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Background: Obesity, type 2 diabetes (T2D), dyslipidemia, arterial hypertension as well as hepatic steatosis (HS) are common conditions that can affect clinical outcomes of patients with chronic hepatitis C (CHC) who achieved sustained virologic response (SVR). The aim of this study was to assess the impact of metabolic cofactors on the occurrence of clinical events during follow-up (FU) in a group of CHC long-term responders (LTRs) to interferon- (IFN) based therapy., Methods: A total of 5172 medical records of CHC patients enrolled from 1990 to 2011 were examined; 1034 of 5172 (20%) patients were treated with IFN-based therapy and 382 of 1034 (37%) of them achieved SVR. A total of 188 (49%) LTRs underwent liver biopsy before antiviral treatment. Data on liver and cardiometabolic events such as cirrhosis and its complications, hepatocellular carcinoma, coronary artery disease, arterial hypertension, impaired fasting glucose (IFG)/type 2 diabetes (T2D) and dyslipidemia, were collected over time., Results: The mean age of the whole cohort was 46±12 years and 114/188 (61%) patients were males. HS was found in 82 of 188 (43.6%) patients and most of them were infected by HCV genotype 3a. The prevalence of obesity, IFG/T2D, dyslipidemia and arterial hypertension was 4.3%, 6.9%, 37.2%, and 5.9%, and was similarly distributed among patients with and without HS. Cirrhosis was histologically diagnosed in 18 of 188 (9.6%) patients. After a median follow-up of 11 years (range 3-21 years), the cumulative incidence of cardiovascular events, IFG/T2D and dyslipidemia was higher in CHC-LTRs who had HS at baseline compared to those without HS (1.2%, 2.3%, and 3.0% vs. 0.4%, 0.8%, and 2.5%, respectively). At multivariable Cox regression analysis, HS was significantly associated to the development of cardiovascular events and IFG/T2D (HR=5.2, 95% CI: 1.3-20.7, P=0.019, and HR=2.6, 95% CI: 1.1-6.2, P=0.027, respectively)., Conclusions: In CHC-LTRs, HS at baseline may predispose to the development of cardiovascular events and T2D during follow-up emphasizing the importance of an accurate counseling in order to prevent extra-hepatic complications.

The capacity of endoscopic ultrasound (EUS) to distinguish the different wall layers of the gastrointestinal (GI) tract and the possibility to obtain samples of suspicious lesions or lymph nodes by means of EUS-guided fine-needle aspiration (EUS-FNA), make EUS an ideal staging modality for GI cancers. After an endoscopic and histological diagnosis of gastric cancer (GC), an accurate preoperative evaluation is essential to choose the correct management decision, because for this malignancy various and radically different stage-oriented therapies can be performed. Even if EUS is inserted in the last guidelines for the management of GC as an essential pretherapeutic staging modality, in the literature the reported accuracy, the imaging features and the performances of the technique are variable. In this review, we synthesize the current status and the imaging findings of EUS when describing and staging GC, with a particular attention to the early GC that represents till today a diagnostic and therapeutic challenge. Currently, the EUS study is mandatory for the preoperative staging, to assess with a good accuracy the tumor depth of wall invasion, the presence of suspicious lymph-nodes and of ascites (predictive of peritoneal involvement). The main limitations for a correct EUS staging remain some features of the lesion or its localization, so more attention should be paid when these characteristics are present.

Gastroenteropancreatic neuroendocrine tumours (GEP-NETs) represent in clinical practice a diagnostic dilemma because they are often very small, located deeply within the retroperitoneum or in an extramucosal site in the gastrointestinal (GI) tract and, lastly, because they may be multi-sited. Modern digestive endoscopy offers a myriad of techniques, useful for localization, diagnosis and treatment (therapeutic endoscopy). The available tools include upper digestive endoscopy (esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography), lower digestive endoscopy (ileo-colonoscopy), enteroscopy (push-type, intra-operative, capsule, double or single balloon), for examining the small intestine, diagnostic and interventional echo-endoscopy (EUS), with radial, linear and miniprobe equipment. This narrative review offers scientific support to affirm that endoscopy and EUS give imaging and diagnostic possibilities that are unbeatable in the localization of GEP-NETs both of the GI tract and the pancreas. Endoscopy is useful for localization, bioptic diagnosis and curative resection of small neuroendocrine lesions of the stomach, duodenum, colon-rectum and more recently of the jejuno-ileum. EUS associated with dedicated instruments, particularly high frequency miniprobes, is a valuable procedure in locoregional staging of lesions of the GI wall and can supply information which has a clinical impact on therapeutic options and prognostic value. EUS is still today the sole technique in a certain number of cases which provides a definitive diagnosis of pancreatic insulinoma and to detect and follow subcentimetric lesions of the pancreas in patients with MEN-1 syndrome. It should be used in all those cases where results from radiographic imaging or nuclear medicine techniques show negative or dubious.

Aim: Endoscopic variceal ligation (EVL) is recommended for the treatment of esophageal variceal bleeding. The aim of this study was to assess the most cost-effective timing of endoscopic follow-up after variceal eradication., Methods: Cirrhotics with esophageal varices treated between January 2008 and January 2009 until reached variceal obliteration were retrospectively analyzed for technical aspects and for outcomes., Results: Out of 127 patients treated with EVL, 103 were included. Number of sessions to achieve variceal obliteration and number of bands for each session were 2.8±1.3 (range 1-7) and 4.6±1 (range 2-7), respectively. The placement of >5 bands per session was not associated with higher incidence of complications (19.6% vs. 17.8%, P=ns). Esophageal ulcers were observed in 42% of patients when the interbanding interval was <20 days (versus 15% for interval >20 days, P<0.05). Once obliteration was achieved, varices reappeared in 28% of patients; the early appearance of small varices was not associated with bleeding., Conclusion: A longer interbanding interval reduces the incidence of procedural-related complications. After variceal obliteration an early endoscopic control is not useful because it does not influence the approach and does not change the patient outcome.

Over the past fifteen years, numerous observations have linked Helicobacter pylori (H. pylori) infection to ischemic heart disease (IHD). Despite the controversial literature data, it has been postulated that if a role is plausible, it will be in the early events of the acute coronary syndrome. According to this model, we focused on the potential pathogenic mechanisms relating H. pylori to IHD like platelet aggregation and thrombosis. To identify all publications in this field, a MEDLINE search of studies published in English from 1965 to 2009 was conducted. Although very few investigations were found, these showed data of paramount importance. In particular, it has been demonstrated that some strains of H. pylori bind von Willebrand factor and interact with glycoprotein Ib to induce platelet aggregation in humans. In experiments from animal models, such infection promoted the formation of platelet aggregates by both a marked increase in the flux of rolling leukocytes and the appearance of platelet and leukocyte-platelet aggregates in gastric venules. This aggregate formation was abrogated by antibodies against specific adhesion molecules (L- and P-selectin). The future challenge is to gain more knowledge in this field and to translate these information into clinical practice.

Aim: Because of the multifactorial pathogenesis of functional dyspepsia, strategies alternative to antacid therapy are being sought for treating the disorder. This prospective study evaluated the benefit of treatment with a dietary integrator composed of sodium alginate, sodium bicarbonate, bromelin and essential oils., Methods: The study population included 53 consecutive patients (22 males, 31 females; mean age, 54+/-2.5 years) with functional dyspepsia and negative for Helicobacter pylori infection. The patients were categorized into four subgroups according to predominant symptom: ulcer-like dyspepsia, motility-like dyspepsia, reflux-like dyspepsia, and nonspecific dyspepsia. All received TUBES gastro (0.80 g oral tablets bid) for a minimum of 3 months (range, 3-11). Treatment efficacy was measured by means of a Visual Analogue Scale (VAS)., Results: Two patients were lost to follow-up; of the remaining 51 patients who completed the study, 35 (68%) showed an improvement in VAS score. The difference in scores between the initial and the final visit was -1.9+/-2.1 cm (range, -6 to +3), or 23.8+/-40.8% (range, -150% to 100%) compared to the scores at the baseline visit (P=0.0001)., Conclusions: The study results indicate that in the short term TUBES gastro can significantly improve dyspeptic symptoms in dyspeptic patients negative for H. pylori infection through the synergistic action of its components: alginate buffers gastric acid; bicarbonate helps to eliminate gas and rebalance pH; essential oils regulate motility; and bromelin stimulates enzymatic activity.

The progression of chronic liver diseases is characterized by a common histopathological pathway comprising fibrosis formation and distortion of hepatic architecture which are the hallmark of evolution to cirrhosis. Several factors are responsible for the severity and progression of chronic hepatitis C. Here, we describe the most important data regarding the association between regular smoking and histological hepatic lesions. Some reports have shown that the proportion of patients with moderate or significant histological activity gradually increases with the daily consumption of tobacco. Moreover, fibrosis is associated with regular smoking in some studies. However, controversies result from other studies. Nicotine is mainly metabolised by the liver, and its administration in experimental animals showed development of steatosis and focal or confluent hepatic necrosis, probably linked to the oxidative stress associated with lipid peroxidation. In chronic hepatitis C patients, preliminary studies have suggested that hypoxia caused by smoking may induce expression of the cytokines vascular endothelial growth factor (VEGF) and VEGF-D and their corresponding soluble tyrosine kinase receptors fms-like tyrosine kinase receptor and kinase insert domain receptor. Since this issue is controversial and smoking is in any case unsafe, stopping is recommended for patients with liver diseases.

A precise understanding of the source of infection and modes of transmission of hepatitis C virus (HCV) is a worldwide priority in terms of public health. This is more evident where multi-ethnic customs cohabit. Despite the knowledge on risk factors for HCV transmission, nearly 50% of infected patients do not have a history suggesting a parenteral route of acquisition. In the present paper, the authors, focusing on ethnic and cultural aspects of HCV transmission, emphasize the need for health education in order to avoid the acquisition and the diffusion of the infection. With the current globalization and large-scale migrations, only by following a preventive strategy based on disseminate information risk behaviours may be modified.

Autoantibodies are disease markers of autoimmune hepatitis (AIH). Antinuclear antibodies, smooth muscle antibodies, antibodies to liver/kidney microsome type 1, and perinuclear antibodies to neutrophil cytoplasm constitute the ''conventional'' battery of autoantibodies, while an emerging interest to evaluate new autoantibodies as diagnostic or prognostic markers, such as the anti-Saccharomyces cerevisiae antibodies, is detectable (ASCA). This paper focuses mainly on the findings and the potential role of ASCA in AIH. These antibodies are present in 5-6.3% of blood donors and in the gastrointestinal setting, ASCA have been found most often in Crohn's disease and with lower frequency in the course of ulcerative colitis and celiac disease. Furthermore, they have been described, to a lesser extent, in patients with primary sclerosing cholangitis and primary biliary cirrhosis and in AIH. ASCA occur in 20-30% of patients suffering from AIH with a statistically significant increase observed only for IgG ASCA in type 1 AIH. This probably indicates collateral immune reactivities to the primary pathogenic process. The outcome of hepatitis is not influenced by the presence of ASCA. In conclusion, ASCA positivity does not imply that there exists a distinct subgroup of patients with AIH and these autoantibodies are not involved in the pathogenetic mechanism of AIH.

Both hepatic parenchymal and biliary tract diseases are common in patients with human immunodeficiency virus (HIV). In this paper, the authors focus mainly on clinical aspects of acquired immunodeficiency syndrome (AIDS)-related cholangiopathy. Although the etiology is unclear, several opportunistic infections (cytomegalovirus, Cryptosporidium and others) are suspected to cause it. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic gold standard and it offers a therapeutic means to provide symptomatic relief in case of papillary stenosis. The most common ERCP pattern is diffuse sclerosing cholangitis in combination with papillary stenosis. Clinically, the presentation may be variable, although right upper quadrant pain and fever accompanied by an elevated serum alkaline phosphatase (ALP) level are the most common manifestations. Jaundice is unusual suggesting that complete ductal obstruction is rare. While ERCP results and the need of sphincterotomy do not influence the prognosis, antiretroviral therapy is a protective factor and, on the contrary, high ALP level is related to a less favorable outcome. Regarding the possible pathogenic mechanisms through which HIV infection could be involved in AIDS-related cholangiopathy, in vitro experiments have shown that concurrent active HIV replication and Cryptosporidium parvum infection synergistically increase cholangiocyte apoptosis and thus jointly contribute to AIDS-related cholangiopathies.

Aim: Triple therapy consisting of a proton pump inhibitor (PPI) and two antibiotics is used as first choice in treating Helicobacter pylori (H. pylori) infection. Since in the North Italian population, metronidazole resistance is less than 40%, this antibiotic would be preferable as first approach. The aim of this randomized study was to assess the efficacy of a metronidazole-based versus a tinidazole-based treatment, in naïve patients with H. pylori infection., Methods: Diagnosis and eradication of H. pylori infection were assessed by 13C-urea breath test, and by histology when an endoscopic examination was necessary. A total of 171 patients was treated: 91 (47 males, mean age 50+/-3 years) with metronidazole 250 mg q.i.d., amoxicilline 1 gr b.i.d. and PPI standard dose (MAO), and 80 (36 males, mean age 52+/-3.8 years) with tinidazole 500 mg b.i.d., amoxicilline 1 gr b.i.d. and PPI standard dose (TAO) regimen for 7, 10 or 14 days., Results: Three patients suspended MAO treatment due to side effects. H. pylori eradication was obtained as follow indicated. After 7 days, in 23/30 (76.6%) patients in MAO versus 20/27 (74.0%) in TAO regimen. After 10 days, in 20/26 (76.9%) patients in MAO versus 20/26 (76.9%) in TAO regimen. After 14 days, in 25/32 subjects (78.1%) in MAO versus 21/27 (77.7%) in TAO treatment. The differences among durations or between metronidazole-versus tinidazole-based triple therapy were not statistically different., Conclusion: Treatment with metronidazole is as effective as that with tinidazole in terms of efficacy. Moreover, duration did not influence efficacy of treatment.

Irritable bowel syndrome (IBS), as defined by Rome III diagnostic criteria, affects 10-20% of the general population, with women 20-40 years old accounting for the majority of patients. Although variable and intermittent, IBS symptoms may persist for many years. Repeated referrals for medical consultation and diagnostic studies generate huge healthcare costs. Since there is no evidence that IBS leads to more severe gastrointestinal disorders, in absence of alarm symptoms or signs, an invasive diagnostic algorithm is not indicated. Optimal treatment for IBS still needs to be defined. The clinical approach is based on treatment of the prevalent symptom. When pain predominates, antispasmodics are the first choice. In case of diarrhea, loperamide is useful for reducing bowel frequency. Soluble fiber represents the first option in subjects with IBS and constipation or mixed IBS. Dietary integrators composed of probiotics and serotonin precursors are a promising therapeutic option.

Aim: Third-level Day-Hospital Services of Gastro-Hepatology are likely to recruit patients with an increased disease severity. The burden of request for immunomodulation drugs is presently unclear., Methods: The charts of 1 012 consecutive patients who underwent day-hospital admission were reviewed. Among them, 975 were admitted for several reasons (percutaneous liver biopsies, abdominal fluid aspirations, infiltrations of hepatic nodules, gastrointestinal endoscopies with specific treatments). Data of the remaining 37 patients were elaborated., Results: Of them, 31 (83%) suffered from ulcerative colitis (UC) or Crohn's disease (CD) (17 and 14, respectively) and 6 from autoimmune type 1 hepatitis (AIH). Of the 14 non-operated UC patients, 12 were taking azathioprine (AZA) and 2 infliximab (IFX). Among CD patients, the majority received AZA (N=6) or IFX (N=6). Of the AIH patients, 5 were treated with AZA and 2 had also cyclosporine. Overall, corticosteroids (32%) and IFX (21%) ranked first and second among the induction drugs, and AZA ranked first (62%) as maintenance option. Of the 4 CD patients under IFX treatment, 2 were switched to leukapheresis for incomplete response, the third one developed thrombotic complications, and the last one achieved disease remission after 12 months. Of the 2 cases of UC, one lost response soon and was colectomized, the other is maintaining moderately active disease, requiring scheduled injections every 8 weeks., Conclusion: Despite the caution imposed by the very small numbers, this analysis confirms that the potent available options are difficult to be correctly positioned in the therapeutic algorithm of inflammatory bowel disease.

Portal hypertension (PHT) is more frequently caused by cirrhosis. Increase in portal pressure induces development of collateral circulation with shunting resulting in disturbances such as gastroesophageal varices (GEV). Prevention and therapy of bleeding from GEV are mandatory. Therefore, the diagnosis of PHT represents a crucial step. Endoscopic ultrasound (EUS), with its combination of endoscopic imaging and ultrasonic capabilities, can offer an almost comprehensive evaluation of portal venous system and porto-systemic collateral circulation. The improved endoscopic view of several video-echoendoscopes has filled the gap between EUS and standard video-endoscopy in diagnosing GEV and in assessing endoscopic criteria of bleeding risk. EUS combined with Color-Doppler capabilities are able to provide hemodynamic information. Furthermore, EUS data allow to stratify patients on the basis of PHT severity and first bleeding risk, monitor the results of pharmacologic and/or endoscopic therapy, predict the response to treatment, quantify the risk of variceal recurrence and recurrent bleeding after GEV obliteration and guide or assist EGD therapy. Despite having this amount of information, there is lack of scientific evidence that EUS imaging and EUS-assisted therapy can have a clear-cut clinical impact and affect patients outcome.

The availability of osteodensitometry has contributed significantly to increase the awareness of inflammatory bowel disease (IBD)-associated bone disease. Reported osteoporosis prevalence in patients with IBD range from 2% to 30%. The fractures risk varies between studies, influenced by demographic, clinical and genetic factors. The main pathogenetic factors involved are malabsorption, treatment with glucocorticoids, inflammation (increased cytokine production) and hypogonadism. A screening should be considered for all patients with small bowel Crohn's disease and especially for those with extensive disease, multiple resections, and malnutrition. Supplementation with both calcium and vitamin D is frequently the first step taken, but is insufficient to inhibit bone loss in many patients requiring use of glucocorticoids. Among available therapies, only biphosphonates are effective for treatment of glucocorticoid-induced osteoporosis.

The prevalence of primary sclerosing cholangitis (PSC) in Crohn's disease (CD) patients is up to 8.5%. Although cholangiocarcinoma may complicate long-standing PSC in one third of the cases if follow-up is extended long enough, hepatocellular carcinoma (HCC) is a rare complication of PSC. The concomitant presence of PSC, HCC and CD have been reported sporadically. We discuss here a case of association of these three conditions.

Endoscopic ultrasound (EUS) is a relatively new technology developed in the early 80's, but introduced into the clinical practice only in the late 80's. Nowadays there is an increase in demand for EUS examinations and services, because this technique is more and more recognized as an important and integral part in the diagnostic and staging algorithm of many gastrointestinal (GI) and nongastrointestinal pathologies. Even if today the EUS panorama enrich itself with a large number of different instruments, mechanical and electronic scopes, radial and linear ones, several types of miniprobes and specialty probes, for diagnostic purposes the dedicated radial scanning instruments remain the more adopted choice while miniprobes can have applications only in niche areas, like superficial GI cancers staging, small subepithelial lesions evaluation or intraductal ultrasound and some technological advances are needed to solve the potential drawbacks of this miniaturized probes. At last the EUS equipment borrowed most of the electronic sophistication from the mainstream ultrasonography, this made the choice of an EUS instrument even more difficult and challenging, but you must consider that there is no right or wrong equipment, there is only the right instrument for that specific clinical need or situation.

In the Western world, gallstone disease accounts for approximately half of the cases of acute pancreatitis. The benefit of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been clearly proven for this disease. On the basis of history, laboratory, and noninvasive imaging studies, about 10-30% of patients with acute pancreatitis have no apparent aetiology. This is critical because it limits the optimal therapeutic management and the prevention of recurrence. Endoscopic ultrasound (EUS) has emerged as an important procedure to clarify the aetiology of acute pancreatitis. After extensive investigation that included EUS, 8-20% of episodes remained idiopathic. Moreover, EUS carried minimal risk when compared to ERCP. The present short review attempts to update on the indications for the employment of EUS in the diagnosis of biliary stones as well as in the clarification of aetiology in the case of unexplained pancreatitis.

In the last decade, several studies have approached the issue of a potential relationship between Helicobacter pylori (H. pylori) infection and gastro-esophageal reflux disease (GERD). The different aspects debated were the possibility that the bacterium could have a protective role or worsen the disease or have no relationship at all. Hitherto, although some researchers have proposed fascinating pathogenic pathways, no scientific evidences exist to support the need to treat or not H. pylori infection in order to modify the natural history of GERD. In this review, the authors report the main updated considerations regarding this matter.

Celiac disease (CD) is a permanent intolerance to gluten characterized by destructions of the small intestinal villi and malabsorption. The gluten-free diet (GFD) results in healing of the mucosa, resolution of the malabsorpitive states, and reversal of great part of CD effects. Among the extradigestive complications associated with CD, unexplained infertility has been reported since the 70's. The prevalence of CD among women with unexplained infertility is 2.5-3.5%, higher, although not always significantly, than control population. To date, it is widely accepted that untreated CD represents a risk for abortion, low birth weight babies and short-breast feeding period. These features can be corrected by GFD. Some discrepancies could stem from the heterogeneity of the studies. Regarding a potential pathogenic mechanism, since CD causes malabsorption of folic acid and other nutrients, this pathway has been proposed to explain the unfavourable outcomes of pregnancy. However, this remains a speculation. In conclusion, each woman with unexplained infertility should be screened for CD.

Clinical management of compensated chronic liver diseases (CLD) requires precise definition of the stage of liver fibrosis which is the key histologic predictor of progression to cirrhosis. Several methods are used to assess liver fibrosis. Among those, percutaneous liver biopsy is still the gold standard. However, the recent introduction of liver imaging techniques, the rising of statistical tests able to classify CLD noninvasively, and a reconsideration of its potential complications, have contributed to an audit of the evolving role of liver biopsy. At present, there is an increasing interest for noninvasive approaches to evaluate the stage of liver fibrosis in the clinical work-up of patients with CLD. Transient elastography (FibroScan) is a new, noninvasive method to assess liver stiffness and, consequently, the degree of liver fibrosis. Since its use in the clinical setting is of great interest, further studies should define the exact role of this procedure.

The interest that surrounds the bacterium Helicobacter pylori (H. pylori) is due not only to its causal role in several gastroduodenal diseases, but also to its supposed involvement in the pathogenesis of extragastric manifestations. This review provides a literature update on the hypothetic correlation between H. pylori and headache. The authors examine three aspects of this potential association: epidemiology, intervention trials and pathogenesis. Regarding the first, apart in some subgroups, no difference in prevalence exists between patients and controls. Considering the intervention studies, it is documented that, at 6 and 12 months, bacterial eradication is associated to disappearance of symptoms in 23% and 28% of cases, and to a significant decrease of intensity, frequency and duration of acute attacks in the remaining patients. As to the pathogenetic aspect, if H. pylori has a role, it does not act through oxidative stress. In conclusion, the involvement of H. pylori infection in the pathogenesis of headache is unclear. Further investigations should focalize on particular subgroups of patients and, encouraged from data produced by intervention studies, evaluate the long-term benefit of eradication.

Aim: Given the demographic shifts and needs of cost rationalization, it is of high priority to organize health care on the basis of ambulatory outpatients models. The aim of this study was to examine activity at the gastro-hepatology outpatients clinic of the Molinette Hospital. In this facility, the management is based on a work team organization that follows cohorts of patients with specific pathologies., Methods: All services, consultations and urea breath test (UBT) for the diagnosis of Helicobacter pylori infection, carried out from January 2003 to December 2006, were extrapolated from the computerized system. Consultations were divided into first examination and controls. Furthermore, the destination of the patients after each consultation was considered., Results: During the year 2003, 8 842 consultations and 4 071 UBT were carried out, in the year 2004, 11 342 consultations and 2 409 UBT, in the year 2005, 12 474 consultations and 2 510 UBT, in the year 2006, 12 249 consultations and 2 357 UBT. No further specialistic management was required for 25% of patients, while 2% had been hospitalized in the bed unit, 3% in the short hospitalization unit or the day-hospital. The remaining 70% were included in work teams or monitored thereafter. The comparison with consultations from 1994 shows an increase due to both first examination (+300%) and controls (+83%)., Conclusions: The burden of the requests from the population and primary care structures addressed to the outpatients clinic of gastro-hepatology is relevant. The activity of this facility leads to a low rate of hospitalization as well as of cost reduction.

Aim: As optimal therapy for irritable bowel syndrome (IBS) remains elusive, current approach to therapy is based on symptomatic treatment. With this case-control experience we wanted to determine the beneficial effect in IBS patients of a dietary integrator (IBS Active), composed of L-tryptophan, inulin, angelica, vegetal charcoal, vitamin PP, group B vitamins (B1, B2, B6) and probiotics (Lactobacillus sporogenes, Lactobacillus acidophilus, Streptococcus thermophilus)., Methods: The treatment group comprised 37 patients (11 men and 27 women; mean age, 44.3+/-5.1 years) given IBS Active (440 mg bid) over a mean period of 6 months (range, 5-8). The control group comprised 28 patients (6 men and 22 women; mean age, 48.6+/-3.7 years) who were instructed to continue their customary therapy for 6 months (range, 5-7). All subjects were assessed for the presence of abdominal pain and/or distension, constipation, diarrhea and alternating constipation and diarrhea., Results: Compared with baseline values, the reduction in abdominal pain in the treatment group was 62% (P<0.0001), 55% (P<0.0001) in abdominal distension, 58% (P=0.05) in constipation, 33% (P=0.3) in diarrhea, and 62% (P=0.01) in alternation constipation and diarrhea. Compared with baseline values, no statistically significant reduction in symptoms was found in the control group. Post-treatment comparison between the two groups showed that the study product had reduced symptoms and that the difference was statistically significant for abdominal pain (P<0.000001), abdominal distension (P=0.003) and constipation (P=0.03)., Conclusions: The use of IBS Active led to a significant improvement in pain symptoms, abdominal distension and regulation of bowel movement in IBS patients. Further study is needed to evaluate the long-term benefit of the study product.

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.

Currently, different approaches are employed to detect the presence of Helicobacter pylori (H. pylori): invasive, if based on biopsies performed during endoscopy (urease test, histology, culture, polymerase chain reaction), and non-invasive, if endoscopy is not carried out. Another option is offered by the invasive non-endoscopic methods (string test). An update on the diagnostic invasive approaches to patients in the clinical setting is presented in this review. Although non-invasive tests are preferred, important information can be gained from histology, the unique technique which permits the evaluation of the status of the mucosa, and from culture, that allows strain typing and tests for antibiotic susceptibility. Until today, polymerase chain reaction has had a limited application in the clinical practice and the role of non-endoscopic methods needs to be better clarified in the future.

Aim: In spite of the diffusion of endoscopic treatment, mortality rate due to peptic ulcer haemorrhage (PUH) remains high. Helicobacter pylori (H. pylori) infection and nonsteroidal anti-inflammatory drugs (NSAIDs) are the 2 main aetiological factors, but their interactive role is controversial. The aim of this study was to determine both the prevalence of H. pylori infection and NSAIDs consumption in PUH and their prognostic importance., Methods: In a prospective study, 41 consecutive patients (33 males, 8 females) admitted for PUH were recruited. H. pylori status was investigated both by measuring specific antibodies in serum and by histological detection on gastric biopsies obtained after one month from bleeding. In case of doubt, either a 13C urea breath test, or a stool antigen test were associated. All patients were treated with medical therapy associated to endoscopic treatment in most severe cases., Results: Sixteen patients were infected from H. pylori (group A), 12 had a history of NSAIDs consumption (group B), and 13 had both risk factors (group C). The median duration of hospitalisation was 7 days for each group and correlated with age (P<0.04). Severity of PUH (high risk of rebleeding) was higher in group A (13/16; 81%) and group C (9/13; 69%), with respect to group B (6/12; 50%). This difference was not significant., Conclusions: H. pylori infection has a predominant role in causing PUH as well as in the prognosis and clinical course of this condition. Hence, it is important to determine H. pylori status in every patient with PUH.

At present, 2 approaches are used to detect Helicobacter pylori (H. pylori): invasive, if based on biopsies taken during endoscopy, and non-invasive, if they do not rely on endoscopic approach. A 3rd option is offered by the string test, that employs an invasive non-endoscopic strategy. The present review attempts to update on the diagnostic non-invasive approaches to patients in the clinical setting. Non-invasive tests include urea breath test (UBT), antigen stool assay, serology, and ''doctor's tests''. The choice of the methods depends on the situation, for example, the clinical circumstances, the diagnostic accuracy, the costs of the testing strategy, and the availability of the tests in the respective area. According to European guidelines, UBT and antigen stool assay are recommended in patients without alarm symptoms or under 45 years of age, at low risk of malignancy in the test and treat strategy. Confirmation of H. pylori eradication following treatment should be tested by UBT; the stool antigen assay is the alternative if the former is not available.

Gastric carcinogenesis involves a slow but continuous, stepwise evolution from superficial gastritis to glandular atrophy, metaplasia, dysplasia, and finally, to adenocarcinoma. In 1994, the International Agency for Research on Cancer defined Helicobacter pylori (H. pylori) as a group I carcinogen. Evidence supporting a causal association has been demonstrated by epidemiological data as well as by experimental animal models. The process of carcinogenesis, which may well extend over decades, provides an excellent opportunity for prevention or early detection of the events preceding development of the neoplasm. This is especially true because, at present, H. pylori can be readily treated. Despite this, the prognosis for gastric cancer is poor and, in most industrialised countries, the survival is only 10% after 5 years from diagnosis. The sole exception is Japan where this malignancy is often identified at an early stage when cure by radical surgery is more probable.

Hepatocellular carcinoma (HCC) is common throughout the world. The incidence of HCC is higher in cirrhotic patients and, among these patients, the incidence rate is 3% in Europe. The overall survival rate of HCC ranges between 20 and 30 months, and is influenced by the local stage of the neoplasm and by the liver function. The literature reports several serological, urinary and radiological markers used for the early detection of HCC. Currently, it is highly recommended to periodically screen cirrhotic patients and hepatitis B virus carriers older than 35 by serum alpha-fetoprotein (AFP) and liver ultrasound (US) every 6 months. The concomitant determination of des-g-carboxy prothrombin and AFP allows a 23% increase in sensibility of the diagnosis for HCC avoiding the need for invasive diagnostic procedures.

Hepatitis C is a heterogeneous disease and is responsible for considerable mortality and morbidity. The hepatitis C virus (HCV) infects nearly 170 million people world-wide. More than 80% of infected individuals develop chronic infection; the remaining 10-20% develop spontaneous clearance with natural immunity. Acute hepatitis is icteric in only 20% of patients and is rarely severe. The majority of patients who develop chronic HCV infection are asymptomatic; but 60-80% develop chronic hepatitis as indicated by elevated alanine aminotransferase (ALT), around 30% maintain persistently normal ALT levels despite having detectable HCV-RNA in serum. One-third of chronically infected patients develop progressive liver injury, fibrosis and cirrhosis over a period of 20-30 years. The relationship between virus load, HCV genotype, quasi-species variability and progression of liver disease is controversial. Acquired infection after age 40, male sex, excessive alcohol-consumption, hepatitis B virus (HBV) or HIV co-infection, steatosis, and immunosuppressed state have been identified as co-factors associated with progression of fibrosis and development of cirrhosis. In patients with cirrhosis, the incidence of hepatocellular carcinoma is 2-5% per year. At present, HCV-related end-stage cirrhosis is the first cause of liver transplantation.

In face of numerous benefits induced by therapy based on interferon (IFN) associated with ribavirin for the treatment of chronic hepatitis C, there is an increasing concern regarding its tolerance, which can, in some cases, reduce the quality of life as well as compliance of patients. Among the less common side effects, there are the autoimmune ones which can be globally divided into appearance or increase in titres of auto-antibodies and/or manifestation of overt autoimmune pathologies. Whereas the former may concern more than 50% of treated subjects, the latter is reported in only 1-2% of patients under therapy. Thyroid dysfunction represents the well-studied autoimmune disorder. The presence of pre-existing anti-thyroid antibodies and being of female sex, constitute relevant risk factors for the development of a disease involving this gland. Often the treatment of thyropathy must be continuous in spite of IFN discontinuation because the disturbance usually does not abate with stopping antiviral therapy. Some observations have pointed out to the fact that IFN can lead to the development of insulin-dependent diabetes mellitus. Sometimes, during, as well as after IFN treatment, the appearance of anti-islet cell antibodies has been shown, but its interrelationship with the development of disease is uncertain. While being treated with IFN for chronic hepatitis C, the finding of non-organ specific antibodies at baseline can increase the likelihood of the development of autoimmune hepatitis. However, their presence does not constitute an absolute contraindication to the treatment, except in case of high titre. Other disorders, such as a lupus erythematosus-like syndrome, haemolytic anaemia, and immune-mediated thrombocytopenia have been reported. In conclusion, although the presence of auto-antibodies is considered to be an epiphenomenon without pathogenic significance in most patients suffering from chronic hepatitis C, it poses a problem when they need to be treated with IFN. This antiviral drug can induce or exacerbate a multitude of autoimmune-related disorders, however, clinically overt immune-mediated diseases are rare and affect a subset of subjects who have an underlying autoimmune diathesis.

Gastric cancer (GC) is the world's second leading cause of cancer-related mortality, and carries a bad prognosis. In 1994, Helicobacter pylori (H. pylori) has been classified by the International Agency for Research on Cancer as a group I carcinogen. There are increasing indications that this infection is associated with both the initiation and progress of gastric carcinoma and lymphoma. Evidence supporting a causal association has been demonstrated by epidemiological data and in experimental animal models. Despite this, there is still lack of final conclusion regarding the association between the infection and the malignancy due both to marked geographic variations and heterogeneity in study designs. Given the high rate of morbidity and mortality associated with GC, any means of reducing the occurrence of the disease or increase its early detection is most desirable. In this paper, the epidemiological aspects on the evidence of a causal relationship between H. pylori and GC are discussed. Prospective cohort studies and interventional trials focused on the effects of H. pylori eradication on lesions predisposing to GC should be performed in order to provide further data.

With patients referring symptoms of gastro-esophageal reflux disease (GERD), 2 initial approaches should be considered: an empiric therapy (treat and test strategy) or a strategy based on instrumental investigations (test and treat). In most cases a well-taken history is usually sufficient to confirm the diagnosis of GERD and initiate treatment. However, some patients may present with ''atypical'' symptoms, classic symptoms refractory to standard medical therapy or ''alarm'' symptoms. In these cases, one must rely on diagnostic studies to document the presence of mucosal damage related or not to GERD and/or quantify the degree of gastro-esophageal reflux. The most relevant test to diagnose esophageal injury and complications of GERD is represented by upper gastrointestinal endoscopy, while the most diffuse procedure to quantify the degree of acid reflux is pH monitoring. Further studies are required to delineate the appropriate use and the possible impact of new techniques, such as intraluminal impedance monitoring, Bilitec and, wireless ambulatory pH monitoring in the management of GERD.

The European Helicobacter pylori Study Group (EHPSG), during the Maastricht 2-2000 Workshop, revised and updated the original guidelines on the management of Helicobacter pylori (H. pylori) infection. The present review focuses on the diagnostic approach for patients referred to the primary care as well as to the specialist. Currently, two diagnostic methods can be used to detect H. pylori: invasive (urease test, histological detection, culture, polymerase chain reaction, smear examination, string test) or non-invasive (serology, urea breath test, antigen stool assay, ''doctor's tests'') tests. These methods vary in their sensitivity and specificity, and the choice depends on the situation, for example, whether the aim is to detect infection or the success of eradication treatment. Urea breath test (UBT) and antigen stool assay are recommended from EHPSG in patients without alarm symptoms or under 45 years of age, at low risk of malignancy in the ''test and treat strategy''. Confirmation of H. pylori eradication following treatment should be tested by UBT; a stool antigen assay is the alternative if the former is not available. Important added value can be gained from other tests: histology allows evaluation of the status of the mucosa while culture allows strain typing and tests for antibiotic susceptibility.