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During a 10-year period we observed 10 patients who suffered from an inflammatory-fibrosing disease mimicking pancreatic carcinoma and primary sclerosing cholangitis (PSC).A review of the presenting features, the clinical course and the relevant literature.Ten male patients (mean age 55 years) presented with weight loss, jaundice and pruritus. Pancreatic cancer was suggested by imaging studies, which showed focal or generalized pancreatic enlargement and compression of the distal common bile duct. Cholangiography also demonstrated intrahepatic biliary stenoses consistent with sclerosing cholangitis. None had evidence of IBD. Exocrine pancreatic insufficiency was found in six cases and diabetes in four. Pancreatic histology (n=3) showed fibrosis and extensive inflammatory infiltrates. Immunosuppressive treatment was instituted in five patients. Clinical and biochemical remission occurred in three; in one other patient, previously documented intrahepatic biliary strictures had disappeared after 3 months. One patient had concomitant Sjögren's disease. The clinical features, pancreatic involvement, age at presentation, absence of IBD and response to steroids all plead against a diagnosis of "classical" PSC. The natural course of the disease was highly variable. Thirty-five comparable cases, with a largest series of three, have been reported in the literature. The disease has been associated with Sjögren's disease, retroperitoneal fibrosis and other fibrosing conditions, and may be a manifestation of a systemic fibro-inflammatory disorder.Autoimmune pancreatocholangitis is a distinct inflammatory disorder involving the pancreas and biliary tree. The disease may mimick pancreatic carcinoma and PSC and responds to immunosuppressives.

In a Dutch working population, the apparent association between dyspeptic symptoms and Helicobacter pylori infection was found to be entirely due to subjects with an ulcer history. In general populations with a much higher prevalence of H. pylori infection and peptic ulcer disease, such as in Japan, the relationship between dyspepsia and H. pylori has yet to be clarified. A questionnaire on ulcer history and dyspeptic symptoms during the preceding 3 month period was obtained from apparently healthy Japanese employees who underwent a periodic medical examination. In addition, serum samples were analysed for anti-H. pylori IgG antibodies. A total of 196 men and 35 women, aged 23-71 years, participated in the study. Seven women (20%) and 49 men (25%) had a diagnosis of peptic ulcer disease. Among 41 subjects with verified duodenal (26) and/or gastric (17) ulcer, 95% were H. pylori positive while 32% had had frequent dyspeptic symptoms in the 3 months prior to the study (29% of the 35 men and 50% of the 6 women). Among the 147 men and 28 women without an ulcer history, the 3 month period prevalence of frequent dyspepsia was 14 and 32%, respectively. The rate of H. pylori positivity was 80% in non-ulcer dyspeptics and 68% in all other non-ulcer subjects (95% confidence intervals: 61-92 and 61-76%, respectively). Significant differences in symptoms between H. pylori positive and negative subjects could not be detected, neither in the whole population nor in the non-ulcer group. In conclusion, in this Japanese working population, no association was found between dyspeptic symptoms and H. pylori infection, irrespective of the inclusion of subjects with a peptic ulcer history.

Contains fulltext : 69534.pdf (Publisher’s version ) (Open Access) BACKGROUND: With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction.The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs. METHODS/DESIGN: The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007. DISCUSSION: The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease. TRIAL REGISTRATION: Nederlands Trial Register NTR1150.

In reply We thank Loffeld and Werdmuller for their interest in our article. 1 We took great care to find out whether Helicobacter pylori is associated in any way with nonulcer dyspepsia (NUD) by analyzing a subgroup of subjects with "essential dyspepsia." The presence of subjects with NUD from other identifiable causes might weaken a possible association with H pylori infection. Therefore, essential dyspepsia was defined as NUD in the absence of irritable bowel syndrome and regular nonsteroidal anti-inflammatory drug use, as well as in the absence of heartburn and/or acid regurgitation as the only frequent dyspeptic symptom(s). When heartburn or acid regurgitation clearly dominated a patient's complaints, these symptoms were shown to have a high specificity (85% and 96%) for gastroesophageal reflux disease. 2 Loffeld and Werdmuller imply that we only defined a specific set of symptoms to determine whether H pylori plays a role in NUD. On the

Background: There is considerable debate about whetherHelicobacter pyloriinfection is important in causing non-ulcer dyspepsia. Many studies assessing this relationship have been performed in selected patient populations and included patients with a history of peptic ulcer. General population-based data with attention to ulcer history are needed to clarify this relationship. Methods: A questionnaire on ulcer history and dyspeptic symptoms during the preceding 3-month period was obtained from apparently healthy employees who underwent a periodic medical examination in the Netherlands. In addition, serum samples were analyzed for anti—H pyloriIgG antibodies. Results: A total of 427 men and 73 women, aged 22 to 69 years, participated in the study. None of the women but 27 men (6%) had a previous diagnosis of peptic ulcer. Among 19 unoperated-on men with verified duodenal (17 subjects) and gastric (two subjects) ulcer, 89% were H pylori positive, while 74% had frequent dyspeptic symptoms in the 3 months before the study. Among the 400 men and 73 women without an ulcer history, the 3-month period prevalence of frequent dyspepsia was 13% and 21%, respectively. The rate ofH pyloripositivity was 25% in subjects with nonulcer dyspepsia and 29% in all others. TheH pyloriinfection rate increased with age and with a lower occupational level but was independent of gender. In the male population, various differences in symptoms betweenH pylori—positive andH pylori—negative subjects could be detected when the 27 subjects with a history of ulcer were included, whereas these differences disappeared when these subjects were excluded. Conclusions: In the Dutch working population, nonulcer dyspepsia is not related toH pyloriinfection, whereas for duodenal ulcer the relationship is clear. The apparent association between dyspeptic symptoms andH pyloriinfection is entirely accounted for by subjects with an ulcer history. (Arch Intern Med. 1995;155:82-87)