Methods and patients: We investigated sections of 70 appendices using rRNA-based fluorescence in situ hybridization. Four hundred cecal biopsies and 400 faecal samples from patients with inflammatory bowel disease and other conditions were used as controls. A set of 73 group-specific bacterial probes was applied for the study.

Results: The mucosal surface in catarrhal appendicitis showed characteristic lesions of single epithelial cells filled with a mixed bacterial population ("pinned cells") without ulceration of the surroundings. Bacteria deeply infiltrated the tissue in suppurative appendicitis. Fusobacteria (mainly Fusobacterium nucleatum and necrophorum) were a specific component of these epithelial and submucosal infiltrates in 62% of patients with proven appendicitis. The presence of Fusobacteria in mucosal lesions correlated positively with the severity of the appendicitis and was completely absent in cecal biopsies from healthy and disease controls. Main fecal microbiota represented by Bacteroides, Eubacterium rectale, Faecalibacterium prausnitzii groups and Akkermansia muciniphila were inversely related to the severity of the disease. The occurrence of other bacterial groups within mucosal lesions of acute appendicitis was not related to the severity of the appendicitis. No Fusobacteria were found in rectal swabs of patients with acute appendicitis.

Conclusions: Local infection with Fusobacterium nucleatum/necrophorum is responsible for the majority of cases of acute appendicitis.

Methods: Human Barrett’s cell line BAR-T and EA cell line FLO were transfected by using Lipofectamine 2000 or Amaxa-Nucleofector-System. mRNAs were measured by real-time PCR. H₂O₂ was measured by a fluorescent assay. Cell proliferation was determined by measurement of thymidine incorporation.

Results: NOX5-S was present in FLO cells. TDCA significantly increased NOX5-S expression, H₂O₂ production and thymidine incorporation in FLO and BAR-T cells. This increase in thymidine incorporation was significantly reduced by knockdown of NOX5-S. TGR5 mRNA and protein levels were significantly higher in EA tissues than in normal esophageal mucosa or Barrett’s mucosa. Knockdown of TGR5 markedly inhibited TDCA-induced increase in NOX5-S expression, H₂O₂ production and thymidine incorporation in FLO and BAR-T cells. Overexpression of TGR5 significantly enhanced TDCA’s effects in FLO cells. TGR5 receptors were coupled with Gq and Gi-3 proteins, but only Gq mediated TDCA-induced increase in NOX5-S expression, H₂O₂ production and thymidine incorporation in FLO cells.

Conclusions: TDCA-induced increase in cell proliferation depends on upregulation of NOX5-S expression in BAR-T and FLO cells. TDCA-induced NOX5-S expression may be mediated by activation of the TGR5 receptor and Gq protein. Our data may provide potential targets to prevent and/or treat Barrett’s EA.

Methods: Biopsies from patients with inactive UC (n=18), active UC (n=28), UC with low-grade dysplasia (LGD) (n=9), UC with high-grade dysplasia (HGD) (n=7), UC-CRC (n=11) and sporadic CRC (n=14) were included. Biopsies (n=9) from patients without colonic abnormalities served as control. The protein expression of IL-6, p-STAT3 and SOCS3 was determined immunohistochemically.

Results: Patients with active UC had significantly more IL-6 and p-STAT3 positive epithelial cells than both inactive UC patients and controls (strong positive IL-6: 53.6%, 11.1% and 0% respectively; p-STAT3: 64.3%, 22.2% and 11.1% respectively; all p≤0.012). SOCS3-positive cells were significantly increased in colonic epithelium of both inactive and active UC compared with controls (strong positive: 94.4%, 96.4% and 11.1% respectively; both p<0.001). In dysplasia and cancer, significantly more epithelial cells expressed IL-6 and p-STAT3 compared with controls (strong positive IL-6: 72.7% and 0% respectively; p-STAT3: 54.5% and 11.1% respectively; both p<0.05), whereas the proportion of SOCS3-positive cells in this progression reduced (LGD 33.3%; HGD 14.3%; UC-CRC 9.1%). In addition, methylation of the SOCS3 gene was detected in epithelial cells from UC-CRC biopsies.

Conclusion: We demonstrated the importance of IL-6/p-STAT3 in patients with inflammation induced CRC. Moreover, SOCS3 may be involved UC pathogenesis and the absence of SOCS3 seems critical for CRC progression.

Methods: Abdominal CT and histological examination of liver biopsy specimens were used to estimate the degree of steatosis in patients with NAFLD and chronic hepatitis C controls. SPIO-MRI was then performed in all patients. Normal rats fed a methionine-choline deficient (MCD) diet to induce non-alcoholic steatohepatitis (NASH), the more severe stage of NAFLD, and obese, insulin resistant, Zucker fa/fa rats with steatohepatitis, were also studied with SPIO-MRI and analysed for hepatic uptake of fluorescent microbeads. Immunohistochemical analysis evaluated the numbers of KC in patients and rat livers.

Results: Relative signal enhancement (RSE), inversely proportional to KC function, was higher in patients with NAFLD compared to controls and with the degree of steatosis on CT. RSE also positively correlated with the degree of steatosis on histology and was similarly higher in rats with induced severe NAFLD (NASH). On immunohistochemistry defective phagocytic function was the result of reduced phagocytic uptake and not due to reduced KC numbers in rats or patients with NAFLD. Conclusions: KC uptake function is significantly impaired in NAFLD patients and experimental animals with NASH, worsens with the degree of steatosis and is not due to a reduction of KC numbers.

Methods: Gunn rats received, for various time periods, oral polyethylene glycol (PEG) with or without conventional phototherapy treatment to accelerate, or oral loperamide to delay the gastrointestinal transit. Gastrointestinal transit time and UCB concentrations in plasma, feces, intestinal content and bile were determined.

Results: Within 36 hours, PEG administration accelerated the gastrointestinal transit by 45% and simultaneously decreased plasma UCB concentrations by 23% (each p<0.001). The decrease in plasma UCB coincided with an increased small intestinal UCB content (+340%, p<0.05) and an increased fecal UCB excretion (+153%, p<0.05). After two weeks, PEG decreased plasma UCB by 41% as single treatment, and by 62% if combined with phototherapy (each p<0.001). Loperamide delayed gastrointestinal transit by 57% and increased plasma UCB by 30% (each p<0.001). Dose-response experiments showed a strong, linear relation between the gastrointestinal transit time and plasma UCB concentrations (r=0.87, p<0.001).

Conclusion: Gastrointestinal transit time and plasma UCB concentrations are linearly related in Gunn rats. This relationship can be exploited by pharmacologically accelerating the gastrointestinal transit, which increases transmucosal UCB diffusion and thereby effectively treats unconjugated hyperbilirubinemia. Present results support the feasibility of PEG treatment, either solitary or combined with phototherapy, in patients with severe unconjugated hyperbilirubinemia.

Methods: 14 healthy volunteers underwent upper GI endoscopy with biopsies at 3 and 13 cm proximal to the EGJ. In following sessions, subjects received 30 min perfusions with neutral, weakly acidic, acidic and acidic-bile acid solutions at 5 cm above the EGJ (separated 4 weeks). Biopsies were taken 20 min after perfusions. Electron microscopy was used to measure DIS. Subjects scored heartburn during perfusions using a VAS scale.

Results: 1) oesophageal perfusion with acid solutions, with or without bile acids, provoked DIS in the "exposed" oesophageal mucosa; 2) oesophageal perfusion with weakly acidic solutions, provoked identical changes to those observed after perfusion with acid solutions; 3) distal oesophageal perfusions not only provoked changes in the "exposed" but also in the more proximal "non exposed" mucosa and 4) in spite of the presence of perfusion-induced DIS, most healthy subjects did not perceive heartburn during the experiments.

Conclusions: Human oesophageal mucosa is very sensitive to continuous exposure with acidic and weakly acidic solutions. In spite of the presence of intraluminal acid and DIS, healthy subjects did not experience heartburn, suggesting that NERD patients should have other critical factors underlying their symptoms.

Methods and results: In the present study activated HPCs and its microenvironment (niche) were investigated in acute and chronic human liver disease by gene-expression analysis and immuno-histochemistry/-fluorescence. Cryopreserved liver tissues were used from patients with parenchymal versus biliary diseases: acute necrotising hepatitis (AH), cirrhosis after hepatitis C infection (HCV), and primary biliary cirrhosis (PBC) in order to study differentiation of HPCs towards hepatocytic versus biliary lineage. Keratin 7 (K7) positive HPCs/reactive ductules were captured by means of Laser Capture Microdissection (LCM) and gene-expression profiles were obtained by using a customized PCR Array. Gene expression results were confirmed by immunohistochemistry and immunofluorescence double staining. In all disease groups, microdissected HPCs expressed progenitor cell markers such as KRT7, KRT19, NCAM, ABCG2, LIF, KIT, OCT4, CD44, and TERT. In AH, HPCs were most activated and showed a high expression of prominin-1 (CD133) and alpha-fetoprotein (AFP), and a strong activation of the Wnt-pathway. In contrast to parenchymal diseases, HPCs in PBC (biliary differentiation) showed a high activation of Notch signalling.

Conclusion: A distinct pattern of HPC surface markers was found between acute- and chronic-liver diseases. Similar to what is known from animal experiments, strong evidence has been found signifying the role of Wnt signalling in proliferation of human HPCs whereas Notch signalling is involved in biliary differentiation. These pathways can be targeted in future therapies.

Methods: LsL-KrasG12D; Pdx1-Cre or LsL-KrasG12D; LsL-Trp53R172H; Pdx1-Cre transgenic mice were randomly assigned to receive either mock treatment, aspirin, enalapril, or a combination of both. After three and five months, animals were sacrificed. The effect of aspirin and enalapril was evaluated by histopathological analyses, immunostaining, and real-time PCR.

Results: After three and five months of treatment, enalapril and aspirin were able to significantly delay progression of mPanINs in LsL-KrasG12D; Pdx1-Cre mice. Furthermore, development of invasive pancreatic cancer in LsL-KrasG12D; LsL-Trp53R172H; Pdx1-Cre transgenic mice was partially inhibited by. Invasive pancreatic cancer was identified in 15 of 25 (60%) LsL-KrasG12D; LsL-Trp53R172H; Pdx1-Cre untreated mice, but in only 3 of 17 (17.6%, p=0.01) mice treated with aspirin, in 4 of 17 (23.5%, p=0.03) in mice treated with Enalapril alone, and in 5 of 16 (31.2%, p=0.11) mice treated with a combination of both drugs. Using real-time PCR we found a significant down-regulation of the target genes VEGF and RelA demonstrating our ability to achieve effective pharmacological levels of aspirin and enalapril during pancreatic cancer formation in vivo.

Conclusion: Using a transgenic mouse model that imitates human pancreatic cancer, this study provides first evidence that aspirin and enalapril are effective chemopreventive agents by delaying the progression of PanINs and partially inhibiting the formation of murine pancreatic cancer.

Methods: The proliferation of primary hepatocytes was examined by [3H]Thymidine incorporation and immunohistological staining of PCNA. RNA interference (RNAi) was performed to knock-down the endogenous expression of HPS. The proliferation of L02 cells was examined by MTS assay. The phosphorylation of ERK1/2 was investigated by Western blotting analysis. Assessment of liver injury (histology, serum ALT and AST levels), apoptosis by TUNEL assay, were performed.

Results: Purified recombinant human HPS showed specific mitogenic activity on primary hepatocytes and normal liver cell lines in a MAPK-dependent manner and stimulated the proliferation of hepatocytes in rats with 70% PHx. Administration of HPS in rats after D-gal and CCl4 treatment protected against the liver injury (minimal liver necrosis, depressed ALT and AST levels, and decreased lethality), reduced apoptosis and enhanced proliferation. Knock-down of endogenous HPS in vivo enhanced the liver injury induced by D-gal by increasing the apoptosis and elevated ALT and AST levels.

Conclusions: HPS is a hepatic growth factor to accelerate hepatocytes proliferation in vivo and protect against liver injury. These data point out the potential interest of HPS in the treatment of FHF.

Design and setting: Population-based case-control study.

Participants: Cases were patients with oesophageal [OAC] (n=365) or gastro-oesophageal junction [GOJAC] (n=426) adenocarcinomas, or squamous cell carcinomas [OSCC] (n=303). Controls were sampled from a population register (n=1580).

Main outcome measure: Odds ratio and 95% confidence interval.

Results: Frequent (at least weekly) symptoms of GOR were associated with significant 6.4-fold, 4.6-fold and 2.2 fold increased risks of OAC, GOJAC and OSCC respectively. Under models examining effects of combined exposure, patients with frequent GOR symptoms who were also heavy smokers had markedly higher OAC risks (OR = 12.3, 6.3 to 24.0) than those with frequent GOR who did not smoke (OR = 6.8, 3.6 to 12.9). Similar patterns were observed for GOJAC and OSCC. Among people with frequent GOR symptoms, regular use of aspirin/NSAIDs was associated with almost two-thirds lower OAC risks (OR = 4.8, 95% CI 2.5 to 9.2) than non-use (13.9, 6.5 to 30.0). In contrast, among those with frequent GOR symptoms, users of acid suppressants had similar OAC risks (7.8, 5.2 to 11.8) to non-users (5.3, 3.2 to 9.0).

Conclusions: People experiencing frequent GOR symptoms have markedly increased risks of OAC and GOJAC, and this effect may be greater amongst smokers. Use of aspirin and NSAIDs, but not acid suppressants, significantly reduced the risks of oesophageal cancers associated with GOR.

Design: Observational pilot study.

Setting: University hospital and District hospital

Patients: 10 women suffering from anal incontinence due to obstetric anal sphincter injury, refractory to conventional non-surgical therapy.

Interventions: Autologous myoblasts were cultured from a pectoralis muscle biopsy, harvested, and injected into the external anal sphincter defect using direct ultrasound guidance.

Main outcome measures: Wexner incontinence score, anal squeeze pressures, and quality of life 12-months after injection. Safety and technical feasibility.

Results: The procedure was well tolerated and no adverse events were observed. At 12-months the Wexner incontince score had decreased by a mean of 13.7 units (95%CI -16.3 to -11.2), anal squeeze pressures were unchanged, and overall quality of life scores improved by a median of 30 points (95%CI 25 to 42). Anal squeeze pressures did rise significantly at 1-month and 6-months post injection (p=0.03).

Conclusions: Injection of autologous myoblasts is safe, well tolerated, and significantly improves symptoms of anal incontinence due to obstetric anal sphincter trauma.

Hepatocellular carcinoma (HCC) frequently results from synergism between chemical and infectious liver carcinogens. Worldwide, the highest incidence of HCC is in regions endemic for the food-borne contaminant aflatoxin B1 (AFB1) and hepatitis B virus (HBV) infection. Recently, gut microbes have been implicated in multisystemic diseases including obesity and diabetes. Here, we tested in chemical and viral-transgenic mouse models the hypothesis that specific intestinal bacteria promote liver cancer.

Endoscopic dilation of Crohn’s disease related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and concomitant medical therapy on long term outcomes is largely unknown.

Adipose tissue releases angiogenic factors that may promote tumour growth. We sought to determine whether body mass index (BMI), subcutaneous fat area (SFA), and visceral fat area (VFA) were associated with outcomes in patients given first-line bevacizumab-based treatment for metastatic colorectal cancer (MCC).

Recent studies suggest that cardiac dysfunction precedes development of the hepatorenal syndrome. In this follow-up study, we aimed to investigate the relation between cardiac- and renal function in patients with cirrhosis and ascites and the impact of cardiac systolic function on survival.

It thus appears that Nod2 modulates the cross-talk between CD4⁺ T-cells and the epithelium recovering PP and that it down-regulates the pro-inflammatory effect driven by the ileal microflora, likely by inhibiting the TLR pathways.

Alcohol consumption and cigarette smoking may be differentially associated with oesophageal squamous cell carcinoma (OSCC), oesophageal adenocarcinoma (OAC), gastric cardia adenocarcinoma (GCA) and gastric noncardia adenocarcinoma (GNCA). However, because this was based on retrospective studies, we examined these hypotheses in a prospective cohort.

Although critical for methylation reactions, how dietary folate and B vitamins affect global DNA methylation level in colon cancers is currently unknown. Long interspersed nucleotide element-1 (LINE-1) is an emerging indicator of genome-wide DNA methylation level that has previously been linked to colon cancer survival.

To examine the role of CD10, a characteristic marker of liver metastasis of colorectal cancers (CRCs).

The attaching and effacing (A/E) pathogens enterohemorrhagic E. coli, enteropathogenic E. coli and C. rodentium colonize intestinal tracts, attach to enterocytes, collapse infected cell microvilli and alter numerous host cell processes during infection. Enterocyte alterations result in numerous small molecules being released from host cells that likely contribute to diarrheal phenotypes observed during these infections. One possible route for small molecules to be released from intestinal cells may be through functional gap junction hemichannels. Here we examine the involvement of these hemichannels during the diarrheal disease caused by A/E pathogens in vivo.

Evidence suggests haematopoietic stem cells (HSCs) can migrate to injured liver and influence tissue repair. However, mechanisms governing HSC recruitment to injured hepatic microcirculation are poorly understood. These were investigated in vivo following hepatic ischemia-reperfusion (IR) injury and in vitro using flow-based adhesion assays.

Recently, virtual-reality (VR) computer simulators have been used to enhance traditional endoscopy teaching. Previous studies have demonstrated construct validity of these systems and transfer of virtual skills to the operating room. However, to date no simulator-training curricula have been designed and there is very little evidence on the impact of external feedback on acquisition of endoscopic skills.

Eosinophilic oesophagitis (EoE) is a clinico-pathological condition defined by proton-pump-inhibitor refractory oesophageal symptoms combined with oesophageal eosinophilia. We evaluated the pharmacodynamic effect of mepolizumab (a humanized anti-interleukin-5 monoclonal antibody) in EoE.

Patients with cancer have antibodies against tumour antigens. Characterizing the antibody repertoire may provide insights into aberrant cellular mechanisms in cancer development, ultimately leading to novel diagnostic or therapeutic targets. Here we set out to characterize the antibody profiles in patients whose symptoms warranted colonoscopy, to see if there was a difference in patients with and without colorectal cancer.

Background and aim: Human growth factors are potential therapeutic agents for various inflammatory disorders affecting the gastrointestinal tract [1, 2]. However, they are unstable when administered orally and systemic administration requires high doses increasing the risk of unwanted side effects. Live microorganism-based delivery systems can overcome these problems although they suffer from the inability to control heterologous protein production [3]. To overcome these limitations we have developed a new live bacteria drug-delivery system using the human commensal gut bacterium Bacteroides ovatus engineered to secrete human growth factors in response to dietary xylan.

Methods: B. ovatus strains expressing human keratinocyte growth factor-2 that plays a central role in intestinal epithelial homeostasis (BO-KGF) were generated by homologous recombination and evaluated using the dextran sodium sulphate (DSS)-induced model of intestinal epithelial injury and colitis.

Results: In response to xylan BO-KGF produced high levels of biologically active KGF both in vitro and in vivo. In DSS-treated mice administration of xylan and BO-KGF had a significant therapeutic effect in reducing weight loss, improving stool consistency, reducing rectal bleeding, accelerating healing of damaged epithelium, reducing inflammation and neutrophil infiltration, reducing expression of pro-inflammatory cytokines, and accelerating production of goblet cells. BO-KGF and xylan treatment also had a prophylactic effect limiting the development of inflammation and disruption of the epithelial barrier.

Conclusion: Treatment with BO-KGF and xylan was effective at both treating and limiting the development of epithelial injury and acute colitis. This novel diet-regulated, live bacterial drug delivery system may be applicable to treating various bowel disorders.

Objective: In patients with HCV/HIV co-infection, a faster progression of liver fibrosis to cirrhosis has been reported. In this study we investigated whether gp120, a HIV envelope protein, modulates the biology of human hepatic stellate cells (HSC), key cell types in the pathogenesis of fibrosis.

Methods: Myofibroblastic HSC were isolated from normal human liver tissue. Gene expression was measured by real time PCR. Cell migration was assessed in Boyden chambers. Intracellular signalling pathways were evaluated using phosphorylation-specific antibodies or by transfection of a reporter plasmid.

Results: Transcripts for the chemokine receptors CCR5 and CXCR4, which bind gp120, were detectable in human HSC. Upon exposure to M-tropic recombinant gp120, which binds CCR5, a significant increase in HSC chemotaxis was observed (1.6±0.3 –fold, P=0.03). The effects of gp120 were prevented by protein inactivation. gp120 also resulted in a significant increase in secretion (1.5±0.3-fold, P=0.03) and gene expression (1.47±0.13-fold, P=0.02) of the pro-inflammatory chemokine MCP-1, and in increased gene expression of tissue inhibitor of metalloprotease-1 and interleukin-6 (2.03±0.57-fold, P=0.02). gp120-induced migration required Akt activation. gp120 also induced activation of NF-B and p38MAPK. Preincubation of HSC with TAK779, a CCR5 receptor antagonist, prevented gp120-mediated chemotaxis and MCP-1 secretion. Expression of CCR5 was detectable in areas of inflammation and fibrogenesis in liver biopsies of patients with HCV/HIV coinfection.

Conclusions: This study shows that HIV-gp120 modulates different aspects of HSC biology, including directional cell movement and expression of pro-inflammatory cytokines. These results identify a direct pathway possibly linking HIV infection with liver fibrogenesis via envelope proteins.

Background and aims: Patients with hyperplastic polyposis syndrome (HPS) receive endoscopic surveillance to prevent malignant progression of polyps. However, the optimal treatment and surveillance protocol for these patients is unknown. The aim of this study was to describe the clinical and pathological features of a large HPS cohort during multiple years of endoscopic surveillance.

Methods: Databases were searched for HPS patients who were retrospectively analysed. Endoscopy reports and histopathology reports were collected to evaluate frequency of endoscopic surveillance and to obtain information regarding polyp and CRC presence.

Results: In 77 HPS patients, 1984 polyps were identified during a mean follow-up period of 5.6 years (range:0.5-26.6). In 27(35%) patients CRC was detected of which 22(28.5%) at initial endoscopy. CRC was detected during surveillance in five patients (cumulative incidence: 6.5%) after a median follow-up time of 1.3 years and a median interval of 11 months. Of these interval CRCs, 4/5 were detected in diminutive serrated polyps (range: 4-16mm). The cumulative risk of CRC under surveillance was 7% at five years. At multivariate logistic regression, an increasing number of hyperplastic polyps (odds ratio:1.05, p=0.013) and serrated adenomas (odds ratio:1.09, p=0.048) was significantly associated with CRC presence.

Conclusions: HPS patients undergoing endoscopic surveillance have an increased CRC risk. The number of serrated polyps is positively correlated with the presence of CRC in HPS, thus supporting a 'serrated pathway' to CRC. To prevent malignant progression, adequate detection and removal of all polyps seems advisable. If this is not feasible, surgical resection should be considered.

The pathogenetic mechanism of hepatorenal syndrome (HRS) is paradoxical renal vasoconstriction consequent upon systemic and splanchnic arterial vasodilatation. Molecular adsorbent recirculating system (MARS) is a specialized form of dialysis that clears albumin-bound substances, including vasodilators, and therefore can potentially reduce systemic vasodilatation in cirrhosis.

Objective: To assess the efficacy of MARS in improving systemic and renal hemodynamics in cirrhotic patients with refractory ascites and type 1 HRS not responding to vasoconstrictor therapy.

Design: Pilot study.

Setting: Academic teaching hospital.

Patients: Six patients with cirrhosis, refractory ascites and type 1 HRS not responding to vasoconstrictor therapy.

Interventions: All patients received 5 days of 6 to 8 hours of MARS dialysis.

Main outcome measures: Pre- and post- MARS measurements of glomerular filtration rate (GFR), renal blood flow, neurohormones, cytokines and nitric oxide, as well as daily biochemistry, hemotology, and urinary volume were performed.

Results: There were no significant changes in systemic hemodynamics and GFR following MARS treatments, despite significant reduction in nitric oxide (NO) concentrations (111.5 ± 18.8 µmol/L pre-MARS, to 65.1 ± 8.2 µmol/L post-MARS, p=0.05). There was a transient reduction in serum creatinine (p<0.05), Child-Pugh and MELD scores with MARS, but no significant difference was observed in neurohormones and cytokines levels. Four of six patients died following MARS treatments. Conclusions: In patients with cirrhosis, refractory ascites, and type 1 hepatorenal syndrome not responding to vasoconstrictor therapy, MARS is ineffective in improving systemic hemodynamics and renal function despite reduction in NO levels, suggesting that vasodilatation in advanced cirrhosis is not due to excess systemic vasodilators alone. Transient reduction in serum creatinine indicates direct removal by MARS, and may not represent improved renal function.

Background: Screening for colorectal cancer (CRC) is widely accepted, but there is no consensus on the preferred strategy. We conducted a randomised trial comparing participation and detection rates (DR) per screenee of guaiac-based faecal occult blood test (gFOBT), immunochemical FOBT (FIT), and flexible sigmoidoscopy (FS) for CRC screening.

Methods: A representative sample of the Dutch population (n=15.011), aged 50-74 years, was 1:1:1 randomised prior to invitation to one of the three screening strategies. Colonoscopy was indicated for screenees with a positive gFOBT or FIT, and for those in whom FS revealed a polyp with a diameter ≥10 mm; adenoma with ≥25% villous component or high grade dysplasia; serrated adenoma; ≥3 adenomas; ≥20 hyperplastic polyps; or CRC.

Results: The participation rate was 49.5% (95% confidence interval(CI) 48.1-50.9%) for gFOBT, 61.5% (CI:60.1-62.9%) for FIT and 32.4% (CI:31.1-33.7%) for FS screening. gFOBT was positive in 2.8%, FIT in 4.8% and FS in 10.2%. The DR of advanced neoplasia was significantly higher in the FIT (2.4%; OR 2.0; CI:1.3-3.1) and the FS arm (8.0%; OR 7.0; CI:4.6-10.7) than the gFOBT arm (1.1%). FS demonstrated a higher diagnostic yield of advanced neoplasia per 100 invitees (2.4; CI:2.0-2.8) than gFOBT (0.6; CI:0.4-0.8) or FIT (1.5; CI:1.2-1.9) screening.

Conclusion: This randomised population-based CRC-screening trial demonstrated superior participation and detection rates for FIT compared to gFOBT screening. FIT screening should therefore be strongly preferred over gFOBT screening. FS screening demonstrated a higher diagnostic yield per 100 invitees than both FOBTs.

Background & Aims: Hepatocyte nuclear factor 4 (HNF4) is a central transcriptional regulator of hepatocyte differentiation and function. The aim of this study is to evaluate the effect of HNF4 on attenuation of hepatic fibrosis.

Methods: The adenoviruses carrying HNF4 gene or containing siRNA targeting HNF4 were injected through tail vein on two distinct hepatic fibrosis models either induced by dimethylnitrosamine or by bile duct ligation in rats. Moreover, HNF4, epithelial-mesenchymal transition (EMT)-related and fibrotic markers in hepatocytes, hepatic stellate cells (HSCs) and liver tissues were detected by real time PCR, immunofluorescence or immunohistochemistry.

Results: We demonstrated that decreased expression of HNF4 and epithelial markers accompanied by enhanced expression of mesenchymal markers occurred in fibrotic liver. More importantly, forced expression of HNF4 remarkably alleviated hepatic fibrosis and improved liver function with suppression of EMT in both fibrosis models. In contrast, down-regulation of HNF4 by siRNA aggravated hepatic fibrosis and decreased the expression of E-cadherin in company with the enhanced expression of vimentin and fibroblast-specific protein-1. In vitro study revealed that HNF4 could suppress the EMT process of hepatocytes induced by transforming growth factor-β1 and increase the expression of liver-specific genes. Similar phenomenon of EMT process was observed during the activation of HSCs, which was abrogated by HNF4. Additionally, HNF4 deactivated the myofibroblasts through inducing the mesenchymal to epithelial transition and inhibited their proliferation.

Conclusions: Our study suggests that HNF4 is critical for hepatic fibrogenesis and up-regulation of HNF4 might present as an ideal option for the treatment of hepatic fibrosis.

Objective: Coeliac disease (CD) is a multisystemic autoimmune inflammation of the intestinal tract induced by wheat gluten and related cereals in HLA-DQ2/8 positive individuals. The molecular mechanisms relevant to oral tolerance induction towards toxic cereals such as gliadin remain poorly understood. Enterocytes, which express predominantly HLA-DR proteins, are capable of processing, transcytosing and presenting food antigens from intestinal lumen to T lymphocytes of the lamina propria.

Design: We utilize epitope-specific monoclonal anti-gliadin antibodies to unravel the intraepithelial transport processes of gliadin peptides in human duodenal biopsy specimens from coeliac patients and reconstitute the transepithelial and endocytic pathways of gliadin in intestinal epithelial HT29 cells.

Results: The gliadin peptide AA 31-49 is segregated from the peptides AA 56-68 and AA 229-246 along the endosomal pathway. Thus, AA 31-49 bypasses HLA-DR positive late endosomes in intestinal cells and in biopsy specimens of patients with untreated CD. Further, it is localized into early endosomes and consequently escapes antigen presentation at the basolateral membrane, unlike peptides AA 56-68 and AA 229-246 that reach HLA-DR positive late endosomes. Strikingly, conjugated forms of gliadin peptide AA 31-49 with cholera toxin B are sorted into late endosomes of HT29 cells.

Conclusions: Endocytic segregation of gliadin peptide AA 31-49 seems to be a constitutive process. It explains why this peptide cannot stimulate gluten sensitive T cells. Presentation of gliadin peptides by HLA-DR proteins via late endosomes within enterocytes might induce a tolerogenic effect and constitutes a potentially promising therapeutic approach for induction of tolerance towards gliadin.

Background & Aims: Antibodies to infliximab reduce serum infliximab with loss of clinical benefit, but undetectable trough serum concentrations of infliximab may occur without antibody formation. The relation between trough serum infliximab and clinical outcomes was evaluated in acute ulcerative colitis.

Methods: In a cohort of 115 ulcerative colitis patients treated with 3-dose induction followed by scheduled maintenance infliximab, rates of clinical remission, colectomy, antibodies to infliximab and trough serum infliximab were determined.

Results: Rates of remission were 32% at week 10 and 37% at week 54. Colectomy occurred in 40% of patients, at a median of 5.3 (IQR: 1.9-12.1) months. Detectable trough serum infliximab was present in 39% of patients and among patients with undetectable infliximab, 41% were antibody positive and 20% were antibody negative. For antibody positive and antibody negative patients, rates of remission (18% vs. 14%), endoscopic improvement (25% vs. 35%) and colectomy (52% vs. 59%) were not different. A detectable serum infliximab was associated with higher rates of remission (69% vs. 15%; P <0.001) and endoscopic improvement (76% vs. 28%, P <0.001). An undetectable serum infliximab predicted an increased risk for colectomy (55% vs. 7%, odds ratio 9.3; 95% confidence interval, 2.9 - 29.9; P <0.001). Concurrent immunosuppression was not associated with clinical outcomes.

Conclusions: For ulcerative colitis patients treated with infliximab, a detectable trough serum infliximab predicts clinical remission, endoscopic improvement, and a lower risk for colectomy. In assessing clinical outcomes to infliximab, the presence of antibodies to infliximab is a surrogate for absent drug.

Background: Barrett’s esophagus (BE) is a common premalignant lesion caused partly by acid reflux. The requisite therapy, proton pump inhibitors (PPI), have been implicated in the progression of BE. We therefore aimed to test the role of PPI induced hypergastrinaemia in vitro and see whether any biological parameters were useful surrogates of long term therapy in man.

Methods: We then undertook detailed serological and tissue assessment of gastrin and CCK₂ receptors in 90 patients randomised to different doses of PPI therapy during a detailed 2 year follow up. We also undertook a comprehensive study of cell models to study the consequential biological effects of gastrin on the mucosa.

Results: Gastrin and its cognate receptor CCK₂ were expressed highest in the stomach, then next BE and least in squamous esophagus (SqE) (n=20 paired t-test, p<0.01). Analysis of the change in BE segment length change in 70 patients who were randomised to high or low PPI dose showed no difference over 2 years (n=70 t-test, p=0.8). Prolonged PPI use did however increase the serum gastrin, (36 pg/ml ± 57 to 103 pg/ml ± 94 (paired t-test, p<0.05)). In vitro gastrin also induced changes in OE33(E)_cckr BE cells, but not OE21(E)_cckr squamous cells, transfected with CCK₂; migration was induced by 1ng/ml of gastrin but proliferation only arose with 100ng/ml (paired t-test, p<0.01) and both were abolished by antagonists.

Conclusions: While the short term effects of gastrin enhance epithelial restitution in BE there is no clinical evidence that BE length expands over time. This large and long term randomised controlled trial of gastrin biology in BE is further proof of the clinical safety of PPI therapy.

Introduction: Gastroesophageal reflux occurs twice as much during transient lower esophageal sphincter relaxations (TLESR) in GERD patients compared to healthy volunteers (HV). Our aim was to assess whether the localisation of the postprandial acid pocket and its interaction with a hiatal hernia (HH) play a role in the occurrence of acidic reflux during TLESRs.

Methods: 10 HV and 22 GERD patients (12 with HH<3cm (s-HH), 10 with HH≥3cm (l-HH)) were studied. The squamocolumnar junction and diaphragmatic impression were marked with a radio-labelled clip. To visualize the acid pocket, 99mTc-pertechnetate was injected iv and images were acquired up to 2hrs postprandial. Concurrently, combined manometry/impedance and 4-channel pH-metry were performed, with pH pull-through at multiple time-points.

Results: The rate of TLESRs and the % associated with reflux was comparable between all groups. However, acidic reflux was significantly increased in patients, especially in l-HH patients. Acid pocket length was significantly enlarged in patients. Moreover, immediately before a TLESR, the acid pocket was more frequently located within the hiatus or above the diaphragm in GERD patients (s-HH: 54%, l-HH: 77%) compared to HV (22% of TLESRs). Acidic reflux was significantly increased when the acid pocket was located above the diaphragm in all groups compared to a subdiaphragmatic localization.

Conclusion: The position of the acid pocket is largely determined by the presence of a HH. Entrapment of the pocket above the diaphragm, especially in l-HH patients, is a major risk factor underlying the increased occurrence of acidic reflux during a TLESR in GERD patients.

Objective: To address the role of anxiety and depression symptoms in altered pain processing in irritable bowel syndrome (IBS).

Design: In this functional magnetic resonance imaging (fMRI) study, the blood oxygen level-dependent (BOLD) response to rectal distensions delivered at previously determined individual discomfort thresholds were assessed.

Patients: N=15 female irritable bowel syndrome (IBS) patients with normal rectal pain thresholds and N=12 healthy women.

Measures: The correlation of anxiety and depression symptoms, measured with the Hospital Anxiety and Depression Scale (HADS), with subjective pain ratings and the BOLD response during distension-induced brain activation were analyzed within IBS. Group differences in pain-induced brain activation with and without controlling for HADS scores were evaluated.

Results: IBS patients experienced significantly more pain and discomfort upon rectal distensions in the scanner, despite unaltered rectal sensory thresholds. Anxiety and depression scores were associated with these subjective stimulus ratings, but not with rectal sensory thresholds. Anxiety symptoms in IBS were significantly associated with pain-induced activation of the anterior midcingulate cortex (aMCC) and pregenual anterior cingulate cortex (pACC). Depression scores correlated with activation of the prefrontal cortex (PFC) and cerebellar areas within IBS. Group comparisons with 2-sample t-test revealed significant activation in the IBS versus controls contrast in the anterior insular cortex (IC) and PFC. Inclusion of anxiety and depression scores, respectively, as confounding variables led to a loss of significant group differences.

Conclusions: Altered central processing of visceral stimuli in IBS is at least in part mediated by symptoms of anxiety and depression, which may modulate the affective-motivational aspects of the pain response.

Objective: The aim of the study was to compare sequential versus combined diuretic therapy in patients with cirrhosis, moderate ascites and without renal failure.

Design: One hundred patients were randomly assigned to the two diuretic treatments. The sequential one provided potassium canrenoate at the initial dose of 200 mg/day, then increased up to 400 mg/day. Non responders were treated with 400 mg/day of potassium canrenoate and furosemide at an initial dose of 50 mg/day, then increased up to 150 mg/day. The combined treatment provided the initial dose of 200 mg/day of potassium canrenoate and 50 mg/day of furosemide, then increased up to 400 mg/day and 150 mg/day, respectively.

Results: Most patients who received sequential treatment responded to potassium canrenoate alone (19 % to 200 mg/day and 52.63 % to 400 mg/day, respectively). Most patients who received the combined treatment responded to the first two steps (40% to the first one and 50% to the second one i.e. 400 mg/day of potassium canrenoate plus 100 mg/day of furosemide) Adverse effects (38% vs 20%, p < 0.05), in particular hyperkalemia (18% vs 4%, p < 0.05), were more frequent in patients who received sequential therapy. As a consequence, the percent of patients who resolved ascites without changing the effective diuretic step was higher in those who received the combined treatment (56 % vs 76%, p < 0.05).

Conclusions: The combined diuretic treatment is preferable to the sequential one in the treatment of moderate ascites in patients with cirrhosis and without renal failure.

Background: Eosinophilic esophagitis (EE) is an emerging yet increasingly prevalent disorder characterized by a dense and selective eosinophilic infiltration of the esophageal wall. While EE is considered an atopic disease primarily triggered by food antigens, disparities between standard allergen testing and clinical responses to exclusion diets suggest the participation of distinct antigen-specific IgE in the pathophysiology of EE.

Aim: To find evidence for a local IgE response.

Methods: Endoscopic biopsies of the distal esophagus of atopic and nonatopic EE and control individuals (CTL)were processed for immunohistochemistry and immunofluorescence to assess the presence of B cells, mast cells, and IgE-bearing cells. Esophageal RNA was analyzed for the expression of genes involved in B cell activation, class switch recombination to IgE and IgE production, including germline transcripts (GLT), activation-induced cytidine deaminase (AID), IgE heavy chain (C) and mature IgE mRNA using PCR and microarray analysis.

Results: Regardless of atopy, EE showed increased density of B cells (P<0.05) and of IgE-bounded mast cells compared to CTL. Both, EE and CTL, expressed µGLT, GLT, 4GLT, AID, C and IgE mRNA. However, the frequency of expression of total GLT (P=0.002), GLT (P=0.024), and C(P=0.0003) was significantly higher in EE than in CTL, independent of the atopic status.

Conclusion: These results support the heretofore unproven occurrence of both local immunoglobulin class switching to IgE and IgE production in the esophageal mucosa of EE patients. Sensitization and activation of mast cells involving local IgE may therefore critically contribute to disease pathogenesis.

Background: Obese subjects with chronic hepatitis C virus (HCV) infection have more rapidly progressive liver disease.

Objective: We aimed to compare the intrahepatic cytokine and chemokine profiles in obese and lean subjects with chronic HCV infection using qRT-PCR and immunohistochemistry.

Methods: Liver biopsies from 55 subjects were studied, including 20 with chronic hepatitis C (CHC), 25 with non-alcoholic fatty liver disease (NAFLD) and 10 non-diseased liver.

Results: Compared to the control groups, the liver injury in CHC was characterized by increased expression of interferon (IFN)- and tumour necrosis factor (TNF)-, and chemokines such as RANTES, IP-10 and MCP-1. In comparison with lean -HCV infected subjects, obese-HCV infected subjects had increased hepatic expression of IFN-p=0.004) and TNF-(p<0.001) as well as increased expression of IP-10 (p=0.009) and MCP-1 (p<0.001). Localization of these inflammatory chemokines revealed that in comparison to lean-HCV subjects, HCV infected liver from obese subjects exhibited increased expression of IP-10 (p<0.001) and MCP-1 (p=0.02) in the inflammatory infiltrate of the portal tracts. In parallel, there was increased CD3+ T cell infiltration in the liver of obese-HCV subjects.

Conclusions: The data provide important mechanistic information on the cause of hepatic injury in obese-HCV subjects including: 1) enhanced TH-1 cytokine response-to promote hepatocellular injury; 2) increased expression of the chemokines IP-10 and MCP-1 at both the mRNA and protein levels-to enhance inflammatory cell recruitment; 3) differing localization of these chemokines within the liver of obese-HCV versus lean-HCV subjects and; 4) increased CD3+ cells expression in the liver of obese-HCV subject.

Background & Aims: Interleukin-6 (IL-6) is a well-recognized mediator of liver disease and regeneration. However, the in vivo effects of IL-6 on enterocytes and the intestinal tract have not been elucidated. We sought to determine the in vivo effects of IL-6 on enterocytes.

Methods: Murine models of increased or absent IL-6 were examined.

Results: Systemic, high-dose IL-6 administration to mice over 7-10 days resulted in intestinal hyperplasia with a ~40% increase in small bowel mass and in intestinal villus height. No increase in crypt cell proliferation was noted. IL-6 administration was associated with induction of pSTAT3 in enterocytes along the lower and middle regions of villi but not in crypts. IL-6 administration was also associated with induction of anti-apoptotic proteins including pAKT, ref-1, and FLIP. along with decreased executor caspase activity and PARP cleavage. Pulse bromodeoxyuridine (BrdU) labeling demonstrated equivalent crypt cell proliferation rates but prolonged enterocyte lifespan and slowed enterocyte migration rates in IL-6 treated mice. Furthermore, IL-6–treated mice showed less intestinal injury and improved barrier function following ischemia reperfusion of the small bowel. Conversely, Il6 null mice exhibited impaired recovery following massive enterectomy and increased apoptosis after 5-fluorouracil chemotherapy relative to wild-type controls.

Conclusions: IL-6 inhibited both constitutive and induced enterocyte cell death in vivo. Loss of IL-6 in mice resulted in increased activation of pro-apoptotic and necrotic pathways in enterocytes after injury. Therapies that augment IL-6 or its signaling pathways may help manage intestinal disorders associated with increased apoptosis, necrosis, and gut injury.

Introduction: Probiotics may benefit irritable bowel syndrome (IBS) symptoms but randomized controlled trials (RCTs) have been conflicting so we conducted a systematic review.

Methods: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register electronic databases were searched (up to May 2008), as were conference proceedings, and authors were contacted for extra information. We included only parallel group RCTs with at least one week of therapy comparing probiotics with placebo or no treatment in adults with IBS according to any acceptable definition. Studies had to provide abdominal pain or global IBS symptom improvement as an outcome. Eligibility assessment and data extraction were performed by two independent researchers. Data were synthesized using relative risk (RR) of symptoms persisting for dichotomous data and standardized mean difference (SMD) for continuous data using random effects models.

Results: We identified 19 RCTs. Trial quality was generally good. There were 10 RCTs involving 918 patients providing dichotomous data. Probiotics were statistically significantly better than placebo (RR of IBS not improving = 0.71; 95% CI 0.57-0.88) with an NNT = 4 (95% CI = 3-12.5). There was significant heterogeneity (I2 = 68%) and possible funnel plot asymmetry. Fifteen trials assessing 1351 patients reported on improvement in IBS score as a continuous outcome (SMD = -0.34; 95% CI -0.60 to -0.07). There was statistically significant heterogeneity (I2 = 79%), but this was explained by one outlying trial.

Conclusion: Probiotics appear to be efficacious in IBS but the magnitude of benefit and the most effective species and strain are uncertain.

The incidence of the inflammatory bowel diseases (IBD) ulcerative colitis (UC) and Crohn's disease (CD) markedly increased in industrialised countries during the past decades. In contrast to these countries where helminthosis are rare, IBD is still uncommon in global areas where most people carry worms. Thus lack of exposure to parasites may critically contribute to the risk of IBD. In a recent article in Gut, Summers et al. demonstrated efficacy of treatment with Trichuris suis in active CD (Gut 2005;54:87-90). Trichuris suis was additionally shown to be effective in UC in a randomized trial carried out by the same group. Both studies did not address mechanisms of action. Here we present a real life scenario, which supports the impact of helminths in the prevention of IBD, and provide a rationale for the mechanisms of action.

We read the article by ten Kate et al.(1), from the Dutch HNPCC group regarding small bowel cancer (SBC) risk in HNPCC patients with great interest. The study confirms our data from 2005 (2) regarding the localization of tumors and the absence of identifiable risk factors for SBC in HNPCC patients (i.e. gender, mutation, family history, personal cancer history). The authors additionally calculated a life-time risk of 4.2% for SBC using Kaplan-Meier statistics. Ten Kate et al. recommend a non-invasive surveillance strategy. However, the authors argue that the life time risk for gastric cancer (GC) may influence a surveillance strategy for SBC regarding upper intestinal endoscopy.

Background: The pathogenetic mechanisms of enhanced laryngeal reflex reactivity (ELRR) in patients with extraoesophageal reflux (EOR) are unclear. In a rat EOR model, a laryngeal acid-pepsin insult produces an ELRR that is mediated through sensitization of the capsaicin-sensitive laryngeal afferent fibers by reactive oxygen species (ROS).

Aims: We investigated whether activation of P2X receptors by ATP subsequent to an increase in ROS may induce ELRR in an inflamed larynx that has been insulted by acid-pepsin or H₂O₂.

Subjects and Methods: The larynxes of 184 anesthetized rats were functionally isolated while the animals breathed spontaneously. Ammonia vapor was delivered into the larynx to measure laryngeal reflex reactivity.

Results: Laryngeal insult with acid-pepsin or H₂O₂ produced ELRR with similar characteristics. These two ELRR events were completely prevented by ATP scavengers (a combination of apyrase and adenosine deaminase) or a P2X receptor antagonist (iso-pyridoxalphosphate-6-azophenyl-2',5'-disulphonate). Laryngeal application of a P2X receptor agonist (,β-methylene-ATP) also produced ELRR. An insult with either acid-pepsin or H₂O₂ similarly promoted an increase in the levels of ATP, lipid peroxidation and inflammation in the larynx.

Conclusions: Laryngeal insult with acid-pepsin or H₂O₂ induces inflammation and produces excess ROS in the rat's larynx. The latter may in turn promote the release of ATP to activate P2X receptors resulting in sensitization of capsaicin-sensitive laryngeal afferent fibers and ELRR.