We present the video of 4 patients with biliary parasitosis, diagnosed and treated by endoscopic retrograde cholangiopancreatography (ERCP), in a series of more than 3000 CPREs performed in a gastroenterology department (prevalence < 0.14%).

ERCP is the first-line technique for the treatment of biliary stones. Most stones are successfully removed using extraction balloons and/or Dormia baskets, and in more complex cases, using mechanical lithotripsy and/or balloon dilation of the ampulla after sphincterotomy. There are, however, a small group of patients with complicated stones, in which these techniques are not effective.

We present the video of 4 cases of obstructive jaundice solved with endoscopic ultrasonography guided biliary drainage. In 3 of these patients, it was not possible to access the second duodenal portion and/or to visualize the papilla major due to the presence of pancreatic head adenocarcinomas with subsequent duodenal invasion, which led to choledochoduodenostomies in two of them, and the placement of a anterograde transpapillar metal stent through the duodenal bulb in the other patient.

Selective biliary duct cannulation is an essential prerequisite for biliary ERCP. Some authors suggest that the difficulty of biliary cannulation and the use of rescue techniques (rT) can be conditioned, among other factors, by the papillary morphology. We intend to evaluate if the duration of biliary cannulation, the existence of a difficult cannulation and the use of rT are influenced by the papillary morphology.

Background Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular.Aim The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H-2-breath testing in gastrointestinal diseases.Methods Experts were selected on the basis of a proven knowledge/expertise in H-2-breath testing and divided into Working Groups ( methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group.Results and conclusions The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H-2-breath testing in the clinical practice and methods to be used for performing the tests.

Blue rubber bleb nevus syndrome (BRBNS) is a rare condition that consists of multiple venous malformations involving several organ systems, particularly the skin and the gastrointestinal tract, but any part of the body may be affected. Less than 250 cases have been reported in the literature. The authors describe the thoracic, abdominal, and pelvic imaging characteristics at computed tomography (CT) in a 50-year-old man with BRBNS.

Objective. Celiac disease ( CD) is characterized by malabsorption, weight loss and increased energy expenditure. The aim of this study was to investigate the relationship between circulating ghrelin and leptin, which are produced at gastrointestinal level and are involved in energy balance regulation, and changes in body composition and energy metabolism in CD patients before and after gluten-free diet (GFD)-induced restoration of the intestinal mucosa. Material and methods. Body composition (by dual-energy X-ray absorptiometry), resting metabolic rate and substrate oxidation rates (by indirect calorimetry) were assessed in 18 adult women with the classic form of CD (age 31.4 +/- 7.8 years, body mass index (BMI) 20.6 +/- 2.1 kg/m(2)) before and at least 2 years after GFD treatment and in 22 age-matched healthy women (age 33.1 +/- 7.2 years, BMI 22.9 +/- 2.1 kg/m(2)). Plasma leptin and ghrelin concentrations were assessed by the ELISA and RIA procedures, respectively. Results. Fat-free mass was reduced before and after GFD compared to control subjects (p <0.01), while fat mass increased after treatment (p <0.01). Plasma leptin concentration was similar between groups and correlated only with BMI (r = 0.84; p <0.0001) and percentage body fat (r = 0.86; p <0.0001). Circulating ghrelin levels (pg/ml) were similar between untreated patients and control subjects, but decreased after GFD treatment (untreated CD: 282.6 +/- 55.5 versus treated 109.2 +/- 49.9; p <0.0001 and versus control subjects 262.2 +/- 30.0; p <0.0001) and were negatively correlated with BMI in CD patients (r = -0.32; p <0.01). Conclusions. The low plasma ghrelin concentration found in CD patients after GFD treatment could only be partially explained by the slight increase in body-weight and fat mass. Further studies are needed to better ascertain the role played by an incomplete functional or quantitative recovery of ghrelin-producing cells in CD.

We evaluated the prevalence and features of colonic polyps in a population of acromegalic subjects, compared to a control group of patients with irritable bowel syndrome (IBS). Colonic polyps were found in 30 acromegalic subjects (40%) and in 10 controls (13%) (P < 0.0001). Among the acromegalic patients, polyps were of the hyperplastic type in 27 subjects (90%) and adenomatous in 3 (10%). In the control group, polyps were hyperplastic in nine subjects (90%) and adenomatous in one (10%). We also observed a significant association (P < 0.0001) between the presence of hyperplastic polyps and the older age in both the acromegalic and the control groups. There were no differences between the two groups regarding sex, site, size, or macroscopic and histological types of polyps. Acromegalic patients have a higher prevalence of colonic hyperplastic polyps than IBS subjects, while the prevalence of adenomatous polyps is similar in the two groups.

Background Although previous studies have shown increased mortality in patients with coeliac disease and their relatives, no data are available in relation to different patterns of clinical presentation. We assessed mortality in patients with coeliac disease and their first-degree relatives.Methods We enrolled, in a prospective cohort study, 1072 adult patients with coeliac disease consecutively diagnosed in 11 gastroenterology units between 1962 and 1994, and their 3384 first-degree relatives. We compared the number of deaths up to 1998 with expected deaths and expressed the comparison as standardised mortality ratio (SMR) and relative survival ratio.Findings 53 coeliac patients died compared with 25.9 expected deaths (SMR 2.0 [95% CI 1.5-2.7]). A significant excess of mortality was evident during the first 3 years after diagnosis of coeliac disease and in patients who presented with malabsorption symptoms (2.5 [1.8-3.4]), but not in those diagnosed because of minor symptoms (1.1 [0.5-2.2]) or because of antibody screening (1.2 [0.1-7.0]). SMR increased with increasing delay in diagnosis and for patients with poor compliance with gluten-free diet. Non-Hodgkin lymphoma was the main cause of death. No excess of deaths was recorded in relatives with coeliac disease.Interpretation. Prompt and strict dietary treatment decreases mortality in coeliac patients. Prospective studies are needed to clarify the progression of mild or symptomless coeliac disease and its relation to intestinal lymphoma.

Background and aims. Coeliac disease is associated with several autoimmune,tune disorders such as insulin-dependent diabetes, Sjogren's syndrome, Addison's disease and thyroid diseases. The aim of our study was to evaluate the prevalence of coeliac disease in patients affected by autoimmune thyroid diseases by means of anti-gliadin and anti-endomysial antibodies.Patients. We studied 92 patients affected by autoimmune thyroid diseases (47 chronic autoimmune thyroiditis, 22 Hashimoto's thyroiditis and 23 Graves' disease). Ninety patients with non autoimmune thyroid disorders (51 multifollicular goitre, 28 solitary nodule and II papillary carcinoma) and 236 blood donors also took part in the study as control groups.Methods. Total serum IgA were measured in all subjects to exclude selective IgA deficiency; then we measured antigliadin antibodies and anti-endomysial antibodies. In patients with anti-gliadin/anti-endomysial antibody positivity and/or with haematinic and laboratory signs of malabsorption we carried out gastrointestinal endoscopy with duodenal histological examination.Results, Among the 92 patients with autoimmune thyroid disease, 4 (4.3%) showed anti-gliadin and anti-endomysial positivity and had coeliac disease; among the 90 patients with non autoimmune thyroid diseases, I (1.1%) had coeliac disease; finally, among the blood donors, I subject (0.4%) was anti-gliadin-anti-endomysium antibody positive and had coeliac disease, Those subjects presenting with only anti-gliadin antibody positivity did nor have coeliac disease.Conclusions. These results show that the prevalence of coeliac disease in patients with autoimmune thyroid diseases is significantly increased when compared with the general population (p=0.009) but not with patients affected by non autoimmune thyroid disorders (p=0.18), We suggest a serological screening for coeliac disease in all patients with autoimmune thyroid disease measuring anti-endomysial antibodies, considering that early detection and treatment of coeliac disease are effective in preventing its complications.

BACKGROUND:Mucosa-associated lymphoid tissue (MALT) develops in gastric mucosa in response to chronic antigenic stimulation, such as Helicobacter pylori infection. However, reactive lymphoid follicles have been found also in the stomach of H. pylori-negative coeliac patients, suggesting that other environmental factors may be involved in MALT genesis. The aim of our study was to evaluate the effects of gluten withdrawal in H. pylori-negative coeliac patients with gastric MALT.METHODS:We studied 23 H. pylori-negative untreated coeliac patients with gastric MALT. All patients underwent determination of antigliadin (AGA) and antiendomysium antibodies (EMA) and upper endoscopy with multiple biopsies in duodenum, gastric corpus, and antrum. Lymphoid follicles and H. pylori status were assessed by histopathologic and enzymatic analysis. All patients were started on a gluten-free diet and were reevaluated after 12 months. To consider their adherence to the gluten-free diet we relied on direct patient questioning. Thirteen patients who had strictly adhered to the gluten-free diet constituted our study group. Ten patients who had not strictly adhered to gluten withdrawal from their diet constituted the control group.RESULTS:Regression of MALT was obtained in 9 of 13 (69%) patients who strictly followed the gluten-free diet; in the control group MALT disappeared in 2 of 10 (20%) patients (P=0.0361).DISCUSSION:Disappearance of reactive lymphoid follicles in the gastric mucosa of H. pylori-negative coeliac patients after gluten withdrawal suggests that antigens related to alimentary gluten may constitute persistent stimuli for development of gastric MALT in coeliac patients.

BACKGROUND/AIMS: This is a seven-year prospective study based on all gastroscopic examinations of our patient population in order to study gastric polyps.METHODOLOGY: One hundred and twenty-one polyps, removed from 96 patients were analysed. All polyps, after endoscopic polypectomy, were classified according to their histotype. The follow-up was carried out in 49 patients for a mean time of 40 months.RESULTS: Polypoid lesions were more frequent in females (57.3%) and they were preferentially located in antrum (60.3%). Hyperplastic and inflammatory polyps were 55.4% and 28.9%, respectively, while adenomatous lesions were 9.9%. Four fundic gland polyps, 1 carcinoid, 1 type I early gastric cancer and 1 pancreatic heterotopia were also found. During the follow-up no malignant lesion was encountered. On the other hand 25 benign polyps were found in 19 patients.CONCLUSIONS: Our experience confirms that there is a close relationship between the size of the polyps and the neoplastic change. In fact, in our series all polyps were smaller than 2 cm and only one malignancy was found (an early gastric cancer). None of adenomatous polyps was associated with gastric adenocarcinoma. Our data also indicates that when a polypectomy is carried out for small polyps (smaller than 2 cm.) a strict follow-up is necessary for the neoplastic polyps only.

BACKGROUND:Alcohol abusers frequently have gastrointestinal symptoms, such as diarrhea, nausea and vomiting. In the genesis of these symptoms multiple mechanisms are involved, including alteration of gastrointestinal motility. The aim of our study was to investigate oro-cecal transit time (OCTT) using the H2-breath test (H2-BT) in moderate and heavy drinkers.MATERIALS AND METHODS:We studied 40 chronic drinkers: 20 with heavy alcohol consumption (> or = 60 g/day for men and > or = 40 g/day for women) and 20 with moderate alcohol intake (< 60 g/day for men and < 40 g/day for women). The control group consisted of 20 teetotal subjects. All subjects underwent a lactulose H2-BT to assess OCTT.RESULTS:OCTT in heavy alcohol drinkers ranged from 100 to 240 min, with a mean of 149.5 min, while OCTT in moderate drinkers ranged from 70 to 140 min, with a mean of 109 min. In the control group the mean OCTT was 100 mins, ranging from 70 to 130 min. The difference between alcohol abusers and controls was statistically significant; on the contrary, there was no statistically significant difference between moderate alcohol drinkers and teetotallers.CONCLUSIONS:Our study shows that only in chronic heavy alcohol drinkers is OCTT clearly increased. Multiple mechanisms are hypothesized to explain motility disorder, such as visceral autonomic neuropathy, inflammation and loss of contractile proteins of smooth muscle layer of the small intestine.

BACKGROUND/AIMS:Gastrointestinal disturbances such as diarrhea and malabsorption with steatorrhea may show up in hyperthyroid patients. The aim of our study was to evaluate oro-caecal transit time (OCTT) and gastrointestinal symptoms in hyperthyroid patients before and after propylthiouracil administration.MATERIALS AND METHODS:Twenty hyperthyroid patients (15 Females and 5 Males, mean age 47 years) were studied. Eight of them had diarrhea and 10 steatorrhea. The control group was composed of 20 healthy volunteers (13 F and 7 M, mean age 49 yrs). OCTT and fecal fat excretion were measured before and after propylthiouracil administration (300 mg/day for 10 day and then 200 mg/day for 30 days).RESULTS:Before the treatment in hyperthyroid patients had began the mean OCTT was significantly lower than in the control group (64 min. versus 107 min; p < 0.0001). After treatment mean OCTT became similar to the controls (p = ns); diarrhea disappeared in all affected patients and mean fecal fat excretion was reduced from 7.9 gr/24h to 3.4 gr/24h, with a statistically significantly difference (p < 0.0001).CONCLUSIONS:The treatment with propylthiouracil induces the normalization of thyroid hormone status and consequently of OCTT with the disappearance of gastrointestinal symptoms, such as diarrhea and steatorrhea, with a better efficacy if compared to other drugs utilized in the treatment of hyperthyroidism.