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The statements produced by the Chairmen of the 2nd International Symposium on Diverticular Disease, held in Rome on April 8th to 9th, 2016, are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease in patients with uncomplicated and complicated diverticular disease were reviewed by the Chairmen who proposed 41 statements graded according to level of evidence and strength of recommendation. Each topic was explored focusing on the more relevant clinical questions. The vote was conducted on a 6-point scale and consensus was defined a priori as 67% agreement of the participants. The voting group consisted of 80 physicians from 6 countries, and agreement with all statements was provided. Comments were added explaining some controversial areas.

Symptomatic uncomplicated diverticular disease (SUDD) is a common gastrointestinal disease, because it affects about one fourth of the patient harboring colonic diverticula.To assess the effectiveness of mesalazine in improving symptoms (namely abdominal pain) and in preventing diverticulitis occurrence in patients with SUDD.Only randomized clinical trials (irrespective of language, blinding, or publication status) that compared mesalazine with placebo or any other therapy in SUDD were evaluated. The selected endpoints were symptom relief and diverticulitis occurrence at maximal follow-up. Absolute risk reduction (ARR, with 95% confidence interval) and the number needed to treat were used as measures of the therapeutic effect.Six randomized clinical trials enrolled 1021 patients: 526 patients were treated with mesalazine and 495 with placebo or other therapies. Symptom relief with mesalazine was always larger than that with placebo and other therapies. However, absolute risk reduction was significant only when mesalazine was compared with placebo, a high-fiber diet, and low-dose rifaximin. The incidence of diverticulitis with mesalazine was lower than that observed with placebo and other treatments, being significant only when compared with placebo.Mesalazine is effective in achieving symptom relief and primary prevention of diverticulitis in patients with SUDD.

The segmental colitis associated with diverticulosis," better known by its acronym "SCAD," is a chronic inflammatory process localized in the colonic area presenting diverticulosis, and therefore mainly in the sigmoid colon. By definition, both the rectum and the right colon are spared from any inflammation both endoscopically and from a histologic point of view. Recent data have hypothesized that SCAD may be an independent clinical entity within the inflammatory bowel disease set of diseases. Compared with inflammatory bowel disease, SCAD seems to have a more benign outcome, with low rate of complications.

Diverticulosis of the colon is an acquired condition that results from herniation of the mucosa and submucosa through defects in the muscular layer. The true prevalence of colonic diverticulosis is difficult to measure because most individuals are asymptomatic. In particularly, in literature, there are few studies about the prevalence of colonic diverticulosis in patients affected by ulcerative colitis (UC).To investigate the prevalence of colonic diverticulosis in UC and in adult patients referred in a single center.Consecutive patients, referred to our institution to undergo a colonoscopy for colorectal cancer screening and/or for UC assessment, between January 1, 2014 and December 31, 2014, were studied.Six hundred five consecutive patients were studied: 438 (72.4%) due to colorectal cancer screening (group A) and 167 (27.6%) for UC assessment (group B). Prevalence of colonic diverticulosis was higher in group A than group B (27.8% vs. 10.8%, P0.0001). Female gender in patients with colonic diverticulosis was higher in group A than group B (55.7% vs. 22.2%, P=0.0106). Sigma and left colon was mainly involved in group A than group B (97.6% vs. 66.7%, P=0.0001), whereas in group B the right colon was mainly involved in group B versus group A (22.2% vs. 0.8%, P=0.0009).Prevalence of colonic diverticulosis was significantly lower in patients with UC than in control group. UC may, therefore, be a protective factor for colonic diverticulosis occurrence.

GOALS To investigate the current opinion of Italian general practitioners (GPs) on the management of patients with diverticular disease (DD) of the colon. BACKGROUND The management of DD remains a point of debate, and guidelines are not uniform in their advice. STUDY A web-based survey was conducted among Italian GPs. Twelve questions were aimed at the diagnosis, treatment, and management options for diverticulosis and symptomatic DD. RESULTS In total, 245 surveys were filled out. A high-fiber diet was prescribed widely in diverticulosis (44%), together with advice to allow seeds (30%). Rifaximin (26%) and probiotics (25%) were the most frequently prescribed drugs in this population. Colonoscopy was the most prescribed instrumental tool in the diagnosis (77%) and follow-up (21%) of symptomatic uncomplicated diverticular disease patients. Rifaximin, probiotics, and mesalazine were the most frequently prescribed drugs in symptomatic uncomplicated diverticular disease patients (82.8, 59.5%, and 36.3%, respectively). Finally, 77% of the Italian GPs prescribed laboratory exams in the follow-up of these patients. The vast majority of the Italian GPs (83%) managed suspected acute diverticulitis at home, and did not consider two episodes of acute diverticulitis as a strict surgical indication (86%). Rifaximin, probiotics, and mesalazine were the most frequently prescribed drugs to prevent recurrence of the disease (42.5%, 28.2%, and 12.4%, respectively). Finally, 87% of the Italian GPs prescribed laboratory examinations in the follow-up of these patients. CONCLUSIONS This survey shows that the current management of DD in primary care by Italian GPs is not fully in line with current guidelines and more recent literature data.

Management of diverticular disease (DD) remains a point of debate.To investigate the current opinion of participants of the 2nd International Symposium on Diverticular Disease, on real-life management of patients with DD of the colon.Twelve questions were aimed at the diagnosis, treatment, and management options for diverticulosis and symptomatic DD.In total, 115 surveys from 8 European Countries were filled out. High fiber diet was widely prescribed in diverticulosis (59.1%). Probiotics (25%) were the most frequent prescribed drug, whereas 29.8% of participants did not prescribe any treatment in diverticulosis. Colonoscopy was frequently prescribed in symptomatic patients (69.3%), whereas 72.9% of participants did not prescribe any instrumental tool in their follow-up. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs both in symptomatic patients (28.1, 14.9%, and 11.4%, respectively) and to prevent recurrence of the disease (42.5%, 12.4%, and 28.2%, respectively). With respect to laboratory exams, 57.9% of participants prescribed them during follow-up. The majority of participants (64.9%) managed suspected acute diverticulitis at home. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs to prevent recurrence of the disease (32.2%, 13.2%, and 11.4%, respectively), whereas 25.4% of participants did not prescribe any drugs. Finally, no differences were found among gastroenterologists, surgeons, and general practitioners in managing this disease.This surveys shows that current management of DD is similar between different medical specialities, generally in line with current literature.

Changes in the colonic microbiota are critical to the pathogenesis of diverticular complications such as diverticulitis and peridiverticular abscesses. However, more subtle changes in microbiota composition may well be important to the more chronic manifestations of diverticulosis. Some studies have shown the presence of bacterial overgrowth in subgroups of patients with diverticular disease and recent studies, using molecular biology techniques, found an increase of proteobacteria and actinobacteria in patients with symptomatic uncomplicated diverticular disease (SUDD), compared with healthy controls. The use of probiotics to modulate intestinal microecology in SUDD appears therefore rational. Although several investigations evaluating the clinical efficacy of probiotics have been performed, no definitive results have yet been achieved, mainly due to the heterogeneity of the available studies. Most of the studies used probiotics in combination with poorly absorbed antimicrobials or anti-inflammatory drugs. In only 4 studies, there was a harm using probiotics alone, but only 1 was a placebo-controlled, double-blind trial. The analysis of the available evidence reveals a poor quality of the published studies, whose design was heterogeneous, with only 2 out of 11 trials being double-blind and randomized. Therefore, available data can only suggest a benefit of probiotics in SUDD, but do not allow any evidence-based definite conclusion. As a consequence, current guidelines state that there is insufficient evidence to recommend probiotics for symptom relief in patients with diverticular disease.

Diverticular inflammation and complication assessment (DICA) endoscopic classification has been recently developed for patients suffering from diverticulosis and diverticular disease. Its predictive value in those patients was recently retrospectively assessed. For each patient, the following parameters were recorded: age, severity of DICA, presence of abdominal pain, C-reactive protein, fecal calprotectin test (if available) at the time of diagnosis, months of follow-up, therapy taken during the follow-up to maintain remission (if any), occurrence/recurrence of diverticulitis, and need of surgery. A total of 1651 patients (793 male, 858 female, mean age 66.6±11.1 y) were enrolled: 939 (56.9%) classified as DICA 1, 501 (30.3%) as DICA 2, and 211 (12.8%) as DICA 3. The median follow-up was 24 (9 to 138) months. Acute diverticulitis (AD) occurred/recurred in 263 (15.9%) patients, and surgery was necessary in 57 (21.7%) cases. DICA was the only factor significantly associated with the occurrence/recurrence of diverticulitis and surgery either at univariate (χ=405.029; P

Diverticular disease is one of the most common diseases of Western industrialized countries, and it may be associated with numerous abdominal symptoms (including pain, bloating, nausea, diarrhea, and constipation). Although antibiotics are the mainstay treatment for patients with acute diverticulitis, these drugs are still recommended for patients with uncomplicated diverticular disease. Changing concepts on pathophysiology of the disease suggest that diverticular disease may share many of the hallmarks of the inflammatory bowel diseases. On this basis, a new therapeutic approach based on mesalazine and probiotics may enhance treatment efficacy in shortening the course of the disease and in preventing recurrences.

Balsalazide is a 5-amino salicylic acid prodrug well-tolerated and effective in treating acute ulcerative colitis. VSL[sharp]3, a high-potency probiotic mixture, has proved to be effective in preventing flare-ups of chronic pouchitis and in obtaining remission of mild-to-moderate ulcerative colitis. Recent studies found the association of low-dose balsalazide/VLS no. 3 effective in treating mild-to-moderate ulcerative colitis and in preventing the recurrence of uncomplicated diverticulitis of the colon. In this paper, the framework for using this association to treat ulcerative colitis or to prevent the recurrence of colonic diverticulitis is reviewed, and 2 studies on this therapeutic approach are briefly summarized.

This study assesses the epithelial cell proliferation in different degrees of diverticular disease and compares this with two different control groups.Hyperproliferation of the colonic mucosa has been recently described in diverticular disease (DD), but it is unknown whether this finding is present in every degree of DD.Thirty consecutive patients with a new endoscopic diagnosis of DD (10 with asymptomatic diverticulosis, 10 with symptomatic uncomplicated DD, and 10 with acute uncomplicated diverticulitis) were enrolled. Ten matched healthy people and 10 patients with ulcerative colitis (UC) (5 with UC in remission and 5 with active UC) were enrolled as control groups. The Ki-67 antigen index of the whole crypt and the upper third was separately evaluated.Ki-67 index of the whole crypt and the upper third of the crypt was significantly higher in all degrees of DD compared with the healthy control group. In particular, asymptomatic diverticulosis showed a threefold higher Ki-67 index compared with that of the healthy control group (5.4% and 5.6% vs. 1.6% and 1.8%, respectively, P = 0.005), and similar to that of UC in remission (5.4% and 5.6% vs. 5.9% and 5.8%, respectively, P = not significant).We found an upward shifting of cellular proliferation of the colonic mucosa in patients with different degrees of DD. In particular, asymptomatic diverticulosis seems to show the same risk for colonic carcinoma as that of UC.

To investigate the effectiveness and safety of mesalazine, with or without Lactobacillus casei, in preventing recurrence of symptomatic diverticular disease of the colon.Both mesalazine and probiotics showed recently their effectiveness in obtaining remission of symptomatic uncomplicated diverticular disease of the colon. Consistent data are not available on the optimal therapy to prevent recurrence of symptomatic diverticular disease of the colon.Multicenter, prospective, randomized, open-label study. Ninety consecutive patients (36 men, 54 women, mean age 67.5 y, range 39 to 84 y), previously affected by symptomatic uncomplicated diverticular disease of the colon (remission obtained with rifaximin 800 mg/d plus mesalazine 2.4 g/d for 10 d, followed by mesalazine 1.6 g/d for 8 wk), were enrolled in a 12-month follow-up. The following symptoms were assessed at entry and through follow-up by using a quantitative scale: (1) constipation, (2) diarrhea, (3) abdominal pain, (4) rectal bleeding, and (5) mucus with the stools. After recruitment, the patients were randomly assigned to one of the following 3 groups: mesalazine 1.6 g/d (group M), L. casei DG 16 billion/d for 15 d/mo (group L); mesalazine 1.6 g/d+L. casei DG 16 billion/d for 15 d/mo (group LM).Eighty-five patients completed the study (94.5%): 2 patients (2.22%, 1 of group M and 1 of group LM) were withdrawn from the study for protocol violation and 1 (1.11%) for hospital admission due to acute pulmonary disease (group L); 2 patients (2.22%) were lost to follow-up. Seventy-five patients (88.2%) were symptom free after the 12th month of treatment (overall symptomatic score: (0): 23/27 patients of group M [on intention to treat: 76.7% confidence interval (CI 95%: 61.5 to 91.8)], 23/29 of group L [on intention to treat: 76.7% (CI 95%: 61.5 to 91.8)], 29/29 of group LM [on intention to treat: 96% (CI 95%: 94.2 to 100)] (P0.05). Only 10 patients (11.1%) showed recurrence of symptoms (overall symptomatic score: 68).Both mesalazine and L. casei DG seem to be effective in preventing recurrence of symptomatic uncomplicated diverticular disease of the colon, but their association seems to be more promising in this field.

Gluten-free diet (GFD) plays a key role in the treatment of celiac disease (CD), but it is difficult to evaluate the effect of GFD on the improvement of villous architecture using sensitive, non-invasive tests. Aim of this study is to evaluate anti-transglutaminase (tTG) antibodies in the follow-up of CD to detect histologic recovery. We studied 42 consecutive patients with CD. In all the patients anti-tTG antibodies (evaluated by the enzyme linked immunosorbent assay method) and EGDscopy with multiple bioptic samples before GFD and then 6, 12, and 18 months after GFD were evaluated. For comparison, a sorbitol H2-breath test (H2-BT) and anti-endomysium (EMA) antibodies test were carried out concomitantly. Anti-tTG results were positive in 36 of 42 patients before GFD (80.95%), while they were positive in 11 of 34 (32.35%), 1 of 17 (5.88%), and 0 of 6 (0%) of patients with a persistence in histologic lesions 6, 12, and 18 months of GFD respectively, without any correlation with persistence of histologic lesions (P = NS). Also EMA failed to show correlation with improvement of histologic lesions. They were positive in 31 of 42 patients before GFD (73.80%), while they were positive in 18 of 34 (52.94%), 3 of 17 (17.64%), and 0 of 6 (0%) cases 6, 12, and 18 months of GFD respectively (P = NS). Regarding sorbitol H2-BT, it was positive in 40 of 42 (95.24%) patients before GFD, while it was positive in 31 of 34 (91.17%), 13 of 17 (76.47%), and 4 of 6 (50%) of patients with a persistence in histologic lesions 6, 12, and then 18 months after GFD starting (see Fig. 2, infra). So, anti-tTG and EMA were ineffective in assessing the histologic recovery at each follow-up visit (P = NS), while sorbitol H2-BT seems more effective than anti-tTG and EMA in this field (P < 0.0001 sorbitol H2-BT versus anti-tTG and versus EMA at 18 months after gluten withdrawal). Thirty-eight of 42 (90.47%) patients adhered to a strict GFD. Four patients were found to have occasional dietary transgression, and in all we noted a progressive decreasing of anti-tTG after 6 months of GFD and negative anti-tTG after 12 months of GFD, but sorbitol H2-BT persisted being positive during the entire follow-up. Intestinal damage persisted during the follow-up, despite anti-tTG and EMA negativity, and worsened in the presence of dietary lapses. Anti-tTG does not seem effective to assess histologic recovery in the follow-up of celiac patients after they have started GFD due to its poor correlation with histologic damage.

BACKGROUND Left lower-abdominal pain is considered the best symptom to differentiate between symptomatic uncomplicated diverticular disease (SUDD) and irritable bowel syndrome (IBS). However, this statement has not been validated yet. GOALS The aim of this study was to assess whether prolonged left lower-quadrant pain is the best symptom characterizing SUDD and be able to differentiate SUDD from IBS-like symptoms in diverticulosis, and to compare the location of abdominal pain with fecal calprotectin (FC) expression. STUDY Seventy-two patients suffering from abdominal pain and having diverticula at colonoscopy were enrolled. Patients were classified according to SUDD definition (abdominal pain for at least 24 consecutive hours in left lower abdomen) (42 patients) and IBS-like symptoms fulfilling Rome III criteria (30 patients). Abdominal pain was assessed using a 10-point visual scale, assigning numerical values from 0 (absence of pain) to 10 (severe pain). FC expression was assessed by a rapid test in all patients enrolled. RESULTS FC test was positive in 27 (64.3%) patients in the SUDD group and in no patient in the IBS-like group (P

With regard to the role of dental plaque in the transmission of Helicobacter pylori infection, data from the literature vary greatly, owing to differences in sample collection and H. pylori-detecting techniques. Using the polymerase chain reaction (PCR), we have determined the incidence of H. pylori colonization in the dental plaque of 31 consecutive patients who underwent gastroscopy. The patients were divided into two groups on the basis of H. pylori infection, determined by Giemsa stain and the rapid urease test: group A made up of 21 H. pylori-positive patients and group B with 10 H. pylori-negative patients. Our PCR assay of dental plaque samples proved negative in all group A subjects but was positive in only one patient in group B. In our study, we found that H. pylori had a low prevalence (3.2%) in the oral cavity, with no significant relationship between gastric mucosa and dental plaque colonization. More comprehensive studies are needed to determine whether dental plaque is an important reservoir in the epidemiology of H. pylori-induced gastric disease.

Background: Acute uncomplicated diverticulitis (AUD) may showhistologic and serologic signs of inflammation.Goals: To assess whether serologic markers of inflammation maybe predictive of abnormal histology in AUD.Study: Twenty-one consecutive patients affected by AUD werestudied (15 Males, 6 Females, mean age 66.19y, range 43 to 85y).Diagnosis of AUD was based on specific endoscopic and CT scanpatterns. Several serologic markers were assessed [White blood cells(WBC), Erytro-sedimentation Rate, C-reactive protein (CRP),fibrinogen, a1-acid glycoprotein]. Neutrophilic and lymphocyticinflammatory infiltrate was also scored.Results: WBC was increased in 4/21 pts (19.4%), Erytro-sedimentation Rate in 12/21 pts (57.14%), CRP in 13/21 pts(61.9%), fibrinogen in 5/21 pts (23.8%), and a1-acid glycoproteinin 6/21 pts (28.57%). All serologic markers were related with thedegree of histologic damage. In patients scoring 3 in neutrophilicinfiltrate (severe active inflammation), all markers showed astatistical significant relation (ranging from P=0.004 for WBCto P=0.00001 for fibrinogen). CRP was the most sensitive markerof mild-moderate histologic damage, as it was increased in 4/10(40%) patients scoring 0 or 1 in neutrophilic infiltrate (absence ofmild active inflammation) (P=0.005).Conclusions: Serologic markers showed a strict relation with thedegree of histologic damage in AUD. Moreover, CRP is the mostsensitive marker of mild-moderate histologic damage.Key Words: acute uncomplicated diverticulitis, predictive value,serologic markers

Helicobacter pylori infection plays a crucial role not only in the pathogenesis but also in the treatment of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma. The aim of the present study was to evaluate whether H. pylori eradication provides a definite cure in the early stage of this neoplasia by means of a prolonged follow-up. All patients affected by low-grade gastric MALT lymphoma in stage IE that were referred to our department from January 1995 to June 1999 were enrolled in a prospective study. Diagnosis was histologically proved and H. pylori status was evaluated. Staging was performed according to a modified Ann Arbor classification. All patients who proved positive for H. pylori infection were treated with eradicating therapy, and a prolonged clinical and histologic follow-up was carried out. Until June 1999, seven low-grade gastric MALT lymphomas in stage IE were diagnosed (four men and three women; mean age, 56 years). All patients were H. pylori-positive and eradication was obtained in all of them after the first cycle of antibiotic therapy. Complete histologic regression of lymphoma was observed in all cases in a period variable between 3 and 6 months. The mean follow-up period was 42 months (range, 20-54). Only one patient showed a recurrence of lymphoma 22 months after treatment associated with H. pylori reinfection. Our results show the high efficacy of H. pylori eradication in determining a prolonged remission of low-grade gastric MALT lymphomas in stage IE. Thus, this therapeutic approach may avoid or delay the indication for more aggressive therapies, such as surgical resection.

Goal: The aim of this study was to assess and grade the mucosal inflammatory infiltrate in different degrees of diverticular disease (DID) and to compare them with healthy matched controls. Background: Mucosal inflammation in colonic DD has never been investigated. In particular, it is unknown whether inflammation may be found in every degree of DD. Materials and Methods: Thirty consecutive patients with a new endoscopic diagnosis of D-D (10 with asymptomatic diverticulosis, 10 with symptomatic uncomplicated DD, and 10 with acute uncomplicated diverticulitis) and 10 healthy controls were studied. Results: A neutrophilic inflammatory infiltrate was found only in acute uncomplicated diverticulitis (overall score, 26). The mean lymphocytic cell density was significantly higher in symptomatic DD (median lymphocytic density, 7) and acute uncomplicated diverticulitis (median lymphocytic density, 11). Subdividing the patients according to different degrees of DD, we found higher lymphocytic cell density even in asymptomatic diverticulosis (median lymphocytic density, 6.5) than healthy controls (median lymphocytic density, 4; P < 0.02). Conclusions: We found an increased inflammatory infiltrate in DD according to the degree of the disease and higher than healthy controls. Moreover, also asymptomatic diverticulosis shows higher inflammatory cell density than controls.

It is quite frequent to recognize celiac patients who show gastrointestinal motor abnormalities in clinical practice. In fact, in 30 to 60% of patients, physical examination and dyspeptic symptoms (epigastric discomfort, early satiety) suggest a gastrointestinal motility disorder. Consistent data are now available on the presence of a disturbed motility of the esophagus, stomach, small intestine, gallbladder, and colon of untreated celiac patients. Gastrointestinal abnormalities differ in different gastrointestinal districts. In fact, esophageal transit, gastric and gallbladder emptying, and orocecal transit time are delayed, while colonic transit is faster. These findings are related to the complex interactions among reduced absorption of food constituent (in particular, fat), neurologic alteration, and hormonal derangement. Motility disorders of the gut are also a predisposing factor in the development of small intestinal bacterial overgrowth and may contribute both to development of symptoms in some untreated celiacs and to the persistence of symptoms after gluten-free diet in some of them. All these alterations fortunately disappear after gluten-free diet, and patients return to well being status. Whatever the initial event in the pathogenesis of the celiac lesions may be, we know for certain at this time that gastrointestinal disturbances play an important role in the genesis of gastrointestinal symptoms in celiac disease and that surveillance for celiac disease in patients complaining of dysmotility-like dyspeptic symptoms should be increased.

Objective: Mucosa-associated lymphoid tissue, which has a follicular structure closely resembling Peyer patches, is absent in the normal gastric mucosa, but it can develop in several chronic conditions. Since we recently detected hepatitis C virus-RNA in gastric mucosa-associated lymphoid tissue of patients with chronic hepatitis C, we tried to treat hepatitis C virus infection to evaluate the effect of antiviral therapy on gastric mucosa-associated lymphoid tissue. Methods: Eighteen patients (12 men and 6 women; mean age: 52 years, range: 33-71 years) affected by chronic hepatitis C virus and with gastric mucosa-associated lymphoid tissue were enrolled. We enrolled only patients hepatitis C virus--positive, mucosa-associated lymphoid tissue-positive, and Helicobacter pylori-negative (8 patients) or hepatitis C virus-positive patients in whom anti-H. pylori therapy did not obtain disappearance of gastric mucosa-associated lymphoid tissue (10 patients). Hepatitis C virus was evaluated by hepatic biopsy with histologic evaluation and serologic examination; Gastric mucosa-associated lymphoid tissue was scored using Wotherspoon score. All patients were treated with recombinant leukocyte interferon-α-2b plus oral ribavirin for 6 months. The hepatitis C virus RNA was assayed at entry and at 3 months after stopping treatment. Virologic response was defined as undetectable levels of serum hepatitis C virus RNA 3 months after stopping treatment; esophagogastroduodenoscopy was repeated at this time to evaluate the effect of anti-hepatitis C virus therapy on acquired gastric mucosa-associated lymphoid tissue. Results: Two (11.11%) patients were withdrawn from the study. Hepatitis C virus cure was obtained in 11/16 patients (68.75%), and in all of them we obtained disappearance of gastric mucosa-associated lymphoid tissue (P < 0.01). Hepatitis C virus infection persisted, but with very lower levels, in 5 of 16 patients (31.25%): in 3 patients gastric mucosa-associated lymphoid tissue persisted (but in 2 it decreased from grade 3 to grade 2), while in 2 it disappeared. Conclusions: We showed clearly that there is a strict correlation between hepatitis C virus infection and acquired MALT, obtaining the disappearance of this acquired immunologic acquired gastric tissue curing hepatitis C virus infection. However, further studies are needed to clarify there is the same correlation between hepatitis C virus infection and gastric mucosa-associated lymphoid tissue lymphomas in hepatitis C virus-positive patients.

Goals: Although anti-tissue transglutaminase antibodies (antitTG) are effective for celiac disease (CD) routine laboratory screening, there are no studies evaluating correlation between degree of intestinal damage and positivity to anti-tTG. Since recent studies showed that anti-gliadin (AGA) and anti-endomysium (EMA) antibodies are ineffective in diagnosing mild glutensensitive enteropathy, the aim of this study was to evaluate the prevalence of anti-tTG in different degrees of intestinal damage of celiac patients and whether there is a correlation between serum value of anti-tTG and the degree of histologic damage. Study: We studied 119 consecutive adult patients affected by CD (47 men and 72 women; mean age, 28 years; range, 22–51 years). All patients were stratified for histologic damage according to Marsh classification, and in all of them an anti-tTG evaluation was performed. Results: Marsh I lesions were present in 13 patients (10.92%), Marsh II in 24 anti-tTG (20.16%), Marsh IIIa in 27 anti-tTG (22.68%), Marsh IIIb in 31 anti-tTG (26.05%) and Marsh IIIc in 24 anti-tTG (20.16%). Anti-tTG positivity was ranging from 1 of 13 anti-tTG (7.69%) in Marsh I lesions to 23 of 24 anti-tTG (95.83%) in Marsh IIIc lesions respectively (P < 0.005), while mean serum value of anti-tTG ranged from 3.61 (range, 0.7–9.2) UA/mL in Marsh I lesions to 7.3 (range, 1–25.1), 18.5 (range, 1.8–56.2), 36 (range, 3.7–83.5) and 74.95 (range, 6.5–257) UA/mL in Marsh II, IIIb and IIIc lesions respectively (P < 0.005). Conclusions: Our study showed that anti-tTG prevalence and their mean serum value was higher in celiacs with severe enteropathy (Marsh IIIb-c lesions) than in those showing slight enteropathy (Marsh I-IIIa). So, serologic tests without histologic evaluation may underestimate the real prevalence of CD and there is the risk of delaying the diagnosis of CD in patients who run an increased risk of deficiencies, non-malignant conditions and malignancy.

A clinical problem is posed by patients with symptoms suggestive of gluten sensitivity (diarrhea, weight loss, unresponsive iron-deficiency anemia, etc.); however, small intestinal biopsies reveal only minor abnormalities, such as lymphocytosis with or without crypt hyperplasia (Marsh I-II). Our aim was to assess the benefit of a gluten-free diet (GFD) in patients with these small bowel mucosal abnormalities.We studied 35 patients (11 men, 24 women; mean age, 28 years; range, 22-51 years) referred to us for gastrointestinal symptoms or unexplained or unresponsive diseases. Because celiac disease was suspected to be the underlying pathology, small intestinal biopsies were taken. These revealed only minor abnormalities: 11 patients showed Marsh I type lesions, whereas 24 patients demonstrated Marsh II type lesions. Although the histologic lesions were inconsistent for celiac disease and a suspicion of a borderline celiac disease persisted, all patients were motivated to adhere to GFD. RESULTS Only 23 patients adhered to our advice and followed a GFD; follow-up biopsies were taken after 8 to 12 months. In the Marsh I lesion group (seven patients), five patients showed mucosal normalization to Marsh 0 and two showed persistence of Marsh I lesions. In the Marsh II lesion group (16 patients), 9 patients revealed mucosal normalization, 5 improved to a Marsh I lesion, and 3 revealed persistence of Marsh II lesions. A dramatic clinical improvement in symptoms was noted in all patients who were on a GFD, with symptoms virtually disappearing in all patients. Seven patients who refused GFD were reevaluated 8 to 12 months later. Symptoms and histologic lesions were unchanged in six, all of whom refused again to adhere to a GFD. One of the seven with Marsh I lesions had a worsening of symptoms and of histologic lesions (from Marsh I to Marsh IIIa); so, this last patient adhered to a GFD.Symptoms disappeared after GFD in patients suspected to have celiac disease but with slight histologic lesions. Although Marsh I-II lesions cannot be classified as celiac lesions (ESPGAN criteria), the patients' symptoms at presentation and the clear improvement of symptoms when on GFD, with or without improvement of histologic lesions, supports the assumption that these patients are sensitive to gluten and may justify treatment with a GFD.

Mucosa-associated lymphoid tissue is absent physiologically in normal gastric mucosa, but it can develop in some pathologies (dyspepsia, celiac disease, autoimmune diseases) due to certain (Helicobacter pylori, gluten) or uncertain (viruses?) antigenic stimuli. Its importance is related to the consideration that it is the background for the development of gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and its histologic progression to MALT lymphoma may be diagnosed using Isaacson's score. Monoclonal bands can be diagnosed in acquired gastric MALT as well as in gastric MALT lymphoma, but its role is unknown. To prevent development of MALT lymphoma from acquired MALT, currently anti-H. pylori treatment in all H. pylori- and MALT-positive patients is not suggested--only in patients with grade 3 of acquired MALT--due to the high risk of developing MALT lymphoma in these patients. At the same time, the etiology of gastric MALT in autoimmune extragastric diseases is not clear. Additional studies are needed to clarify this relation and its possible causes.