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Objective: Smoking is detrimental for Crohn's disease (CD), but beneficial for ulcerative colitis (UC). Earlier, we studied the effects of active and passive smoking in CD and UC patients from a university hospital. This study was conducted to assess the same effects in patients from a regional hospital., Methods: A questionnaire focusing on cigarette smoke exposure was sent to 382 patients. Returned questionnaires (84%: 128 CD and 192 UC patients) were incorporated into a retrospective chart review about disease behaviour and received therapy., Results: At diagnosis there were 52% (95% confidence interval: 43-60%) smokers among CD patients, 40% in a control population and 25% (95% confidence interval: 18-31%) among UC patients. There were less former (19 vs. 31%, P = 0.013) and never smokers at diagnosis (30 vs. 44%, P = 0.009) in CD than in UC. No detrimental effects of active or passive smoking on the course of CD were observed. UC patients who continued smoking after diagnosis needed less often two or more hospitalizations than never smokers (5 vs. 25%, P = 0.036). Otherwise no clear beneficial effects of active smoking on UC were observed. Passively smoking UC patients experienced more often extraintestinal manifestations (25 vs. 7%, P = 0.029) than nonpassive smokers., Conclusion: Also in a regional hospital inflammatory bowel disease population smoking is a risk factor to develop CD and protects against developing UC. We found no detrimental effects of smoking on the disease course of CD and no clear beneficial effects on the course of UC.

Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.

Objectives: Crohn's disease (CD) is a complex genetic disease with multiple clinical patterns. Clinical classifications may help to identify subgroups of patients that have a distinct pattern of disease, and they are also a prerequisite for the conduction of genetic and therapeutic studies. The aim of this study was to determine the usefulness of the Vienna classification in patient care and clinical studies., Methods: The clinical data of patients were carefully reviewed retrospectively. The behaviour and location of the disease were determined according to the Vienna classification and additional clinical characteristics including surgical data, vitamin B12 status and medication were also assessed., Results: Data according to the Vienna classification of 292 CD cases were available. The mean age at diagnosis was 31.4 years. The operation rate was higher in patients with ileocolonic localization (P<0.05) and stricturing and penetrating disease behaviour (P<0.001). The incidence of vitamin B12 deficiency was 41.9% in cases with ileal involvement and 20.7% in cases with disease confined to the colon. In 187 cases (64.0%) an operation was performed because of CD-related complications, in a majority (126, 67.4%) this took place within 5 years after diagnosis. Intolerance of azathioprine occurred in 36 cases (22.0%)., Conclusions: Ileocolonic disease localization is associated with a complicated course of disease. Vitamin B12 deficiency occurs frequently, also in patients with disease apparently confined to the colon. We propose that location parameters can be used for the prediction of disease course in clinical settings and in interventional studies.

Objectives: Recent studies have suggested that the prevalence of Helicobacter pylori infection in patients with ulcer disease who were not using non-steroidal anti-inflammatory drugs (NSAIDs) has been overestimated. The decreasing prevalence of H. pylori could lead to a relative increase in the number of patients with this idiopathic peptic ulcer disease (IPUD). This study aimed to investigate the prevalence of IPUD and any possible trends., Design and Methods: The reports of all upper gastro-intestinal endoscopies performed in a Dutch regional hospital over the period 1991 to 1998 were reviewed. If a gastric and/or duodenal ulcer had been diagnosed, data concerning possible H. pylori infection (culture, histology, rapid in-house urease test) were retrieved. If H. pylori tests were negative, hospital files were examined for possible use of NSAIDs or other rare causes of ulcer disease. When these were not found, stored biopsy specimens were tested for H. heilmanii by using the polymerase chain reaction technique., Results: Ulcer disease was diagnosed in 405 patients who had undergone endoscopy (159 with gastric ulcer, 235 with duodenal ulcer, and 11 with both gastric and duodenal ulcer). H. pylori infection was found in 349 of these patients (86.2%). Thirty-three of the 56 H. pylori negative patients used NSAIDs and three patients had Crohn's disease, leaving 20 patients with IPUD (4.9%, 12 gastric ulcer and eight duodenal ulcer). Time trends over the study period showed a decrease of H. pylori associated peptic ulcer disease (P <0.002) and an increase of NSAID associated peptic ulcer disease (P <0.0005). The prevalence of IPUD remained stable (P=0.978)., Conclusions: The prevalence of patients with H. pylori negative ulcer disease significantly decreased in our study population due to an increase in the number of patients with NSAID associated peptic ulcer disease. IPUD was rare and its prevalence did not increase over a period of 8 years.

We present a case of fundic gland polyps (FGPs) containing high-grade dysplasia in a 68-year-old man. High-grade dysplasia, and even gastric adenocarcinoma, associated with FGPs have been described in patients with familial adenomatous polyposis (FAP) and attenuated familial adenomatous polyposis (AFAP) but never in non-FAP patients. Two colonoscopies in the past six years virtually rule out FAP and AFAP in our patient. Dysplasia in FGPs from non-FAP patients is extremely rare, and until now only cases of low-grade dysplasia have been described. The literature on dysplasia in FGPs is reviewed briefly. Additional immunohistochemical investigations in this case showed nuclear staining of beta-catenin, increased proliferation and apoptosis in the dysplastic areas of the FGPs. Our case suggests that the malignant potential of FGPs is not limited to FAP-associated FGPs.

Objective & Design: We question whether Helicobacter pylori eradication in peptic ulcer disease patients leads to a decrease in symptoms and reduced use of anti-dyspeptic drugs. Therefore, the recurrence rate of H. pylori, upper abdominal symptoms and the use of acid-suppressive drugs were determined 6 years after successful triple therapy., Methods: Peptic ulcer disease patients successfully treated in 1990-1993 with 'classic' triple therapy were eligible. Patients were asked about symptoms and invited for a 13C-urea breath test or endoscopy in 1997-1998. Data on the use of anti-dyspeptic drugs were obtained from the pharmacy or general practitioner., Results: Of the 113 eligible patients, 90 could be included in the study. The mean follow-up time was 6 years (range 4.6-7.6 years). H. pylori infection recurred in one patient (recurrence rate: 0.19% per patient-year; 95% confidence interval: 0.01-1.1%). Moderate or severe symptoms were experienced before therapy by 79% of the patients and after therapy by 18% of the patients (P< 10(-7)). Before triple therapy, 98% of the patients used H2-receptor antagonists and 54% were on maintenance treatment. After treatment, 30% used anti-dyspeptic medication and only 13% were on maintenance treatment (P < 10(-7))., Conclusions: Six years after successful triple therapy in peptic ulcer disease patients, the recurrence rate of H. pylori infection is low and both symptoms and the use of anti-dyspeptic drugs have decreased significantly.

Objective and Design: To evaluate the performance of the Helicobacter pylori stool antigen test (HpSA test) in detecting H. pylori infection and monitoring the effect of treatment. This was done in two separate studies using either a biopsy or the 13C-urea breath test based 'gold standard' (in untreated and treated patients, respectively)., Setting: Endoscopy units of two general hospitals., Patients: One hundred and twenty-eight dyspeptic patients undergoing endoscopy in the first study. Sixty-five patients receiving anti-H. pylori treatment in the second study., Results: Sensitivity and specificity in untreated patients were 96.3% and 81.8%, respectively. Seven days after treatment, these figures were 20% and 95%, and 4 weeks after treatment they were 40% and 95%., Conclusion: The HpSA test is accurate in untreated patients but fails in monitoring treatment success.

Objective: Recurrence of Heliobacter pylori after apparently successful treatment mostly represents resurgence of the infection, rather than a new one. Therefore, the reliability of biopsy-based tests after treatment was investigated., Methods: Four weeks or more after treatment, antral biopsy samples were taken for culture, histology, urease test and polymerase chain reaction (PCR), and a corpus specimen for culture. Treatment failure was defined as > or = 2 tests positive. If one test was positive, a 13C-urea breath test was performed and considered conclusive., Results: One hundred and ninety-seven patients were evaluated. Endoscopy was performed 53 days (27-92 days) after treatment. Twenty-one patients with missing test results and 19 patients on acid-suppressive drugs were excluded. In 140 of 156 patients (89.7%), H. pylori was eradicated. Sensitivity and specificity of culture of antrum were, respectively, 100% and 100%; culture of corpus, 100% and 100%; rapid urease test, 87% and 99%; haematoxylin/eosin stain, 94% and 95%; Giemsa stain, 81% and 99%; and PCR, 88% and 100%., Conclusion: Although all biopsy-based tests are reliable after treatment, culture is the biopsy-based test of first choice as it is the most accurate and gives additional information on antibiotic resistance.

Objective: This study analyses the 13C-urea breath test with the aim of determining the optimal time interval between dosing and breath sampling and examines the feasibility of having patients perform the test without supervision at home., Design: Prospective study comparing the 13C-urea breath test with four antral biopsy-based tests in a random population undergoing upper gastrointestinal endoscopy., Setting: One university hospital and one general hospital., Patients: One hundred and four patients were included; 61 were Helicobacter pylori-positive and 43 H. pylori-negative according to biopsy-based tests., Interventions: The 13C-urea breath test was performed at home by collecting a baseline and two post-dosing samples; the next day it was performed clinically by collecting a baseline and six post-dosing samples. A 100 mg dose of 13C-urea and a test meal were used., Outcome Measures: The breath samples collected were analysed. Excess delta 13CO2/12CO2 values above five per million were considered positive., Results: The specificity of the clinical test was 100% whereas that of the home-based test was 95.1%. The sensitivity of the clinical test depended on the time interval between dosing and collection of the evaluated sample. Sensitivity was 100% if the sample was taken 50 min or more after dosing. The home-based test had a sensitivity of 94.8%., Conclusion: To obtain maximum sensitivity (100%) using the single-sample technique the sample has to be collected at least 50 min after dosing. It is feasible to have the test performed at home. Patient selection and thorough instruction are necessary.