P353 Coeliac disease in adults

Abstracts

/ European

Journal

of Internal

Background: Liver cirrhosis is associated with a state of splanchnic and systemic vasodilatation that lead to stimulation of several hormonal systems. Effects of smoking tobacco in liver cirrhosis have only rarely searched. Methods: We investigated the effects of chronic smoking tobacco on the circulatory state of patients with liver cirrhosis. For 3 days, patients remained bedridden, in a diet with 60 mM of Na/day, all drugs with cardiovascular actions were withdrawn, all determinations were made in supine position and they were not let to smokein order to let patients reach a steady state. We measured heart output by echocardiography, arterial gases, calculated vascular resistances (VR), femoral fraction of heart output (FFHO) and serum levels of several hormone systems measured by radioimmunoassay or chromatography. Results: We studied 32 patients with liver cirrhosis (Mean age 57 SD 9 years, 98% males). Main etiology was alcohol in 94%. Class A of Child-Pugh were 14 (44%) patients, Class B 10 (31%) and Class C 8 (25%). Smokers were 19 (59%) patients (mean use of tobacco 21SDlO cigarettes per day, 17SD20 packs/years), and nonsmokers 13 (41%). Main differences between smokers and nonsmokers were:

Sub,ect

Smuker

N”” mokei

p value

PilO?

7s Y4 SD IO67

X7.15SD 1068


Hemoplob,n

13.93FD I71

I240 SD ?..I6

<,I 5

H~dfl-lNkX

3 1X SD 0 71

3.88SD IO9

coo5

“R

1252SD 293

1093SD x3


FFHO

15S1SDY44

35S SD ?Y77


Adrennmeduhn

II? SD 41

?I4 SD ?05


Chdd lndrr

7 ?6 SD ?.I6

7.61SD 2 18

NS

\omato\tatin,

VIP. PGI?. endotelin-I,

Rerun. aldouterone.

Glucagon and urinary Nitrite\+nitrate\

calcltonin.

P substance, Insulm.

and catecholamine? all were simdar in both groups.

Conclusions: Nonsmoker patients with liver cirrhosis show a higher degree of systemic and regional vasodilatation that could be mediated by adrenomedulin as direct vasodilator. Hypoxemia caused by tobacco and relative polyglobulia could explain a flattened systemic vasodilatation in cirrhotic smokers.

P351 A prospective study of the morbidity and complications associated with day case flexible sigmoidoscopy from a patients’ perspective at a Single Endoscopy Centre at the UK S.Z. Abbas, N. Kochar, R.H. Teague (Torquay, UK) Background: Flexible Sigmoidoscopy is a common endoscopic procedure, usually performed as a day case. However, there are very few studies on the complications following Flexible Sigmoidoscopy. In addition, there are no data on the 30-day morbidity caused by the procedure from a patients’ perspective in the UK. Aim: To prospectively look at the standards of practice and determine the rate of minor and serious adverse events immediately and thirty days following Flexible Sigmoidoscopy from a patients perspective at a single centre in the UK. Mefhods: 207 consecutive day case flexible sigmoidoscopies were studied (172 diagnostic, 35 therapeutic; 107 men, 105 women). 30 days post procedure, 187 (90%) patients were contactable. Results: Median age of the patients was 58.5 years. Standards of care as per various national guidelines were met. 19% patients chose premedication with sedation. 78/ 172 patients undergoing diagnostic procedure (45%) had biopsies taken. 4 patients had transient immediate medical complication, which subsided with minor medical measures. All the patients were discharged the same day. Thirty days after the procedure, 20 patients (11%) reported having had some morbidity. In 4 patients the problem persisted for over 48 hours and 3 patients required medical advice (2%). Commonest complaint was abdominal discomfort

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(7%). The morbidity was not related to the type of procedure the patients had (diagnostic or therapeutic), sex of the patient or whether the patient had sedation or not. None of the patients had a major complication or death. Conclusion: Flexible Sigmoidoscopy, under optimal conditions is a safe and well-tolerated procedure with a low morbidity rate which in most cases is self limiting and does not require medical attention.

P352 Microvillous report G.A. Piccillo,

atrophy

disease

E. Mondati,

associated

L. Miele,

with

G. Gasbarrini

coeliac

disease:

(Catania,

a case

Rome,

I)

Introduction: Microvillous atrophy disease (MVA) is a very rare recessively inherited disorder or acquired alteration of intestinal microvillous characterised microscopically by total or subtotal absence of microvillous and clinically by a very severe malabsorption syndrome due to refractory diarrhoea. Diagnosis is histologic by biopsies of small intestine. Prognosis is very poor in congenital MVA, while the late onset of the disease has better outcome. Clinica case: A thirty-year-old female patient was admitted to our Department for deep asthenia, sweating, severe abdominal pain resistant to antispastic drugs. She appeared hypoevolute (H 150 cm, W 38 Kg, BMI 17.5). tachypnoic, bradycardic, hypotermic, with hypotension and painful abdomen. Laboratory data pointed out a severe hypocromic microcytic iron-less anaemia, hypokalaemia, hyponatraemia. It was immediately administered salt solution, plasma expander, potassium, steroid, antispastic drugs, 02 and heating obtaining fairly improvement of clinical conditions. At history, hyporexia, nausea and vomiting, relapsing abdominal pain with ballooning, microcytic iron deficiency anoemia since she was a child with important arrest of growth, anorexia at the age of 17 y with important weight loss, immunodeficiency with concomitant anaemia at the age of 20 y. In the last years progressive worsening of anaemia, relapsing intractable abdominal pain with diarrhoea and weight loss. It was executed Ab-antiendomisium and Ab-antitransglutaminase tests and gastroscopy which resulted coherent with diagnosis of coeliac disease (CD). The patient started gluten-free diet only obtaining the resolution of abdominal pain and diarrhoea, but without increase of weight. A new histological evaluation at scanning electron microscopy revealed the presence of concomitant MVA. Discussion: The patient presented with two rare diseases: MVA and CD. Our intriguing hypothesis is that MVA in this clinical case could be acquired and due to the long misdiagnosed CD probably because of continuous chronic insult to intestinal mucosa.

P353 Coeliac disease in adults I. Villamil-Cajoto, A. Capparini, (Santiago de Compostela, E)

A. Gonzalez-Quintela,

J. Campos-Franc0

Objectives: Coeliac disease is an inmunologically-mediated disease. This behaves as a genetic chronic disease related with dietary gluten and classically presents as malabsorption. It usually presents as a paediatric disease, although non-paediatric presentation is increasingly described. European global prevalence seems to be between l/300 and 1/ 1000, and other data shows up to l/ 100. We communicate our experience in newly diagnosticated celiac disease in adults during the period 1996-2001. Material and methods: A review of newly diagnosticated patients 14 or more years old (limit of paediatric age in our country) in our hospital was performed. Data was available at admission, pathology and immunology laboratory. Recording of epidemiological data, clinical presentation was accomplished. Resulrs: Eight patients 14 or more years old were identified. Ages were from 17 to 70 years old at diagnosis. 7 patients (87.5%) were female.

s130

Abstracts

I European

Journal

of Internal

Asthenia was present in all patients; 87.5% presented as diarrhoea and weight loss. Other clinical presentations were anaemia in 2 patients, transaminase elevation (1) and tetany (l), among others. Reproductive failure was present in the oldest patient; no other associated conditions (dermatitis herpetiformis, etc) showed. One patient presented prior anorexia nervosa. Serum antibody assays (Ig A endomysial assay and antigliadin antibody assays) showed high possitivity. Villous atrophy was present in all patients; 3 patients grade III in Mettayer classification. One patient presented grade V. There were no complications (intestinal lymphoma, etc). All patients but one (the oldest) accomplished correctly free gluten diet; this had several hospital admissions because of dietary transgressions. Discussion: Our data shows a female prevalence, frecuent gastrointestinal symptoms and high histologyc stages with no complications even in long term absence of diet compliance. No benefit of screening for no symptomatic disease has been demonstrated, but celiac disease is a diagnostic possibility in all ages old patients.

P3.54 Upper gastrointestinal bleeding of non-variceal origin (UGB) anticoagulated patients: a descriptive analysis C. Vicente, C. Romero, B. Chulvi, C. Femandez Martin, V Alvarez, Moran, R. Rodriguez Rosado, J. Marco (Madrid, E)

in J.L.

Objective: We run an early discharge unit (EDU) with an expected maximum hospital stay of 5 days. Upper gastrointestinal bleeding of non-variceal origin (UGB) is one of many diagnosis admitted in our unit. Our aim was to identify differences in management and outcome between anticoagulated and not anticoagulated patients admitted in our unit with an UGB. Methods: Retrospective analysis of clinical records from patients admitted with the diagnosis of non variceal UGB in the EDU and the rest of the hospital. Results: Between December 1999 and September 2002 we identified 260 cases of non-variceal UGB. A total of 34 (13%) of our patients were on anticoagulation therapy at the moment of bleeding. Concerning sex, 53% of anticoagulated cases were male vs. 70% of non-anticoagulated. Mean age was 73 vs. 60 years for anticoagulated and non-anticoagulated patients respectively (pcO.05) and comorbidity was significantly different between both groups. No significant differences were found on origin of bleeding being peptic ulcer the most prevalent lesion. Transfusion requirements were different for anticoagulated patients (mean 2 units; sd 2.06) in 20 patients (58.8%) vs. the control group (mean 1 unit; sd 2.21) in 82 patients (36.8%); chi square test 5.99, p 0.014. We found no differences in mortality, need of surgery or rebleeding rates between both groups. Length of stay for anticoagulated patients was 7 days (95% CI 6.5 to 13.5) vs. 5 days (95% CI 5.5 to 6.5) in the control group (p 0.002). Discussion: Although anticoagulation therapy has shown clear advantages, the generalisation of this type of therapy to an increasing number of patients will undoubtedly carry a heavy burden of complications. Special strategies should be carried out to reduce the incidence of UGB in this type of patients. Male sex, an older age, longer hospital stay and greater transfusional requirements seems to characterise this subgroup of nonvariceal UGB. It is questionable if this type of patients with non-variceal UGB should be admitted in early discharge units.

P355 Descriptive analysis of 260 consecutive patients with upper gastro-intestinal bleeding (UGB) C. Vicente, P. Rond6n. V Alvarez, P. Serrano, R. Mielgo, Rabago, J. Marco (Madrid, E) Objective:

UGB

is a frequent

diagnoses

admitted

non-variceal S. Plaza,

to our early

discharge

L.

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14 (2003)

SI-S159

unit (EDU). We performed a retrospective descriptive analysis of this diagnosis at our hospital. Methods: Retrospective descriptive analysis of clinical records of 260 randomly selected cases from a total of 380 non-variceal UGB (68.5%). Study period 12-1-1999 to 9-30-2002. Setting: 430-bed hospital in the outskirts of Madrid for a population of 400,000. Results: 260 patients: 177 (68%) male; mean age 60.14 years. Active alcohol consumption was present in 77 (32%) and 76 (32%) were currently smoking. Main complains on arrival were the presence of a black stool (65.4%) and hematemesis (30%). Endoscopic evaluation showed a bleeding peptic ulcer in more than 60% of patients: 85 (32%) duodenal and 78 (30%) gastric. Other less frequent causes were Mallory Weiss syndrome in 12 (4.6%), grades III and IV oesophagitis in 12 (4.6%) and 11 (4.2%) respectively, Delafoie syndrome in 8 (3%) and duodenitis in 7 (2.7%). Type of bleeding was active or recent in 134 (51%) and late or absent signs of bleeding were present in 67 (25%). Variables grades of co-morbidity were present in 68 (24%). A total of 59 (23%) were on non steroid anti-inflammatory treatment, 3 1 (12%) were anti-aggregated and 34 (13%) were on coumarine treatment. A Clotest positive result was obtained in 70% of gastric ulcers, 51% of duodenal ulcers and 100% of duodenitis. Eradication treatment at discharged was prescribed in 91% of patients. Blood transfusion was necessary in 103 (39.8%) with a mean of 3.3 units per patient. Early and late re-bleeding occurred in 7 (2.7%) global in-hospital mortality was 5.4% (14 patients) and median hospital stay was 6 days. Discussion: UGB bleeding of non-variceal origin occurs mainly in males older than 60 years of age. Peptic ulcer is its main cause and a black stool the main complain at presentation. Clotest is performed less frequently than should be desired in our setting. A positive Clotest when performed while actively bleeding was less frequent than has been reported in other series.

P356 Chronic lobular hepatitis as presenting complaint of systemic lupus erythematosus G. &rota, S. Frassanito, G. Delle Monache, D. Orlando, G. Bronzi, M. Rinaldi (Penne (PE), I) A 58-year-old woman was first seen because of a slight increase of aminotransferases along with symmetric polyarthritis, maculopapular rash on sun exposed skin and cognitive defect. There was a history of fetal losses in younger age, autoimmune chronic hepatitis (AICH) and autoimmune chronic thyroiditis (AICT) at the age of 53. During the first admission the laboratory evaluation showed increased aminotransferases (five times the upper normal limit), ESR (35 mm at the first hour), leukopenia (3900/ pL), polyclonal hypergammaglobulinemia (mostly IgG); tests for anti-thyroglobulin and anti-thyroid peroxidase and antinuclear antibodies (with speckled pattern) were positive, whereas serology for hepatitis B and C viruses, tests for cryoglobulins, anti-LKM antibodies and anti-smooth muscle antibodies were negative. Ferritine, alpha1-antittipsine, C3, C4 and TSH were normal. An abdominal ultrasound scan showed a single gallstone, whereas the thyroid ultrasound scan showed a nonhomogeneous pattern, with pseudo-nodular aspects. A needle biopsy of the liver was compatible with chronic lobular hepatitis (CLH). The patient was then treated with prednisone (50 mg/day) for six months: the symptoms improved. At the age of 57 a trunk maculopapular rash recurred after sun exposure; the skin biopsy was compatible with sub-acute cutaneous lupus. Again, the laboratory evaluation and the liver biopsy were substantially unchanged; X-ray films of the hands showed signs of non-erosive arthritis of the wrists. Biopsy of the lip and a Schirmer test gave normal results. According to 1997 American Rheumatological Association criteria a diagnosis of Systemic Lupus Erythematosus was made, due to the presence of five criteria (Photosensitivity, Arthritis, Leukopenia, Cognitive dysfunction, Antinuclear