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Dysphagia or odynophagia occurs in an estimated 21% of patients with human immunodeficiency virus infection. A causal agent can be identified in 60-90% of the cases and generally can be successfully eradicated. Oesophageal candidosis, the predominant disorder, usually responds to nitrate derivatives and amphotericine B after a 10 to 15 day cure. Ulcerations of the oesophagus is the second major cause of dysphagia in these patients and result from cytomegalovirus and herpes simplex infections or unknown causes. Epstein-Barr virus infection has been suggested but is rarely demonstrated in clinical situations. Similar to other localizations in HIV-infected patients, Kaposi sarcoma and non-Hodgkin malignant lymphomas are the predominant tumours in the bowel. Infections are essentially revealed by sometimes very severe diarrhoea. Infective agents include Cryptosporidium parvum, microsporidiosae, cytomegalovirus, adenovirus, Isospora belli, Clostridium difficile, Salmonellae and non-tuberculous mycobacteria among others. When the search for an infective agent is negative, the diarrhoea is usually considered to be the expression of HIV infection itself. The clinical approach to HIV-related diarrhoea can be based on decision making management scheme according to the results of stool cultures or on complete exploration protocols. Whatever the diagnostic procedure, symptomatic treatment is of major importance because of the severe nutritional impact of HIV-related diarrhoea.
Endoscopic ultrasonography uses high-frequency ultrasound to visualize the gut wall and the surrounding structures of the mediastinum, the abdomen and the pelvis. Echoendoscopes are available in two different designs. A radial scanning echoendoscope produces a 360 degree real-time view perpendicular to the shaft of the echoendoscope. A linear-array instrument produces a 100 degrees real-time view parallel to the shaft of the echoendoscope, permitting direct ultrasonographic guidance of fine needles exiting the biopsy channel. Endoscopic ultrasonography has been established as the preferred diagnostic tool for the evaluation of submucosal masses of the upper gastrointestinal tract and the rectosigmoid, for differentiating benign from pathologic thickened gastric folds and for locating pancreatic endocrine tumors. The widest application of endoscopic ultrasonography is in the diagnosis and staging of esophageal, gastric, rectal and pancreaticobiliary neoplasms. Endosonography is the most accurate modality available for determining the T and N stages of these tumors. The recent development of endoscopic ultrasound-guided fine-needle aspiration provides physicians with the ability to cytologically diagnose lesions visualized endosonographically and to confirm cancer staging with tissue.
Endoscopic ultrasonography (EUS) represents a major advance in endoscopic imaging. The usefulness and effectiveness of EUS have been established during the past few years. However, endosonography using dedicated echoendoscopes (7.5/12 MHz) has some serious drawbacks, as follows: 1) Combining endoscopy and ultrasonography in one instrument increases the diameter of such echoendoscopes (12-13 mm); 2) Because of the large diameter, complete passage of severe strictures is often not possible and, for examination of the pancreatobiliary duct system, is not feasible at all; 3) Image quality and resolution for small lesions is not always satisfactory; and 4) Conventional endosonography requires a second examination separate from the previous routine endoscopy. Recently developed ultrasonographic miniprobes (diameters about 2 mm; frequencies 12-20 MHz) can be passed through the working channel of standard endoscopes to provide high frequency ultrasound images. These miniprobes might overcome some of the above-mentioned drawbacks and contribute to patients' security and convenience. Moreover, in various diseases of the GI tract and the pancreatobiliary duct system, diagnostic accuracy of miniprobe ultrasonography has been shown to be even superior to that of EUS. In summary, miniprobe ultrasonography seems to be a promising tool in the armamentarium of gastroenterological diagnostics.
BACKGROUND: Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that occurs when the trachea and esophagus fail to separate during fetal development. The 2 most severe forms of LTEC are type III, with extension of the cleft from the larynx to the carina, and type IV, with extension of the cleft into one or both mainstem bronchi. METHODS: Over the past 25 years, we have accumulated an experience caring for 9 patients with severe LTEC, including 4 with type III and 5 with type IV. RESULTS: Morbidity and mortality from severe LTEC often result from aspiration and chronic lung disease. Patients with types III (1/4) and IV (5/5) LTEC have an extremely high incidence of microgastria with a shortened esophagus for which fundoplication is ineffective. Because gastric feeding often does not initially increase stomach volume and may cause severe aspiration, we suggest early gastric division with later reconstruction of intestinal continuity in patients with microgastria. Postoperative tracheoesophageal fistulas have occurred in 6 of 9 patients. CONCLUSIONS: Generous interposition of vascularized tissue with a multiple-layer closure has helped to prevent further recurrences. Postoperative tracheomalacia may be managed with continuous positive airway pressure and may require customized endotracheal tubes. Evaluation of respiratory and digestive function, school performance, and quality of life for the surviving patients is described.
Exaggerated cytokines productions and development of systemic inflammatory response (SIRS) is the most common cause of postoperative complications and death after major abdominal surgery. The present study was conducted to investigate alterations in systemic production of interleukin-6 (IL-6) and interleukin-8 (IL-8) after total parenteral nutrition (TPN) in surgical patients. Plasma concentrations of IL-6 and IL-8 were measured in 22 patients (10 treated with TPN and 12 without TPN) before major surgery and on the days 1, 3, 7, 10 and 14-16 after, by ELISA test (indications for surgery: stomach, pancreatic and colon carcinoma, complications of IBD and acute pancreatitis). There were no differences between preoperative levels of IL-6 and IL-8 in the examined groups of patients. The highest (on the days 1, 3, 7, 10: 268.3 (p = 0.002), 41.9 (p = 0.03), 122.6 (p = 0.009), 29.3 (p = 0.03) pg/ml respectively) and longer lasting significantly elevated level of IL-6 was observed in the group of patients after major surgery without TPN. In the group of patients received TPN (with glutamine) there was a significantly increased but in comparison with group of patients without TPN, significantly lower level of IL-6 on days 1 and 7 (103.4 and 34.7 pg/ml respectively, p = 0.01). There was no significant change in postoperative concentration of IL-8 after major surgery in the group of patients treated with TPN. The level of IL-8 was significantly elevated (p = 0.01) in the group of patients without TPN on day 1 and 3 following surgery. The IL-8 level in the TPN group vs. group of patients without TPN was significantly lower on day 1 after surgery. After TPN concentration of cholesterol was significantly higher and CRP level significantly lower. We conclude that TPN improved immunological response to major surgical trauma by reduction of the inflammatory response.
The authors report on the results gained from 3000 peroral endoscopies (10% as urgent cases) carried out in adults at the Dakar General Hospital within a period of 30 months. They emphasize the low cost of such an exam, and they underline: a) the young age of examined patients b) the number of examinations on out-patients, demonstrating that oesogastroduodenoscopy is now well accepted by Africans. Digestive hemorrhages are mainly caused by duodenal ulcers, oesophageal varices, hemorrhagic gastritis. A new pathology is raising up: volontary ingestion of caustic pro ducts. The most frequent lesions observed are duodenal ulcers, oesophagic and gastric cancers, gastritis. The interest of endoscopic control of healing of cancers is confirmed. Revealing of oesophageal varices often take place before an hepatopathy is discovered. Therapeutic endoscopy and monitoring endoscopy should be developed. Through improved technics, diagnostic endoscopy has been efficient.
Gap junctional intercellular communication (GJIC) is a mechanism of direct cell-to-cell signalling and is mediated by gap junctions (GJs), consisting of transmembrane proteins called connexins (Cxs). GJIC plays a critical role in tissue development and differentiation and is important in the maintenance of tissue homeostasis resulting from homeostasis through the exchange of ions, signalling molecules, nucleotides, and other small molecules (less than 1kDa) between adjacent cells. Because gap junctions are sites of the propagation or conduction of action potentials between adjacent cells, it is possible that they participate in the generation of rhythmic peristaltic movements by contributing to synchronous contraction in the muscle layer. Many physiological roles have been proposed for gap junctions, such as the maintenance of tissue homeostasis, regulation of tissue development, electrical and metabolic coupling, as well as the regulation of cellular growth, differentiation and apoptosis. Altered expressions of connexins have been observed in various pathological processes of the digestive tract, such as Hischsprung's disease, esophageal cancer, gastric cancer, and colorectal cancer. Using a variety of techniques such as transmission electron microscopy, Lucifer Yellow transfer and immunohistochemistry, gap junctions in the digestive tracts of mammalian species have been identified. This work is a review of recent studies on the role of GJIC in the physiology and pathology of the digestive tract.
Epstein-Barr virus has been demonstrated in angiocentric immunoproliferative lesions. However, these studies, which have used the polymerase chain reaction technique or Southern blot analysis, have not revealed the identity of the cell population harboring the virus. To address this issue, we analyzed 12 angiocentric immunoproliferative lesions (14 biopsy specimens) for Epstein-Barr virus RNA using a sensitive and specific in situ hybridization method. Epstein-Barr virus RNA was detected in five of 12 cases. Each positive lesion was a high-grade angiocentric immunoproliferative lesion (i.e., angiocentric lymphoma) in which Epstein-Barr virus was identified in numerous cells. Furthermore, the Epstein-Barr virus-positive cells were often larger than normal lymphocytes and thus were most likely the malignant cells. Double-labeling immunohistochemistry/in situ hybridization studies revealed that the majority of Epstein-Barr virus-positive cells were CD43-positive and CD20-negative, consistent with T-cell lineage. The remaining seven cases, all grade I or II angiocentric immunoproliferative lesions, were either completely negative (four cases) or had only rare to occasional Epstein-Barr virus-positive cells (three cases). The results obtained with the polymerase chain reaction and Southern blot hybridization studies generally confirmed those obtained with in situ hybridization. We conclude that Epstein-Barr virus is frequently associated with angiocentric immunoproliferative lesions, particularly within high-grade lesions, in which the virus is probably present within the neoplastic cells. These findings also suggest that Epstein-Barr virus may be involved in the transformation of low-grade angiocentric immunoproliferative lesions to histologically unequivocal angiocentric lymphomas.
The reported investigations of haemoglobin (Hb) concentration in stools of healthy subjects and patients with digestive tract diseases were carried out for determining the physiological value of blood loss into the digestive tract, and for comparing the sensitivity of quantitative and qualitative tests for demonstration of occult blood in stools in cases of colonic neoplasms. The qualitative Haemoccult test was compared to the quantitative test based on heme conversion to porphyrins by iron decoupling, which makes possible determination of total Hb content in stools and measurement of the so called intestinal fraction which develops as a result of Hb conversion to porphyrins in the upper digestive tract.
Serum levels of sialyl-Tn antigen (STN) were measured using a one-step radioimmunoassay kit in 257 patients with digestive cancers, 121 patients with benign digestive diseases, and in 64 healthy controls. With 45 U/ml regarded as the cutoff value, the positive rates of serum STN in digestive cancers were as follows: pancreas 40.0%, stomach 28.1, colon and rectum 27.8, biliary tract 25.0, liver 7.1, and esophagus 0%. In benign digestive diseases, the positive rate of STN was low (4.1%). In gastric and colorectal cancers, simultaneous measurements of STN and carcinoembryonic antigen (CEA) revealed that the positive rates of STN, CEA, and STN and/or CEA were 28, 42, and 55%, respectively. There was no significant correlation between STN and CEA in these cancers. STN may be a useful serum marker for digestive cancers, especially gastric and colorectal cancers.
Plasma PGE2 level of 45 patients with digestive cancers, 10 patients with digestive benign diseases and 10 healthy controls were examined. Some patients were also examined plasma levels of TXB2, 6-keto-PGF1 alpha and PGF2 alpha. Plasma PGE2 level of digestive cancer patients (53.5 +/- 69.1 pg/ml, mean +/- SD) were about 10 times higher compared to healthy controls (5.2 +/- 3.8 pg/ml, p less than 0.01). Patients with digestive benign diseases also revealed elevated level of plasma PGE2, but the change of value were smaller than those of digestive cancer patients. Furthermore, in the case of digestive cancer patients, significantly elevated levels of TXB2 (49.7 +/- 60.3 pg/ml, p less than 0.05) and 6-keto-PGF1 alpha (33.9 +/- 31.5 pg/ml, p less than 0.01), and significantly reduced levels of PGF2 alpha (246 +/- 63 pg/ml, p less than 0.01) were noted. The changes in plasma prostaglandin levels of digestive cancer patients may reflect, even though prostaglandins are present in normal human body and are inactivated rapidly, the biological characteristics of tumors and in vivo reactions of the host.
The aim of this study was to assess the accuracy of the copper/zinc ratio (Cu/Zn ratio) in the evaluation of a large group of patients with digestive cancer compared to gender and age-matched control subjects. A total of 282 patients was studied and separated into three groups: group I (n = 75), patients with digestive cancer, group II (n = 112), patients with benign digestive disease, and group III (n = 95), healthy subjects. Serum levels of copper and zinc were measured by atomic absorption spectrophotometry. The results showed that the serum levels of copper (mg/dL) in patients with digestive cancer (91.6 +/- 27.3, p < 0.05) were significantly higher than in patients with benign digestive disease (75.8 +/- 19.8) or healthy subjects (54.4 +/- 8.9) and the serum levels of zinc (mg/dl) were significantly lower (68.7 +/- 21.9, p < 0.05) compared to benign digestive disease patients (80.1 +/- 18.7) or healthy subjects (100 +/- 11.4 mg/dl). The Cu/Zn ratio was also significantly higher in patients with digestive cancer (1.45 +/- .58, p < 0.05) than those with benign digestive disease (0.95 +/- 0.28) or healthy subjects (0.55 +/- 0.13). Considering a cutoff value of 0.87, the sensitivity of the copper/zinc ratio was 82.2%, with a specificity of 65.7%, a positive predictive value of 45.8% and a negative predictive value of 91.3%. In conclusion, Cu/Zn ratio was found to be considerably higher in patients with digestive cancer compared to age- and gender-matched controls, with a sensitivity of 82.2% that might be useful in the evaluation of suspected malignancy.
In a retrospective study, autopsy data of 6668 cases were collected from the first affiliated hospital, West China University of Medical Sciences, to assess the changes in autopsy rate between 1952 and 1987. The autopsy rate of dead patients was 14.3%, with two peaks obtained in the periods of 1954-1956 and 1964-1966 respectively. Anyhow, the autopsy rate declined sharply after 1967. The agreement of clinical diagnosis and pathological findings in this group was 68.9%. The most common diseases in this series were infectious and parasitic diseases' diseases of respiratory system, diseases of digestive system, neoplasms and diseases of cardio-vascular system. Accompanying the increase of age of the autopsied patients, neoplasia and cardio-vascular diseases were more frequently seen in this series.
In patients with digestive complaints, endoscopy is the gold standard and is often the primary exploration. Positive findings in upper gastrointestinal endoscopy occur in 30 to 40% in relation to a benign or malignant structural disease. Negative findings occur therefore in 60 to 70% of cases: dyspepsia and/or reflux are functional diseases. Colonoscopy aims essentially at screening of colorectal cancer. Digestive cancer is very rare under 50 years, and most cases detected with symptoms are advanced; asymptomatic early and curable cancer is detected in screening. A negative finding at endoscopy is reliable in the hands of an experienced endoscopist controlling the risk of false negative and false positive findings. A reliable negative endoscopy is beneficial for the quality of life when it relieves anxiousness of the patient. It may be cost effective if drugs and consultations are decreased. Overuse of negative endoscopy is not so much through large indications, that in repetition of negative procedures. The relevance of negative endoscopy in screening for cancer in the upper and lower digestive tract, is whether is should be repeated. There is tendency to increased intervals in surveillance protocols. In the very near future the first role of endoscopy in the primary diagnosis could be challenged by concurrent techniques. Future progress is based upon a Quality Assurance program for quality, experience of the operator a control of the cost and a research programme on tolerance with a trend to reduced sedation.
Since its introduction into clinical practice in 1980, echo-endoscopy has greatly contributed to improving our capacity to image the digestive tract and now plays a major role in management of digestive tract diseases. Echo-endoscopy is a second intention technique reserved for further investigation of lesions previously identified by endoscopy or other imaging techniques. All five layers of the wall and surroundings of the accessible structures (oesophagus, stomach, duodenum, rectum and colon) can be visualized. Evaluation of locoregional extension of cancer invasion is one of the predominant indications. For example, since the prognosis of tumours of the oesophagus are directly related to parietal and lymph node extension, echo-endoscopy would be indicated to precisely determine the tumoural stage and thus help in adapting therapeutic management. Today, it is generally accepted that echo-endoscopy is superior to computed tomography for staging tumours of the oesophagus and the cardia. For gastric and duodenal adenocarcinomas, the performance of echo-endoscopy is similar and can identify more readily superficial lesions accessible for photocoagulation. For adenocarcinoma of the rectum, echo-endoscopy can be used to identify the tumoural stage and local extension and thus help in therapeutic decision making. Other classical indications include the evaluation of submucosal tumefaction and biliopancreatic disorders (biliary lithiasis, pancreatitis, tumours). Thus for certain well-defined indications, echo-endoscopy is now the highest performing imaging technique currently available for lesions of the digestive tract. Operator experience is however a limiting factor, emphasizing the need for clinical training.