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Volume 74 - 2011 - Fasc.3 - Original articles

Acute upper gastrointestinal bleeding in cirrhosis : Changes and advances over the past two decades

Background and aims : Few studies have compared two or more cohorts of cirrhotic patients admitted for upper gastrointestinal bleeding (UGIB) several decades apart. Our aim was to compare epidemiological, clinical, therapeutic and prognostic characteris- tics of UGIB (whatever the source) in two cohorts of cirrhotic patients admitted to the emergency room of the same general hospital 2 decades apart. Methods : One-hundred cases of UGIB in cirrhotic patients consecutively admitted between 1984 and 1990 (cohort A) were compared with 100 similar cases admitted between 2004 and 2009 (cohort B). Results : The sex ratio (M/F : 2/1), mean age (approximately 55Y) and the proportion of patients with alcoholic cirrhosis (approximately 80%) did not change. Mean Child-Pugh score and the proportion of patients in Child-Pugh stage C increased from 7.6 and 19% in cohort A to 8.8 and 35% in cohort B (p < 0.001). Therapeutic intervention was performed during initial endoscopy in 13 cases from cohort A and 50 from cohort B (p < 0.001), respectively. The number of transfused patients (85 in cohort A, 58 in cohort B) and the number of red blood cell units administered on the first day (median : 4 in cohort A, 2 in cohort B) were significantly decreased in cohort B (p < 0.001). The rate of rebleeding (45 in cohort A, 11 in cohort B), the need for rescue sur- gery (8 in cohort A, 0 in cohort B) and the in-hospital mortality (24 in cohort A, 9 in cohort B) significantly decreased in the more recent cohort (p < 0.005). Conclusion : This study demonstrated that several characteris- tics of cirrhotic patients admitted with UGIB have changed over the past 2 decades. Above all, outcome has improved despite an increase in the severity of cirrhosis. (Acta gastroenterol. belg., 2011, 74, 381-388).


Lean non-alcoholic fatty liver disease (Lean-NAFLD): a major cause of cryptogenic liver disease

Aims : Non-alcoholic fatty liver disease (NAFLD) is strongly associated to obesity and type 2 diabetes, but may occur in the absence of these factors. Based on a large series of liver biopsies, we have evaluated the clinical, biochemical, metabolic and pathologi- cal characteristics of a new entity, which we refer to as "lean- NAFLD". Methods : Among 1,777 patients, who underwent liver biopsy for chronic liver disease, Lean-NAFLD, defined as patients with NAFLD without obesity (BMI < 30 kg/m2) and without diabetes was found in 50 of them (2.8%), being the most frequent cause (38%) of cryptogenic liver disease. Thirty-one patients from the Lean-NAFLD group were compared to 48 Obese-NAFLD patients diagnosed during the same period and 8 healthy control patients. Insulin resistance was determined using the homeostasis model assessment method. Results : In the Lean-NAFLD group as compared to the obese- NAFLD group, patients were younger : median 40 vs. 49 years, p = 0.047, with male predominance : 71 vs. 46%, p = 0.037. Fasting glucose and HbA1c were lower, as was insulin sensitivity : 1.7 vs. 3.0, p = 0.049. Blood pressure was significantly lower (p = 0.001) while triglycerides and HDL-cholesterol were similar. Although there was less inflammation (p = 0.038) and fibrosis (p = 0.029), non-alcoholic steatohepatitis and fibrosis were present in 61% and 55% of the Lean-NAFLD group, respectively. Compared to healthy controls, Lean-NAFLD were less insulin sensitive, with a insulin sensitivity index of 59 vs. 110 (p = 0.015), and more hyper- triglyceridemic (p = 0.003). Conclusions : Lean-NAFLD is a new unrecognized clinico- pathological entity, a frequent cause of cryptogenic liver disease. (Acta gastroenterol. belg., 2011, 74, 389-394).


The importance of upper gastrointestinal lesions detected with capsule endoscopy in patients with obscure digestive bleeding

Study aims : Small bowel capsule endoscopy (SBCE) is the first line procedure for detecting small bowel lesions in patients with an obscure gastrointestinal bleeding (OGIB). Missed upper gastro- intestinal (UGI) lesions at the initial endoscopy may account for the so-called OGIB. This retrospective study was designed to assess the role of SBCE in detecting missed UGI lesions. Methods : All consecutive SBCE that were performed in the last year for patients with OGIB were included in our study. We evalu- ated the visibility of the gastric mucosa, the anatomic landmarks, the presence of UGI lesions as well as their clinical importance. The SBCE findings were compared with the reports of previous UGI endoscopies. Results : 118 patients (45 males, 73 females, mean age 61 ± 19 years) were included in the analysis. The indication for SBCE was obscure overt and occult OGIB in 60 and in 58 patients, respectively. SBCE identified lesions in the small bowel in 42% of the patients. An excellent visibility of gastric mucosa was observed in 83/118 cases (70.3%). SBCE identified gastric lesions with poten- tial clinical significance (high bleed potential) in 25/118 (21.2%) patients. In 12/118 (10.2%) patients the UGI lesions detected by SBCE were considered as the only potential source of bleeding. Conclusions : In patients with OGIB, SBCE detected not only small bowel lesions but also significant UGI lesions that were missed or underestimated at the initial endoscopy in 21% of cases. It is therefore necessary to carefully read the gastric images when performing an SBCE. (Acta gastroenterol. belg., 2011, 74, 395-399)


Single-centre experience on use of videocapsule endoscopy for obscure gastro- intestinal bleeding in 120 consecutive patients

Background and study aims: Capsule endoscopy (CE) has become first choice for evaluation of the small bowel in case of obscure gastrointestinal bleeding (OGIB). The influence of clinical factors on CE diagnostic yield remains controversial and little is known about the exact impact of CE on management and outcome. We aimed to identify the ideal candidates for CE examination in daily practice by reviewing our own data and the available literature. Patients and methods: We retrospectively analyzed data of 120 consecutive patients with OGIB (33 overt - 87 occult) that under- went CE in a single centre. Results : Complete evaluation of the small bowel was achieved in 82,5%, with only one case of capsule retention. The overall diag- nostic yield was 47,5% and no difference was noted in the overt versus the occult group. Only the presence of cardiovascular comorbidity was associated with a statistically significant increase in diagnostic yield (p = 0,041). Arterio-venous malformation (AVM) was diagnosed most frequently in 68,4% of positive studies. Specific management alterations were made in 22 patients (18,3%) following CE, mostly guided by a positive result (91%) (p = 0,0001). Conclusion : In daily practice it remains very difficult to predict pathology detection rate on CE as well as to estimate the impact on further management and outcome in the individual patient. Diagnostic yield is significantly higher in patients with cardio- vascular comorbidity than in those without. (Acta gastroenterol. belg., 2011, 74, 400-406).


“7, 10 and 14-days rabeprazole-based standard triple therapies for H. pylori eradication : Are they still effective ? A randomized trial"

Background & study aims : Increasing data suggests that the efficiency of standard triple therapies of 7-10-14 days duration has fallen below the threshold for acceptability (80% cure rates in intention to treat analysis). Use of rabeprazole, a PPI less influ- enced by CYP2C19 gene polymorphisms is reported to lead to improved eradication rates. This study aims to re-examine the effectiveness of 7-10-14 days triple therapies based on rabeprazole in Greek patients. Patients and methods : 307 patients, from 2 endoscopic centers in Greece, were randomized to receive Rabeprazole 20mg bid, Clarithromycin 500 mg bid, and Amoxycillin 1gr bid for 7-days, for 10-days or for 14-days. Cure rates were assessed by CLO-test and histology. Clarithromycin sensitivity tests were carried out in the cultured pre-treatment H. pylori strains. The success rates were calculated by both intention-to-treat (ITT) and per protocol (PP) analyses. Results : The eradication rates according to ITT analyses were 74.5% (95% CI : 66.5-82.9%) for 7-days, 80.6% (95% CI : 73.2- 88.2%) for 10-days and 90.2% (95% CI : 84.5-95.9%) for 14-days treatment. PP cure rates were 76% (95% CI : 68.4-85.0%) for 7- days, 83% (95% CI : 76.6-91.0%) for 10-days and 93.9% (95% CI : 86.7-97.3%) for 14-days treatment. Side effects were general- ly minor and comparable in all treatment groups. Conclusions : Both 10- and 14-days rabeprazole-based triple regimens reached eradication rates above the threshold of 80% on an intention to treat basis. In our setting, the current regimen using rabeprazole, amoxicillin and clarithromycin was well tolerated, is still effective and should continue to be recommended as first-line therapy for H. pylori eradication. (Acta gastroenterol. belg., 2011, 74, 407-412).