Background: Conventional radiological and endoscopic imaging methods of the small bowel (SB) have several limitations, which often delays diagnosis and adequate treatment of small bowel Crohn's disease (SBCD). The recent introduction of Given M2A capsule enteroscopy (CE) may change this scenario, by enabling direct visualization of the entire SB mucosa. Objective: To evaluate the diagnostic value of CE, versus barium enterography (BE), push enteroscopy (PE) and ileo-colonoscopy (IC) in SBCD. Patients and methods: 53 consecutive patients (40 women and 13 men, mean age 36 years, range 14-62), with clinically suspected active CD were included in a prospective, controlled study. Eligible patients had either suspected (61%), based on predefined clinical and biochemical markers, or previously diagnosed CD (39%). Five patients with SB stricture detected on BE and one patient with ischemic enteropathy were excluded from the study. 47 patients completed all 4 examinations, i.e. standard BE (89% enteroclysis, 11% SB follow through), IC, PE and CE were evaluated. All examinations were performed within 3 months by experienced investigators. Results: Crohn's lesions (multiple erosions, ulcerations and/or strictures) in the SB were visualized by one or more methods in 25 (53%) of the 47 patients. All cases with SBCD detected on BE, PE and IC were also identified using CE except 3 (12%) cases where the capsule did not pass through the entire SB during the examination. Notably, CE identified 4 additional patients with CD and detected more extended SBCD in 6 (24%) patients compared to the other methods. Intubation of ileum was unsuccessful in 3 (12%) cases examined by IC. All examinations were performed without complications. The capsule was easily swallowed by all patients and was expelled without side effects. CE was preferred to BE by 95% of patients. Sensitivity and specificity of the studied methods for detecting SBCD are showed in the table. Conclusions: CE is a safe, well-tolerated and more sensitive imaging modality for visualizing Crohn's lesions in the entire SB compared with BE, PE and IC. Our data suggest that capsule endoscopy may be considered as a first line imaging examination in patients with suspected, non-stricturing small bowel Crohn's disease.

Capsule endoscopy (CE) has greatly facilitated the diagnosis of small-bowel lesions in patients with obscure gastrointestinal bleeding [1]. It was recently reported by Hollerbach et al. [2] that endoscopically assisted video capsule endoscopy facilitates the investigation of the small bowel in patients with functional gastric outlet obstruction. Swallowing difficulties, which are not uncommon in elderly patients, may also make it difficult to carry out CE [3]. To avoid this, we have successfully tested a modified approach to CE in these patients.

Background: Diagnosis of small bowel tumors is frequently delayed due to the difficulty to visualize the small intestine with current standard imaging methods. Wireless Given® capsule endoscopy (CE) provides a new possibility to improved identification of pathologic changes in the small bowel. Aim: To determine the diagnostic value of CE in patients with obscure gastrointestinal (GI) bleeding caused by small bowel tumors.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP)-induced pancreatitis (EIP) provides an opportunity to study different pathophysiologic events early in the course of acute pancreatitis.Aims: To investigate whether the leakage of pancreatic proenzymes (anionic trypsinogen), pancreatic protease activation (carboxypeptidase B activation peptide), cytokine response (interleukin [IL]-1 receptor antagonist, IL-6, and soluble tumor necrosis factor receptor-I) and neutrophil activation (neutrophil gelatinase-associated lipocalin and polymorphonuclear elastase) differ between patients with and without EIP. A second aim was to clarify the temporal relation between these different events.Methodology: Ninety-nine nonconsecutive patients undergoing ERCP were investigated in the study.Results: Fourteen of 99 patients undergoing ERCP developed mild EIP. Six hours after the investigation the concentration of anionic trypsinogen was significantly higher in patients with EIP than in patients without EIP. The day after ERCP, higher concentrations of anionic trypsinogen, carboxypeptidase B activation peptide, IL-6, and polymorphonuclear elastase were recorded in the EIP group. No significant differences in IL-1 receptor antagonist. soluble tumor necrosis factor receptor-I or neutrophil gelatinase-associated lipocalin were found between the groups in this study.Conclusion: Mild EIP was accompanied by early leakage of proenzymes and later activation of trypsinogen/proteases. A significant cytokine response and neutrophil activation were recorded the day after ERCP. but further studies are needed to determine the temporal relation between these different pathophysiologic events.

Background/Aims: This study aims at describing the natural history and outcome of small duct primary sclerosing cholangitis (PSC).Methods: Thirty-two patients with small duct PSC were studied. The average time taken for diagnosis was 69 (1-168) months. The median follow-up time was 63 (1-194) months.Results: All patients including one who underwent liver transplantation because of end-stage liver disease and hepatocellular carcinoma were alive at follow-up. None developed cholangiocarcinoma. In 27 patients repeated cholangiographic examinations were done after a median time of 72 (12-192) months from first ERCP. Four developed features of large duct PSC.Conclusions: Small duct PSC rarely progresses to large bile duct PSC and it seems to have a benign course in most patients and no development of cholangiocarcinoma was found. (C) 2002 European Association for the Study of the Liver. Published by Elsevier Science B.V. All rights reserved.

Background: Flat and depressed colorectal tumours are common in Japan but are very rare or non-existent in Western countries. Aims: To study the occurrence of flat colorectal tumours in a southern Swedish population. Methods: In this prospective study, 371 consecutive European patients were examined by high resolution video colonoscopy combined with chromoendoscopy. The nature of the lesions was determined by histopathological examination. Results: A total of 973 tumours were found; 907 (93.2%) were protruding and 66 (6.8%) were flat or depressed. Of the flat/depressed tumours, five (7.7%) were early adenocarcinomas infiltrating the submucosa. Eleven carcinomas (1.2%) were found among protruding tumours. High grade dysplasia was observed in 18% (n=11) of flat/depressed adenomas in contrast with 7.3% (n=65) of protruding adenomas, and occurred in smaller flat/depressed tumours compared with protruding ones (mean diameter 8 mm v 23 mm, respectively). Furthermore, high grade dysplasia was significantly more common in flat elevated tumours with central depression or in depressed adenomas (35.7%; 5/14) than in flat elevated adenomas (12.8%; 6/47). Conclusion: Flat and depressed tumours exist in a Western population. Future studies should address whether or not chromoendoscopy with video colonoscopy is necessary in the search for flat colorectal neoplasms.

The PiZ allele may be a contributing factor in the development of DU in H. pylori-positive individuals.

Background: Clopidogrel is a new antiplatelet agent that offers increased protection over aspirin in preventing vascular ischaemic events in patients with symptomatic atherosclerosis. In a large, randomized, international study of clopidogrel and aspirin (n = 19,185 patients) clopidogrel was associated with a lower incidence of gastrointestinal adverse events, including gastrointestinal haemorrhage and hospitalizations because of gastrointestinal haemorrhage. The aim of the study was to determine whether macroscopic differences in the gastric mucosa between aspirin- and clopidogrel-treated subjects could be detected by gastroscopy after short-term treatment. Methods: Thirty-six healthy volunteers were randomized in a double-blind, double-dummy, parallel design, to 75 mg/day of clopidogrel or 325 mg/day of aspirin for 8 days. Gastroscopy was performed at base line before administration of study drug and directly after treatment completion. Gastroduodenal effects were measured in accordance with a modified Lanza scale. Results: At base line no difference between the groups was detected (median Lanza score, 0.0 in both groups). At the end of treatment the aspirin group showed a median score of 7.5, and the clopidogrel group showed an unchanged median score of 0.0 (P < 0.001). In the aspirin group 13 individuals reported 19 adverse events versus 8 individuals and 13 adverse events for clopidogrel, with approximately half of the adverse events being gastrointestinal in each group. No serious adverse events were reported. Conclusion: In contrast to aspirin, short-term treatment with clopidogrel does not induce macroscopic changes in the gastroduodenal mucosa. The study results show that in patients without gastroduodenal disease clopidogrel, but not aspirin, does not induce any gastroscopically evident erosions during short-term treatment.

BACKGROUND In patients with a narrow-necked juxtapapillary diverticulum the endoscopic cannulation of the papilla of Vater and the subsequent biliary therapy is sometimes impossible. PATIENTS AND METHODS Three patients referred for endoscopic retrograde cholangiography and stone extraction were included. Earlier attempts to cannulate failed because visual control was impeded by narrow-necked juxtapapillary diverticula with the papilla located in the fundus. Endoscopic balloon dilation of the narrow diverticular neck, using a 15-mm stone retrieval balloon, was carried out. RESULTS In all three cases the papillary orifice was readily brought into view after balloon dilation of the diverticular opening. Subsequent endoscopic treatment to the bile duct was successful without any complications. CONCLUSION Balloon dilation of a narrow-necked juxtapapillary diverticulum is a safe and easy procedure, which facilitates both cannulation of the papilla and subsequent biliary endoscopic treatment.

The bisphosphonate, alendronate sodium (e.g. Fosamax), a bone resorption inhibitor used to treat osteoporosis, has occasionally been reported to cause severe oesophagitis. The characteristic endoscopy findings include oesophageal ulceration with discoloured exudate, a narrowed lumen and denuded, haemorrhagic mucosa. The oesophagitis heals on discontinuation of alendronate medication, and the institution of gastric acid suppression treatment. The article consists in discussion of such adverse reactions, illustrated by three case reports. As many of the patients selected for alendronate treatment are elderly and handicapped, to minimise the risk of serious side-effects it is important not only to give detailed instructions regarding medication, but also to ensure that they are properly understood. As a history of swallowing problems was a feature of all three cases reported, caution is recommended before treating such patients with alendronate sodium.

Indications for enteroscopic examination of the proximal small bowel are expanding, above all in cases of gastro-intestinal bleeding of obscure origin. Of 66 patients examined enteroscopy revealed new and unforeseen diagnoses in about half of them, such as angiodysplasia and erosions (15 per cent of cases each). Former as well as ongoing bleeding was treated with electro cautery, bicap. In four cases the need for blood transfusion ceased. Ulcers, neoplasia and varices were also diagnosed. 16 out of 36 pathologic lesions were located within reach of an ordinary gastroscope, in spite of the patients being selected through repeated normal upper and lower endoscopic examinations. This emphasises the need for better quality assurance in routine endoscopic examinations.

Double-contrast barium enema has a reduced sensitivity in patients with severe sigmoid diverticulosis. Therefore a carboxy methyl cellulose enema was employed after the conventional double-contrast examination in 15 patients with sigmoid diverticulosis. A significant increase in lumen diameter and a superior removal of barium residue from the diverticulas facilitated the interpretation of the sigmoid loops. Conclusion: The addition of methyl cellulose enema to double-contrast barium imaging improves diagnostic imaging in diverticulosis by expanding the lumen and emptying the diverticulas.

PURPOSE:Changes in morbidity pattern of ulcerative colitis have created a need to update understanding of the course of the disease.METHOD:A follow-up study was done of relapse rates and progression of inflammation in 571 non-selected patients with ulcerative and indeterminate colitis.RESULTS:Relapse rate ten years after diagnosis was 70 percent in definite ulcerative colitis, 22 percent in probable ulcerative colitis, and 77 percent in indeterminate colitis. During the study period, there was no change in the relapse rate. In relapsing proctitis, 52 percent developed more extensive inflammation. Fifty-four percent of patients with only one attack of colitis had persistent signs of inflammatory bowel disease.CONCLUSIONS:Shift in morbidity pattern to a greater proportion of patients with proctitis at diagnosis and a shorter time from onset of symptoms to diagnosis had no influence on the relapse rate. Indeterminate colitis has a worse prognosis than definite ulcerative colitis. Considering the documented efficacy of sulfasalazine, the high relapse rate calls for studies of the effectiveness of such treatment in everyday practice.