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Summary Objectives Barrett's mucosa is considered as a mosaic of three epithelial types but little is known about the topography of intestinal metaplasia in columnar lined esophagus. The aims of the study were to determine the prevalence of intestinal metaplasia within long and short segments of columnar lined esophagus and to analyze the distribution of the intestinal metaplasia within long segments of Barrett's esophagus. Patients and methods The study was performed on the initial endoscopy carried out among 112 patients enrolled in an endoscopic surveillance program. Seventy-two patients with columnar mucosa extending more than 3 cm into the esophagus (group I) and 40 patients with a short segment of columnar mucosa (group II) had multiple biopsies according to a standardized protocol. 1163 biopsies were analyzed on the whole: 949 biopsies in group I and 214 biopsies in group II. Results Intestinal metaplasia was identified among 650 (68.5%) and 50 (23.4%) biopsies in groups I and II respectively (P -7 ). The proportion of biopsies with foci of intestinal metaplasia increased significantly with the length of the columnar mucosa. The diagnosis of Barrett's esophagus was confirmed in 100% of the patients in group I and in 45% of the patients in group II. In long segments of Barrett's esophagus, intestinal metaplasia was more frequently observed in the 2 upper thirds of the columnar mucosa that in the lower third (P -7 ). Detailed mapping of the distribution of epithelial types within the columnar lined esophagus identified three patterns of distribution of intestinal metaplasia within long segments of Barrett's esophagus: unifocal, multifocal and diffuse, in 5%, 56% and 39% of the patients respectively. Dysplasia was present in 15% of patients with long segments of Barrett's esophagus and 11% of patients with short segments (NS). Conclusion The distribution of intestinal metaplasia within columnar lined esophagus is heterogeneous and three distinct patterns can be identified: unifocal, multifocal and diffuse. Considering the risk of sampling error, the current recommendations concerning the biopsy protocols are mandatory until the validation of new techniques such as chromoendoscopy or magnifying endoscopy.

Summary Objectives The aims of this prospective study were to evaluate the incidence of hepatocellular carcinoma (HCC) in Finistere, an administrative district of western France, and to highlight epidemiological characteristics. Methods From June 1st 2002 to May 31st 2003, all cases of HCC in Finistere were registered prospectively. Standardized incidence rates were calculated. Results One hundred and six cases of HCC were registered. Standardized incidence rates were 13.8/100000 among men and 0.8/100000 among women. Among the incident cases of HCC, 52% were discovered in patients consulting for symptoms, and 28% in patients undergoing screening. The new non-invasive diagnostic criteria of HCC were used in 60% of cases. HCC was associated with cirrhosis in 89 patients (84%). Excessive alcohol intake was the main cause of cirrhosis. In all, 27 patients (25.5%) received potentially curative treatment. Conclusion Incidence of HCC is high in Finistere. The proportion of patients given potentially curative treatment is still low, illustrating how difficult screening can be when alcoholic cirrhosis predominates in the target population.

Objective To evaluate the main changes in characteristics, practices and outcome between 1996 and 2000 in patients admitted for an acute upper gastrointestinal haemorrhage (AUGIH). Patients and methods All consecutive patients (n=1165) admitted for an AUGIH in four French administrative areas were entered into two separate 6-month studies conducted in 1996 (n=712) and 2000 (n=453). Epidemiological and biological characteristics, endoscopic haemostatic procedures and outcomes were compared. Results Patient characteristics remained unchanged between the two studies; the two main bleeding lesions were peptic ulcer and oesophagogastric varices (30.2 versus 31.1% and 22.5 versus 20.3%). The use of non-steroidal anti-inflammatory drugs or aspirin was more frequent in 2000 (26.5 versus 32.6%; P

Summary Objectives The aims of this study were to evaluate trends in incidence, clinical characteristics, treatment regimen and prognosis of gastric carcinoma in the area of Finistere (France) during a 12-year period. Methods Between 1984 and 1995, the Finistere Registry of GastroIntestinal Tract Tumors listed 2 139 patients with gastric carcinoma in a population of 838 627 inhabitants. Curative resection and operative mortality were analyzed by logistic regression. Prognostic factors were determined using the Kaplan-Meier method and the Cox model. Results When comparing the second period (1990-1995) to the first period (1984-1989) we observed: a) a decrease of standardized incidence (13.2 vs. 15.6/100 000 inhabitants/year in males and 5.4 vs . 7.0/100 000 inhabitants/year in females); b) a significant increase of linitis plastica (21.4% vs . 10.9%) and infiltrative tumors (53.1 vs. 31.2%) (P vs . 45.0%; P Conclusion This study showed a decrease in the incidence of gastric carcinoma over time and an increase of linitis plasticia and infiltrative forms. Despite improvement in management of patients, the global prognosis of gastric carcinoma did not improve significantly over a 12-year period of observation.

Liver steatosis is a common finding in patients infected with hepatitis C virus (HCV). Host and viral factors have been associated with steatosis, but their relative contributions have not been clearly addressed. It has been suggested that steatosis plays a role in the progression of liver fibrosis.To assess: a) factors associated with steatosis in patients infected with hepatitis C virus; b) their impact on liver fibrosis.Three hundred and fourteen untreated patients were included. Lifetime alcohol consumption was estimated. Liver fibrosis, inflammation and necrosis were assessed using the METAVIR score. Body mass index (BMI) was determined. The scoring system for steatosis was as follows: 0, no steatosis; 1, less than 10%; 2, 10% to 30%; 3, 30% to 70%; 4, more than 70% of hepatocytes affected.In univariate analysis, steatosis was associated with elevated BMI (P=0.001), excessive alcohol intake (P=0.005), genotype 3 (P0.001) and moderate to severe histological activity (P=0.01). Multivariate analysis showed that steatosis correlated with two independent factors: genotype 3a (OR=60.7; 95% CI: 7.6-483.4) (P0.001) and BMI (OR=4.86; 95% CI: 1.8-13.15) (P=0.002). In univariate analysis, severe fibrosis (F2-F3-F4) was associated with older age (P10(-5)), male gender (P=0.001), disease duration (P0.006), BMI (P10(-4)), alcohol intake (P10(-6)), severity of histological activity (P10(-5)) and steatosis (P10(-6)). In multivariate analysis, three independent factors were associated with severe fibrosis: disease duration10 years (OR=3.17; 95% CI: 0.65-15.4) (P=0.015), presence of steatosis (OR=3.17; 95% CI: 1-9.99) (P0.049) and genotype 3a (OR=5.56; 95% CI: 1.4-22.1) (P=0.015).In patients with chronic hepatitis C, steatosis is significantly associated with genotype 3 infection and high BMI. Steatosis is an independent risk factor associated with severe fibrosis. These results have major implications for the management of patients with chronic hepatitis C.

Loss of heterozygosity (LOH) on chromosome 9 and p16 (MTS1/CDKN2) gene mutations have been reported in various human cancers. The present study aimed to determine the prevalence of LOH in 100 oesophageal squamous cell carcinomas (OSCCs) by typing microsatellite loci and mutations of the p16 gene. The methods used included denaturing gradient gel electrophoresis (DGGE) and DNA sequencing of exon 2. LOH was found in 14.7% of the OSCC cases. Six gene alterations were identified in exon 2. They consisted of three deletions and the same polymorphism in three samples. The relatively low rate of p16 mutation compared with the frequency of LOH suggests the possible involvement of another tumour suppressor gene located on chromosome 9 in oesophageal carcinogenesis.

Objective To compare incidence rates and epidemiological characteristics of acute upper gastro-intestinal haemorrhage (AUGIH) in France with those of other European studies. Design Population-based multi-centre prospective survey. Setting 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. Subjects A total of 2133 AUGIH patients 18 years and over were included in the six-month study. Outcome measures Incidence and mortality. Results The overall incidence in France was 143 cases per 100 000 persons per year, classified as out-patients (16%), emergency admissions (59%) and in-patients (25%). The incidence rates increased with age except for in-patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, anti-inflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out-patients excluded) was 14.3% (10.7% for emergency patients and 23% for in-patients). Mortality was associated with co-morbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non-steroid anti-inflammatory drugs, and higher in in-patients using corticosteroids. Conclusions In France, patients with AUGIH are frequently managed as out-patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in-patients.

To better understand the mechanisms of esophageal carcinogenesis, abnormalities in DNA content of esophageal squamous cell carcinomas were studied. Cellular DNA content was determined by flow cytometric study of 70 endoscopic biopsy specimens obtained from 26 patients with esophageal squamous carcinoma. High-quality histograms were obtained for 23 patients. Twenty-one patients had at least one aneuploid population in their tumor. In 7 patients, multiple aneuploid peaks were detected. Specimens from 2 patients were diploid. The interpretation of the DNA histograms was difficult in 3 patients; an aneuploid population of cells was probable in 2 of them. A statistically significant relationship was found between the degree of differentiation and DNA content abnormalities in the regions of the tumors that could be evaluated by endoscopic biopsies: well-differentiated carcinomas had diploid or small aneuploid populations containing less than 15% of the cells, whereas DNA histograms of moderately or poorly differentiated carcinomas were characterized by large aneuploid peaks representing 25%-90% of the cells and a higher proliferative fraction. No relationship was found between the size or the stage of the tumor and the DNA content detected in endoscopic biopsy samples. The frequency and the multiplicity of abnormal clones in esophageal squamous carcinomas indicates that this cancer, like esophageal adenocarcinoma, develops an association with an acquired genomic instability that produces abnormal clones of cells, according to the multistep model of neoplastic progression.

The development of a computer-assisted diagnostic system in digestive endoscopy implies to understand the reasoning process of endoscopists. The aim of this study is to validate a reasoning model and a knowledge base previously defined. Eight endoscopists have participated to a diagnostic test including 5 video-sequences and using a "thinking aloud" method. The physician discourse was compared with the knowledge base contents Forty requests, built with indices extracted from endoscopist talks were submitted to the diagnostic research system. The main results show that the endoscopists evoke all the information types defined in the knowledge base. Endoscopists well distinguish the endoscopic findings and diagnoses. They combine data-driven and hypothesis-driven approaches during the diagnostic process. Faced to complex diagnostic problem solving, they promote an analytical approach. The 40 requests have led to the correct finding class, as unique or first response in 25, second or other rank response in 12, and failed to recognize the lesion in 3 cases. These results are consistent with the reasoning model and the knowledge base content They suggest several ways for improving the diagnostic aid system, the research approach as well as the user interface.

To assess epidemiologic features and predictive factors of mortality of acute upper gastrointestinal bleeding (UGIB).During a 6-month period, a prospective population-based study including all the UGIB occurring in a geographic area of 3 million people was conducted. Data from cirrhotic patients were compared with those of noncirrhotic patients.A total of 2,133 UGIB were recorded, 21.9% in cirrhotic patients (n = 468). Endoscopic hemostasis was performed in 46.5% and 8.3% in cirrhotic and noncirrhotic patients, respectively (P0.001). Mortality during hospitalization was 23.5% in cirrhotic patients and 11.2% in noncirrhotic patients (P0.001). Six independent predictive factors of mortality were observed in both patient groups: a prothrombin level less than 40%, an UGIB occurring in inpatients, a concomitant digestive carcinoma, a hematemesis revealing the UGIB, a recent use of steroid drugs, and age over 60 years. Four other predictive factors of mortality were also identified in noncirrhotic patients.Although epidemiologic features, clinical course, management, and prognosis of UGIB were quite different in cirrhotic and noncirrhotic patients, the majority of predictive factors of mortality were the same in both patient groups. These data underline the major role of debilitated status and hepatic failure in the prognosis of UGIB in cirrhotic patients.

The development of a computer-assisted diagnosis system in digestive endoscopy, relying on a reference endoscopical image database, requires that the diagnosis reasoning during the examination is understood. Two main and complementary approaches are described, one is guided by lesions detection, the other is guided by diagnosis hypothesis. The two approaches rely on medical knowledge of normal and pathological aspects of the digestive tract.

The purpose of the authors' project is to build an atlas of indexed endoscopical lesions that could be used in computer-assisted diagnostics as referring data. The analysis of both endoscopists' experience and computerized record format developed by professional shows that the diagnostic reasoning in digestive endoscopy uses a scene-object approach. The objects correspond to the endoscopical findings and the medical context of examination, and the scene to the endoscopical diagnosis. Based on expert assessment, a computer-assisted diagnosis system is described using a classification reasoning approach. The classes of endoscopical findings and diagnoses are listed and the primitive characteristics of objects are extracted. Each class content is defined in an intensive way, and symbolic distances between descriptors and classes leads to an a priori description of classes. Symbolic distances are transformed by heuristic in numeric measures that allow estimation of the membership value of an observed case to a defined class. A simulation test with 50 randomized objects by class demonstrates a good classification of endoscopical findings. The correct class is the unique Response in 71% of the tested objects, the first of multiple Responses in 23% and one of the multiple responses in 6%. Four descriptors are of major importance in the classification algorithm: anatomic location, shape, color and relief. A computerized application is currently developed to archive endoscopical cases according to the classification method.

The aim of this study was to search for a specific antibody pattern in sera from patients suffering from Helicobacter pylori -related gastric adenocarcinoma (GAC). The serological response of 22 patients suffering from GAC, 31 patients with gastroduodenal ulcer, and 39 asymptomatic subjects was analyzed using immunoblotting performed with three H. pylori strains: strain ATCC 43579; strain B110, isolated from a patient with ulcers; and strain B225, isolated from a patient with GAC. In addition, the latex agglutination test Pyloriset Dry was used to analyze ambiguous sera. H. pylori seropositivity was 75% in the GAC group, 61.3% in the ulcer group, and 56.4% in the asymptomatic group. Anti-CagA antibodies were found more often in the GAC group (48.8%) and in the ulcer group (47.3%) than in the asymptomatic group (21.2%). These percentages depended on the strain used as an antigen: in the GAC group, the anti-CagA frequencies were 93.3, 40, and 13.3% with strains B225, B110, and ATCC 43579, respectively. Thus the presence of anti-CagA antibodies was increased in patients suffering from H. pylori -related GAC, in particular when the CagA antigen was from a GAC strain. These data suggest the existence of a CagA protein specifically expressed by H. pylori strains isolated from GAC patients.

Objectif Les buts de cette etude etaient de definir l’incidence des cancers du pancreas exocrine sur le departement du Finistere entre 1990 et 2004, d’evaluer l’evolution de l’incidence, les caracteristiques morphologiques, la prise en charge therapeutique et la survie. Patients et Methodes Sur la periode 1990 a 2004, 925 malades atteints d’un cancer du pancreas exocrine ont ete recenses. Les criteres cliniques et morphologiques ainsi que la prise en charge therapeutique ont ete analyses par une regression logistique. Les taux d’incidence standardises ont ete calcules sur 3 periodes de 5 ans. La survie et les facteurs pronostiques ont ete etudies en utilisant la methode de Kaplan Meier. Resultats Le taux d’incidence etait en augmentation entre les 3 periodes (en 2004, 5,41/100 000 habitants/an chez l’homme et de 3,56/100 000 habitants/an chez la femme). 418 malades etaient operes, dont 158 avec une resection complete (R0). Il n’existait pas d’augmentation significative de la survie apres chirurgie a visee curative R0 (mediane : 21,22 mois pour la periode 2000-2004 versus 14,85 mois pour la periode 1990-1994, p = 0,21) ou en cas de traitement palliatif (mediane 3,28 mois pour la periode 2000-2004 versus 2,82 mois pour la premiere periode, p = 0,1). Apres une intervention chirurgicale R0, on ne notait pas de benefice a un traitement adjuvant, que ce soit une chimiotherapie, une radiotherapie ou l’association des deux (respectivement p = 0,78, p = 0,67, p = 0,8). Par contre, en l’absence de chirurgie curative, la survie etait augmentee en cas de chimiotherapie et/ou radiotherapie (p Conclusion Cette etude a montre une augmentation de l’incidence des cancers du pancreas exocrine sur la periode 1990-2004. Malgre l’evolution de la prise en charge therapeutique, le pronostic ne s’est pas significativement ameliore sur cette periode d’observation de 15 ans. Toutefois, il existe une tendance a l’amelioration de la survie en cas de traitement chirurgical ou palliatif. L’enregistrement au-dela de l’annee 2004 permettra d’evaluer l’influence des nouvelles approches therapeutiques du cancer du pancreas.

Objectif Les buts de cette etude etaient d’apprecier l’evolution de l’incidence, des caracteristiques, de la prise en charge et du pronostic des carcinomes du cardia et de l’estomac distal dans le departement du Finistere entre 1984 et 2003. Patients et Methodes L’incidence standardisee a ete calculee par annees et par periodes quinquennales. Les variables recueillies ont ete etudiees en analyse univariee et multivariee (regression logistique). Les taux de survie ont ete analyses en univarie (Kaplan Meier) et multivarie (modele de Cox). Resultats De 1984 a 2003, 3 962 patients ont ete enregistres. 3 606 etaient atteints de carcinomes gastriques. Entre les periodes 1984-1988 et 1999-2003 l’incidence standardisee a diminue pour les carcinomes de l’estomac distal (p Conclusion Cette etude a montre une diminution significative de l’incidence des carcinomes de l’estomac distal et une augmentation non significative de l’incidence des carcinomes du cardia entre 1984 et 2003 dans le Finistere. Malgre l’evolution de la prise en charge therapeutique le pronostic ne s’est pas ameliore, probablement par une augmentation d’incidence des formes anatomo-cliniques de mauvais pronostic.