinal symptoms (epigastric pain, nausea, and diarrhea). No significant difference was seen between 5-ASA and control (67.8% vs 64.6%; RR 0.98, 95% CI 0.91–1.06; P = 0.63; moderate quality of evidence), nor was significant heterogeneity observed (I2 = 0%; P = 0.50). Authors’ conclusion&nbsp;&nbsp;The effects of 5-ASA on recurrence of diverticulitis are uncertain owing to the small number of heterogenous trials included in this review. Rates of recurrent diverticulitis were similar among participants using 5-ASA and control participants. Effective medical strategies for the prevention of recurrent diverticulitis are needed, and further randomized, double-blinded, placebo-controlled trials of rigorous design are warranted to specify the effects of 5-ASA (mesalamine) in the management of diverticulitis