nederlandse vereniging voor gastroenterologie

NEDERLANDSE VERENIGING VOOR GASTROENTEROLOGIE

Sectie Gastrointestinale Endoscopie

Netherlands Society for Parenteral and Enteral Nutriton

Sectie Endoscopie Assistenten

Sectie Maag-darmmotoriek

Sectie Experimentele Gastroenterologie

Sectie Kindergastroenterologie

NEDERLANDSE VERENIGING VOOR HEPATOLOGIE

NEDERLANDSE VERENIGING VOOR GASTROINTESTINALE CHIRURGIE

NEDERLANDS GENOOTSCHAP VAN MAAG-DARM-LEVERARTSEN

CONGRESCENTRUM KONINGSHOF

VELDHOVEN

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INHOUDSOPGAVE pagina Voorwoord 3 Schematisch overzicht sessies donderdag 21 maart 2002 4 Schematisch overzicht sessies vrijdag 22 maart 2002 5

Programma cursorisch onderwijs 20 en 21 maart 2002 6

Donderdag 21 maart 2002 (middagprogramma) Voordrachten Nederlandse Vereniging voor Gastrointestinale Chirurgie 7 Symposium Inflammatory Bowel Disease 8 Uitreiking NVGE-Gastrointestinale Research Prijs 2001 8 Uitreiking Dicke-medaille aan Prof. dr. K. Huibregtse 8 Voordrachten Nederlandse Vereniging voor Hepatologie 8-10 Voordrachten Netherlands Society of Parenteral and Enteral Nutrition 10-11 Voordrachten Nederlandse Vereniging voor Gastroenterologie (zaal 80) 12-13 Voordrachten Nederlandse Vereniging voor Gastroenterologie (zaal 81) 14-15 Donderdag 21 maart 2002 (avondprogramma) Voordrachten Nederlandse. Vereniging voor Gastroenterologie (plenaire avondsessie) 15 Byk-Lecture door Prof. dr. M.J.G. Farthing 15 Vrijdag 22 maart 2002 (ochtendprogramma) Casuïstiek voor de klinikus 16 Voordrachten Sectie Gastrointestinale Endoscopie 16-17 Symposium “Teaching in Endoscopy” 17 Voordrachten Sectie Experimentele Gastroenterologie 18-19 Van Fundament tot Kliniek: NWO-MW Werkgemeenschap Darmfunctie ontmoet de Experimentele Gastroenterologie 19 Voordrachten Nederlandse Vereniging voor Gastroenterologie 20-22 Voordrachten Sectie Maagdarmmotoriek 22-24 Symposium Nederlandse Vereniging voor Hepatologie: PBC en PSC 24 Vrijdag 22 maart 2002 (middagprogramma) Voordrachten Sectie Experimentele Gastroenterologie 25-26 Symposium “Chemotherapie en chemoradiotherapie in de gastrointestinale oncologie: controversieel of standaard?” 27 Eindpresentaties Maag Lever Darm Stichting 28 Programma Sectie Endoscopie Assistenten 29 Abstracts 30-173 Plattegrond expositie + alfabetische namenlijst standhouders 174-175 Aanmeldingsformulieren lidmaatschappen 177-181

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VOORWOORD Hierbij treft u het volledige programma aan van de komende voorjaarsvergadering in Veldhoven, inclusief de abstracts. Naast vrije voordrachten door de verschillende secties en verenigingen, worden in totaal drie symposia georganiseerd (onderwerpen: Inflammatory Bowel Disease, Chemotherapie en Chemoradiotherapie in de Gastroinestinale Oncologie, en Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis). Ook staat er een state of the art lecture geprogrammeerd op de donder-dagavond, verzorgd door Prof. dr. M.J.G. Farthing, dit in het kader van de Byk lecture. Op vrijdag-middag staan eindpresentaties van wetenschappelijk onderzoek op het programma van MLDS gesubsidieerde projecten. Belangrijk voor sprekers: u dient zich strikt te houden aan de beschikbare spreektijd! Indien u een eigen laptop gebruikt, dan dient u deze aan te sluiten tijdens de discussietijd van de spreker voor u. Tenslotte nog graag even uw aandacht voor het volgende: Wilt u op de dag van vertrek voor 09.00 uur uw kamersleutel inleveren bij de receptie? Voorts ver-zoeken wij u af en toe op de monitoren in het congrescentrum te kijken, dit in verband met even-tuele berichten. Dr. W. Hameeteman, secretaris Nederlandse Vereniging voor Gastroenterologie N.B. De met een asterisk gemerkte abstracts in dit programma zijn ingezonden door leden van de Sectie Kindergastroenterologie.

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Schema donderdag 21 maart 2002

DONDERDAG BRABANTZAAL BARONIEZAAL PARKZAAL ZAAL 80 ZAAL 81

14.00-15.30

vrije voordrachten Nederlandse Vereniging voor Gastrointestinale Chirurgie p. 7

vrije voordrachten Nederlandse Vereniging voor Hepatologie p. 8-9

vrije voordrachten Netherlands Society of Parenteral and Enteral Nutrition p.10-11

vrije voordrachten Nederlandse Vereniging voor Gastroenterologie p. 12-13

vrije voordrachten Nederlandse Vereniging voor Gastroenterologie p. 14-15

15.30-16.00 Theepauze Thee/ledenvergadering Theepauze Theepauze Doorlopend programma

16.00-17.00 Symposium NVGIC:Inflammatory Bowel Disease p. 8

vervolg vrije voor-drachten Nederlandse Vereniging voor Hepatologie p. 9-10

vrije voordrachten NESPEN einde progamma 16.45 p. 11

vrije voordrachten NVGE, einde programma 17.00 p. 13

Vervolg IBD programma in de Brabantzaal.

17.00 17.15

Uitreiking NVGE- Research prijs p. 8 Uitreiking W.K. Dicke medaille p. 8

17.30 Congresborrel aangeboden door Byk aansluitend diner

20.00 vrije voordrachten Nederlandse Vereniging voor Gastroenterologie p. 15

21.00 Byk lecture door M.J.G. Farthing p. 15

21.30 Ledenvergadering NVGE

22.00 Borrel in Dommelpoort aangeboden door AstraZeneca

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Programma vrijdag 22 maart 2002

VRIJDAG BRABANTZAAL BARONIEZAAL ZAAL 80 PARKZAAL AUDITORIUM

09.00 09.30

Casuïstiek p. 16 vrije voordrachten Sectie Gastrointestinale Endoscopie p. 16

vrije voordrachten Sectie Experimentele Gastroenterologie (SEG) p. 18

vrije voordrachten NVGE p. 20

vrije voordrachten Sectie Maagdarm-moto-riek, aanvang 9.00 uur p. 22

Symposium NVH: PBC en PSC aanvang 09.30 p. 24

10.00 vervolg vrije voor-drachten Sectie Gastrointestinale Endoscopie p. 16-17

vervolg vrije voordrach-ten Sectie Experimentele Gastroenterologie p. 18-19

vervolg vrije voordrach-ten NVGE p. 20-21

vervolg vrije voor-drachten Sectie Maagdarm-motoriek p. 22-23

vervolg symposium tot 11.00 uur

11.00 Koffiepauze Koffiepauze Koffiepauze Koffiepauze Koffiepauze (10.30)

11.30 'Teaching in Endoscopy' p. 17

Van fundament tot kliniek p. 19

vervolg vrije voordrachten NVGE p. 21-22

vervolg vrije voor-drachten Maagdarm-motoriek p. 23-24

einde symposium 12.05

12.30 Lunch Lunch Lunch Lunch Lunch

14.00 Sectie Endoscopie Assistenten p. 29

Vrije voordrachten SEG (aanvang 13.30) p. 25-26

geen middagprogramma in deze zaal

symposium gastroente-rologie en oncologie p. 27

Eindpresentaties MLDS p. 28

16.00 theepauze/einde pro-gramma ca. 16.00

theepauze/einde pro-gramma ca. 16.30

theepauze/einde pro-gramma 16.00

theepauze/einde pro-gramma 15.40

Vrijdag 22 maart 2002 tevens programma van de Vereniging van Maag Darm Lever Verpleegkundigen: 10.00 uur oprichtingsvergadering, gevolgd door symposium 'Verpleegkundig spreekuur in de GE Praktijk' Plaats:. Diezehal, 10.00 - 15.30 uur. (i.s.m. Crohn en Colitis Ulcerosa Vereniging Nederland, Maag Lever Darm Stichting en Ferring)

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CURSORISCH ONDERWIJS IN MAAG-, DARM- EN LEVERZIEKTEN, 20 EN 21 MAART IN VELDHOVEN.

Cursuscommissie: Dr. W.A. Bemelman (chirurg, Academisch Medisch Centrum) Dr. H.M. van Dullemen (MDL-arts, Academisch Ziekenhuis Groningen P. Honkoop (MDL-arts i.o. Academisch Ziekenhuis Rotterdam) Dr. C.M.F. Kneepkens (kinderarts, Vrije Universiteit Medisch Centrum) Dr. C.J.J. Mulder (voorzitter) (MDL-arts, Rijnstate Ziekenhuis Arnhem)

Woensdag 20 maart 2002

MALIGNITEITEN VAN DE SLOKDARM/MAAG

20.30 - 21.00 uur NHL van de maag : diagnostiek en therapie. Dr. H. Boot (AVL, Amsterdam)

21.00 - 21.20 uur NHL epidemiologie dunne darm. J.J. Schweizer (LUMC, Leiden)

21.20 - 21.50 uur Coeliakie zonder vlokatrofie. P.J. Wahab (Rijnstate, Arnhem)

21.50 - 22.20 uur Coeliakie: rol van immunogenetica/serologie bij screening en bij case-finding.

Dr. L. Mearin (LUMC, Leiden)

Donderdag 21 maart 2002

08.30 - 09.00 uur Slokdarm- / maagcarcinoom; diagnostiek en stagiëring. Dr. P. Fockens (AMC, Amsterdam)

09.00 - 09.30 uur Chronisch Hp en PPI = intestinale metaplasie / dysplasie / carcinoom ? Prof. dr. E.J. Kuipers (Dijkzigt, Rotterdam)

09.30 - 10.00 uur Resecties voor maag- en slokdarmmaligniteiten. Prof. dr. J.J.B. van Lanschot (AMC, Amsterdam)

10.00 - 10.30 uur koffiepauze

10.30 - 11.00 uur Downstaging met chemotherapie : wie, wat, waar ? Dr. A. van der Gaast (Dijkzigt, Rotterdam)

11.00 - 11.30 uur Endoscopische curatieve therapie bij Barrett dysplasie / carcinooom. J. Haringsma (Dijkzigt, Rotterdam)

11.30 - 12.00 uur Palliatieve therapie bij plaveisel- / adenocarcinoom slokdarm. Dr. P.D. Siersema (Dijkzigt, Rotterdam)

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donderdag 21 maart 2002

Nederlandse Vereniging voor Gastrointestinale Chirurgie Brabantzaal 13.30 Ontvangst, inschrijving, koffie. Voorzitter: O.R. Busch / E.J. Spillenaar Bilgen

14.00 Exercise tonometry for successful treatment of suspected GI ischaemia; analysis of

152 cases. (p. 30) AS van Petersen, RH Geelkerken, AB Huisman, JJ Kolkman. Dept of Surgery,

Radiology and Gastroenterology, Medisch Spectrum Twente, Enschede.

14.10 Enhanced anti-tumor efficacy by combining conventional chemotherapy with angiostatin or endostatin a murine liver metastasis model. (p. 31-32)

EA te Velde, JM Vogten, M. Gebbink, EE Voest, IHM Borel Rinkes. Dept of Surgery and Medical Oncology, University Medical Center Utrecht.

14.20 Endoscopic balloon dilatation of symptomatic intestinal strictures in Crohn’s disease:

a long-term analysis. (p. 33) G Dijkstra, FTM Peters, JH Kleibeuker, HM van Dullemen, AJ Limburg. Dept of

Gastroenterology and Hepatology, University Hospital, Groningen. 14.30 Outcome of surgery for peptic ulcer hemorrhage. (p. 34) ME van Leerdam, HI Bax, EAJ Rauws, GNJ Tygat, JJB van Lanschot. Dept of

Gastroenterology and Surgery, Academic Medical Centre, Amsterdam. 14.40 Feasibility of early closure of diverting ileostomies. (p. 35) R Bakx, ORC Busch, D van Geldere, WA Bemelman, JFM Slors, JJB van Lanschot.

Dept of Surgery, Academic Medical Centre/ University of Amsterdam, Amsterdam. Dept of Surgery, Amstelveen General Hospital, Amstelveen.

14.50 Robot assisted thoracoscopic long esophageal myotomy for diffuse esophageal

spasm (“nutcracker” esophagus). (p. 36) JP Ruurda, IAMJ Broeders, BLAM Weusten, RPM Simmermacher, AJPM Smout, J

Oors, HG Gooszen. Dept of Surgery and Gastrointestinal Motility Research Centre, University Medical Centre Utrecht.

15.00 Two years clinical outcome and costs of a randomised study comparing conventional

and laparoscopic Nissen. (p. 37) JE Bais, E Buskens, HG Gooszen, on behalf of the Netherlands AntiReflux Surgery

Study Group: JE Bais, JFWM Bartelsman, JH Bonjer, MA Cuesta, PNMYH Go, HG Gooszen, Y van der Graaf, EC Klinkenberg, JJB van Lanschot, JHSM Nadorp, AJPM Smout. University Medical Centre Utrecht, Depts of Surgery and Julius Centre.

15.10 Laparoscopic hand assisted transhiatal esophagus resection with cervical esophago-

gastrostomy for esophageal cancer. (p. 38) WT van den Broek, A Houdijk, S Meijer, MA Cuesta. VU Medical Centre, Dept of

Surgery, Amsterdam 15.20 Major delayed haemorrhage after pancreatic and biliary surgery. (p. 39) SMM de Castro, KFD Kuhlmann, NT van Heek, ORC Busch, H Obertop, TM van

Gulik, DJ Gouma. Academic Medical Center, Amsterdam. 15.30 Theepauze

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donderdag 21 maart 2002 Symposium Nederlandse Vereniging voor Gastrointestinale Chirurgie Brabantzaal

Inflammatory Bowel Disease Voorzitters: W.A. Bemelman / M. Russel 16.00 What’s new in IBD? Pathogenese van inflammatoir darmlijden. Prof. dr. S.J.H. van Deventer, Academisch Medisch Centrum, Amsterdam. 16.20 Medicamenteuze behandeling van inflammatoir darmlijden. Dr. H.M. van Dullemen, Academisch Ziekenhuis Groningen. 16.40 Laparoscopische restoratieve proctocolectomie. Dr. A. D’Hoore, Universitair Ziekenhuis Gasthuisberg. Leuven, België.

Einde symposium Nederlandse Vereniging voor Gastroenterologie Brabantzaal

17.00 Uitreiking NVGE-Gastrointestinale Researchprijs 2001 door de voorzitter van de jury,

Prof. dr. J.J.B. van Lanschot, gevolgd door een ere-voordracht door de prijswinnaar.

17.15 Uitreiking van de W.K. Dicke-medaille aan Prof. dr. K. Huibregtse, door Prof. dr. G.P. van Berge Henegouwen, voorzitter van de Nederlandse Vereniging voor Gastro-enterologie.

17.30 Congresborrel, gesponsord door Byk, en aansluitend diner. Nederlandse Vereniging voor Hepatologie Baroniezaal Voorzitters: P.L.M. Jansen / J. Kwekkeboom

14.00 Increased hepatobiliary cholesterol transport by activation of the liver X-receptor LXR

is independent of ABCA1 in mice. (p. 40) T Plösch, T Kok, VW Bloks, R Havinga, MJ Smit, G Chimini, AK Groen en F Kuipers.

Dept of Pediatrics, University Hospital Groningen; Centre de Immunologie, INSERM-CNRS, Marseille, France; Dept of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.

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14.10 Hepatitis B vaccination with a pre-S1 and pre-S2 containing vaccine (Biohep) in previous non-responders to at least two courses of standard vaccination. (p. 41)

RA de Man, R van den Dorpel, B Zietse, M Kemmeren, RA Heijtink. Dept of Gastroenterology & Hepatology, Internal Medicine and Virology, Universtital Hospital Rotterdam.

14.20 Inter mixed-micellar/vesicular fractions of conjugated cholates in model biles are

strongly increased by acidification: potential implications for reflux esophagitis and Barrett’s esophagus. (p. 42)

W Renooij, MB de Smet, HG Gooszen, KJ van Erpecum. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht.

14.30 Lamivudine treatment during pregnancy to prevent perinatal transmission of hepatitis

B virus infection. (p. 43) M van Zonneveld, AB van Nunen, HGM Niesters, RA de Man, SW Schalm, HLA

Janssen. Dept of Gastroenterology & Hepatology and Virology, University Hospital Rotterdam.

14.40 Combined polymorphisms in UDP-glucuronyltransferases 1A1 and 1A6 implications

for patients with Gilbert’s syndrome. (p. 44) WHM Peters, RHM te Morsche, HMJ Roelofs. Dept of Gastroenterology, University

Medical Center St. Radboud, Nijmegen. 14.50 Paired measurements of quantitative hepatitis B virus DNA in saliva en serum:

implications for saliva as infectious agent in selected patients. (p. 45) AA van der Eijk, HGM Niesters, SD Pas, RA de Man. Dept of Gastroenterology &

Hepatology, Virology, University Hospital Rotterdam. 15.00 Copper-induced apical trafficking of an ATP7B-EGFP fusion protein in polarized

MDCK cells correlates with kinetics of apical copper excretion.* (p. 46) H Roelofsen, JR Forbes, H Wolters, DW Cox and RJ Vonk. Center for Liver,

Digestive and Metabolic Diseases, Dept of Pediatrics, University Hospital Groningen, Dept of Medical Genetics University of Alberta, Edmonton, Canada.

15.10 The effect of recombinant bactericidal/permeability-increasing protein (rBPI21) on

circulating Interleukin-6, Vascular Endothelial Growth Factor (VEGF) and Endostatin in patients undergoing major liver resection. (p. 47)

FPK Wu, PG Boelens, PAM van Leeuwen, K Hoekman, AHG Hansma, MJ Wiezer, C Meijer, S Meijer, M Scotté, MA Cuesta. Dept of Surgery and Dept. of Medical Oncology, VU Medical Center, Amsterdam.

15.20 Early differentiation between rejection and infection in liver transplant patients by

serum and biliary cytokine patterns. (p. 48) MC Warlé, HJ Metselaar, IC Gyssens, GJ Bouma, HW Tilanus. Depts of Surgery

and Gastroenterology & Hepatology, Medical Microbiology & Infectious Diseases, University Hospital Rotterdam.

15.30 Theepauze en algemene ledenvergadering NVH Voorzitters: H. Moshage / R.A. de Man 16.00 Association of donor-recipient sharing of HLA-DR antigens and severity of HCV

recurence after liver transplantation. (p. 49) LB Koppert, PE Zondervan, HJ Metselaar, WCJ Hop, JNM IJzermans, G Kazemier,

HW Tilanus, GJ Bouma. Dept of Surgery, Pathology, Gastroenterology & Hepa-tology, Epidemiology and Biostatistics, University Hospital Rotterdam.

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Donderdag 21 maart 2002 16.10 Detection of Helicobacter species in the non-cirrhotic liver of patients with heap-

tocellular carcinoma. (p. 50) K Verhoef, RGJ Pot, R de Man, P Zondervan, JNM IJzermans, EJ Kuipers, JG

Kusters. Depts of Surgery, Gastroenterology and Hepatology, and Pathology, Erasmus Medical Center, Rotterdam.

16.20 The role of intrahepatic immune effector cells in inflammatory liver injury and viral

control during chronic hepatitis B infection. (p. 51) TJ Tang, J Kwekkeboom, J Laman, HGM Niesters, PE Zondervan, RA de Man, SW

Schalm, HLA Janssen. Dept of Gastroenterology & Hepatology, Immunology, Virology and Pathology, University Hospital Rotterdam.

16.30 Rapid HCV RNA decline after daily 18 MU interferon induction combined with

ribavirin and amantadine in chronic HCV patients. (p. 52) R Sentjens, M Beld, CJ Weegink, HW Reesink. Academical Medical Center, Dept of

Gastroenterology and Hepatology, Dept of Calinical Virology, University of Amsterdam.

16.40 A Population-Based Study of the Effects of HFE C282Y and H63D Mutations on

Liver Function. (p. 53) BZ Alizadeh, OT Njajou, JJ Houwing-Duistermaat, N Vaessen, G de Jong, JM

Vergeer, A Hofman, HA Pols, CM van Duijn. Dept of Epidemiology & Biostatictics and Dept of Internal Medicine, Erasmus Medical Centre, Rotterdam.

16.50 HCV-specific immunity after Extracorporeal Whole Body Hyperwermia in patients

with chronic hepatitis C infection. (p. 54) GJ Boland, H van Soest, T van Bommel, C Huijben, S Moschatsis, AM van Loon, J

van Hattum. Dept. of Gastroenterology, dept. of Virology, University Medical Centre Utrecht.

17.00 Vaccination with SBAS4-adjuvanted vaccine against hepatitis B. (p. 55) G Boland, T van Loon, T van Bommel, A Baars, B Vroom, J van Hattum. Dept. of

Gastroenterology and Virology, UMC Utrecht. 17.10 Congresborrel, gesponsord door Byk, in de expositiehal en aansluitend diner.

Netherlands Society for Parenteral and Enteral Nutriton (NESPEN) Parkzaal Voorzitters: H. Pijl / C. de Jong 14.00 Preoperative fasting dramatically increased the permeability of the intestinal wall. A

rat model of ischemia/reperfuson injury. (p. 56) PG Boelens, H Bouritius, MC Middelaar, RJ Nijveldt, DEC van Hoorn, AA van

Lambalgen, K van Norren, PAM van Leeuwen. Dept of Surgery, VUMC, Amsterdam and Numico Research, Wageningen.

14.15 Enteral glutamine reverses the TH1/TH2 shift in trauma patients. A randomised

double-blind study. (p. 57) PG Boelens, APJ Houdijk, JCM Fonk, BME Blomberg, S Meijer, HJThM Haarman,

PAM van Leeuwen. VUMC, Depts of Surgery & Pathology, Amsterdam.

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Donderdag 21 maart 2002 14.30 Antithrombin III substitution inhibits local intravascular coagulation and fibrin

deposition after intestinal ischemia in rats. (p. 58) IG Schoots, EHP Roossink, PB Bijlsma, M Levi, TM van Gulik. Dept of Surgery and

Internal Medicine, Academic Medical Center, Amsterdam. 14.45 Twenty-four hours gastric tonometry testing: a new promising diagnostic tool for

chronic mesenteric ischemia. (p. 59) PBF Mensink, RH Geelkerken, AB Huisman, JJ Kolkman. Dept of Internal Medicine/

Gastroenterology, Surgery and Radiology, Medisch Spectrum Twente, Enschede. 15.00 Jejunal tonometry. Feasibility, normal values and comparison of jejunal with gastric

tonometry exercise testing. (p. 60-61) JA Otte, AB Huisman, RH Geelkerken, JJ Kolkman. Dept of Internal Medicine,

Ziekenhuis Zeeuws-Vlaanderen, Terneuzen. Depts of Vascular Surgery, Radiology and Gastroenterology, Medisch Spectrum Twente.

15.15 Enteral nutrition protects against hemorrhagic shock induced bacterial translocation.

(p. 62) MDP Luyer, ACE Vreugdenhil, JA Jacobs, M Hadfoune, CHC Dejong, WA Buurman,

JW Greve. Dept of Surgery and Dept of Medical Microbiology, University of Maastricht.

15.30 Theepauze. 15.45 The high metabolic cost of a functional gut. * (p. 63)

SRD van der Schoor, JB van Goudoever, B Stoll, DG Burrin, JF Henry, JF Rosen-berger, PJ Reeds. Sophia Kinderziekenhuis; neonatologie; Baylor College of Medicine, Houston, Texas; Pediatrics, University of Illinois, Urbana IL, USA; Dept of Animal Sciences.

16.00 Orlistat treatment of Gunn rats, especially when combined with phototherapy,

decreases plasma billirubin levels by enhancing the fecal excretion and turnover of bilirubin.* (p. 64)

AM Hafkamp, PPE van Lierop, R Havinga, L Pascolo, C Tiribelli, JD Ostrow, HJ Verkade. Dept. Pediatrics, Univ. Hospital, Groningen, The Netherlands; Dept. BBCM, University of Trieste, Italy; Research Svc., Seattle VA Medical Centre, Seattle, WA USA

16.15 The effect of equicaloric amounts of medium-chain and long-chain triglycerides on

pancreas enzyme secretion. (p. 65) T Symersky, MK Vu, M Frölich, I Biemond, AAM Masclee. Dept of Gastroenterology-

Hepatology and Clinical Chemistry, Leiden, University Medical Center, Leiden. 16.30 Effect of oral Lactobaccillus rhamnosus supplementation on IL-2 production and IL-2

receptor expression in healthy individuals and patients with Crohn's Disease. (p. 66) H Braat, H Kroes, DW Hommes, JMH van de Brande, A te Velde, EAF van Tol, SJH

van Deventer. Dept of Experimental Internal Medicine, Academic Medical Center, Amsterdam and Numico Research BV, Wageningen.

16.45 Einde programma 17.30 Congresborrel, gesponsord door Byk, en aansluitend diner.

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donderdag 21 maart 2002 Nederlandse Vereniging voor Gastroenterologie Zaal 80 13.30 Ontvangst, inschrijving, koffie. Voorzitter: E.C. Klinkenberg-Knol 14.00 Study on the occurrence of dysplasia and intestinal metaplasia in longstanding

achalasia. (p. 67) GE Boeckxstaens, JJ Bergman, CB Verkleij, F ten Kate, GNJ Tygat. Divisions of

Gastroenterology & Hepatology and Pathology, Academic Medical Center, Amster-dam.

14.10 Longterm results of pneumatic dilatation in achalasia; a prospective study. (p. 68)

P Scholten, E Ong, EJ Kuipers. Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, Rotterdam

14.20 Increased deoxycholic acid bile concentrations correlate with longer columnar-like

epithelium segments in the esophagus of rats. (p. 69) RR Sital, FWM de Rooij, RWF de Bruin, JG Kusters, JLD Wattimena, EJ Kuipers,

PD Siersema. Depts of Gastroenterology & Hepatology, Internal Medicine and Surgery, Erasmus MC/University Medical Center Rotterdam.

14.30 Duodenal juice, but not human bile alone affects the growth of Helicobacter pylori.

(p. 70). RR Sital, JG Kusters, FWM de Rooij, JLD Wattimena, EJ Kuipers, PD Siersema. Depts of Gastroenterology and Hepatology and Internal Medicine, Erasmus MC/University Medical Center Rotterdam.

14.40 Metronidazole (MET) and clarithromycin (CLAR) resistance of H.pylori: a survey.

(p. 71) RJLF Loffeld, C Feijen Dept of Internal Medicine and Microbiology, De Heel Zaans Medisch Centrum Zaandam.

14.50 A triple basepair mutation in 16S rRNA causes tetracycline resistance in

Helicobacter pylori (p. 72) MM Gerrits, MR de Zoete, NLA Arents, EJ Kuipers, JG Kusters. Dept of Gastro-

enterology and Hepatology, Erasmus Medical Center Rotterdam, Regional Public Health Laboratory Groningen/Drenthe, Hoogeveen.

15.00 Relevance of the IL-1B-511 and the IL-1RN gene polymorphism and their genotypes

in peptic-ulcer-disease (PUD) and non-ulcer-dyspepsia (NUD) in relation to the helicobacter pylori cagA subtype infection. (p. 73)

SA Morré, L Murillo, JBA Crusius, Y Pannekoek, RWM van der Hulst, AS Peña, A van der Ende. Dept of Gastroenterology and Laboratory of Gastrointestinal Immunogenetics, Vrije University Medical Centre Amsterdam. Dept of Microbiology, Academic Medical Center, Amsterdam, Kennemer Gasthuis, Location Johannes de Deo, Dept of Gastroenterology Haarlem.

15.10 Acid-inhibitory effects and pharmacokinetics of pantoprazole 40 mg and omeprazole

20 mg during repeated oral administration: effect of CYP2C19 polymorphism. (p. 74) N Srivastava, DJ Touw, CBHW Lamers, WP Geus. Leiden University Medical

Centre, The Hague Central Pharmacy and Leyenburg Hospital.

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15.20 A prospective study to determine the value of HLA-DQ typing and serological test (AGA, EMA, AtTG) in screening for celiac disease, a step forward to select patients for jejunal biopsy. (p. 75)

M. Hadithi, JBA Crusius, M von Blomberg, E Bloemena, CDA Stehouwer, AS Peña. Vrije Universiteit Medical Center, Amsterdam.

15.30 Theepauze Voorzitter: E.C. Klinkenberg-Knol 16.00 Intestinal current measurements (ICM) on rectal biopsies in cystic fibrosis (CF)

patients and controls. (p. 76)* M Sinaasappel, I Bronsveld, HR de Jonge. Dept of Pediatric Gastroenterology,

Sophia Childeren’s Hospital, Rotterdam, and Dept of Biochemistry, Erasmus University Rotterdam.

16.10 Interleukin-1beta (1L-1beta) stimulates Fos expression in specific subsets of enteric

neurons through a cyclooxygenase-dependent pathway. (p. 77) ETTL Tjwa, JM Bradley, CM Keenan, ABA Kroese, KA Sharkey. Neurosciene

Research Group, University of Galgary, AB Canada; Dept Med Physiology, University of Utrecht, The Netherlands.

16.20 Effect of depot long-acting octreotide (oct-lar) on clinical symptoms and quality of life

in dumping syndrome. (p. 78) AAM Masclee, C Penning, J Vecht, CBHW Lamers. Dept of Gastroenterology-

Hepatology Leiden University Medical Center, Leiden, Dept of Gastroenterology, Isala-klinieken Zwolle.

16.30 Comparison between oral ingestion and intake via nasogastric tube to assess

drinking capacity. (p. 79) BDJ van den Elzen, GNJ Tygat, GEE Boeckxstaens. Department of Gastro-

enterology, Academic Medical Center, Amsterdam. 16.40 3D Transanal ultrasonagraphy: better imaging with an extra dimension. (p. 80) RL West, RJF Felt-Bersma, CEJ Sloots, EJ Kuipers. Dept of Gastroenterology &

Hepatology, Erasmus MC/University Medical Center Rotterdam. 16.50 Hypnotherapy in irritable bowel syndrome: impact on symptoms, quality of life and

visceroperception. (p. 81) M Vidakovic-Vukic, PPJ van der Veek, J Steens, M Steenvoorden, AAM Masclee.

Dept of Internal Medicine, Lucas-Andreas Hospital Amsterdam and Dept of Gastro-enterology-Hepatology, Leiden University Medical Center, Leiden.

17.00 Einde programma Voor de uitreiking van de NVGE-Gastrointestinale Research prijs 2001 en de aan-

sluitende uitreiking van de Dicke medaille aan Prof. dr. K. Huibregtse kunt u zich begeven naar de Brabantzaal.

17.30 Congresborrel, gesponsord door Byk, en aansluitend diner.

13

donderdag 21 maart 2002 Nederlandse Vereniging voor Gastroenterologie Zaal 81 Voorzitter: W. Hameeteman 14.00 Effects of anti-TNF therapy on the quality of life in Crohn’s disease. (p. 82)

BPJ van Balkom, EJ Schoon, RW Stockbrügger, FL Wolters, RA van Hogezand, SJH van Deventer, B Oldenburg, HM van Dullemen, MGVM Russel. Dept. of Gastroenterology & Hepatology, University Hospital Maastricht, Leiden Medical University Center, University Hospital Amsterdam, University Medical Center Utrecht University Hospital Groningen.

14.10 Infliximab treatment for Crohn’s disease: what have we learned after 500 infusions?

(p. 83) DW Hommes, M Hermans, GJ Sterringa, BH van Heisteeg, JFWM Bartelsman, SJH van Deventer. Dept of Gastroenterology and Hepatology, Amsterdam.

14.20 Effect of tumour necrosis factor alpha antibody on circulating gastrin in patients with

Crohn’s disease. (p. 84) WPM Hopman, AHJ Naber, DJ de Jong, JBMJ Jansen. Dept of Gastroenterology

and Hepatology, UMC, Nijmegen. 14.30 Methotrexate therapy for Crohn’s disease: long-term efficacy and safety. (p. 85) DW Hommes, M DeLey, GJ Sterringa, JFW Bartelsman, SJH van Deventer. Dept of

Gastroenterology and Hepatology, Amsterdam. 14.40 6-Thioguanine seems promising in azathioprine intolerant patients. (p. 86) DJ de Jong, LJJ Derijks, LGJB Engels, JBMJ Jansen, PM Hooymans, CJJ Mulder.

Dept of Gastroenterology, University Medical Center Nijmegen, Dept of Clinical Phar-macy and Gastroenterology, Maasland Hospital Sittard, Dept of Gastroenterology, Rijnstate Hospital Arnhem.

14.50 NOD2 and Crohn’s disease: healthy homozygous carriers of 3020insC mutation.

(p. 87) K van der Linde, PPC Boor, JJ Houwing-Duistermaat, EJ Kuipers, JHP Wilson, FWM de Rooij. Depts of Gastroenterology and Hepatology, of Internal Medicine and of Epidemiology & Biostatics, Erasmus MC/University Medical Center, Rotterdam.

15.00 More severe course of Crohn’s disease in affected sib-pairs. (p. 88) S Bekkers, J van Dieren, K van der Linde, EJ Kuipers. Dept of Gastroenterology and

Hepatology, Erasmus MC/University Medical Center, Rotterdam. 15.10 Relation between CARD15 (NOD2) frameshift mutation and Vienna Classification in

Crohn’s disease. (p. 89) RC Mallant-Hent, L Murillo, AM Sambuelli, BZ Alizadeh, S Negreira, J Bai, JBA

Crusius, AA van Bodegraven, AS Peña. Dept of Gastroenterology, VU Medical Center, Amsterdam, Lab of Immunogenetics, VU Medical Center, Amsterdam, Laboratory of Cilincal Immunology, VU Medical Center, Amsterdam The Netherlands, Bonorino Udaondo Gastroenterology Hospital Buenos Aires, Argentina.

15.20 The FAS (TNFRSF6) gene polymorphism at position – 670 plays a role in ulcerative

colitis but not in Crohn’s disease. (p. 90) J Wu, B Xia, AA van Bodegraven, JBA Crusius, AS Peña. Laboratory of Immuno-

genetics and Dept. of Gastroenterology, VUMC, Amsterdam, the Netherlands, the Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, China, and the Wuhan University Zhongnan Hospital, Wuhan, China.

14


15.30 Severe fatigue in patients with IBD in remission. (p. 91) IM Minderhoud, B Oldenburg, GP van Berge Henegouwen. Dept of Gastro-

enterology, University Medical Center Utrecht. 15.40 Work disability and sick leave in Dutch patients with Inflammatory Bowel Disease:

results of a population sampled case-control study. (p. 92) A Bonen, PS Dagnelie, A Feleus, MA Hesselink, JW Muris, RW Stockbrügger, M

Russel. Depts of Rheumatology and Gastroenterology University Hospital Maastricht; Epidemiology and General Practice University Maastricht.

15.50 Cytomegalovirus in Inflammatory Bowel Disease: prevalence and consequences for

therapy. (p. 93) DW Hommes, GJ Sterringa, JFL Weel, JFW Bartelsman, WR Boom, SJH van

Deventer. Dept of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam.

16.00 Vervolg IBD programma in de Brabantzaal. (zie p. 8)

17.30 Congresborrel, gesponsord door Byk, en aansluitend diner

Nederlandse Vereniging voor Gastroenterologie Brabantzaal Voorzitter: G.P. van Berge Henegouwen 20.00 Clinical application of the AMC-Bioartifical Liver; a phase I clinical study. (p. 94) M-P van de Kerkhove, E Di Florio, V Scuderi, A Mancini, M Dauri, F Calise, RAFM

Chamuleau. Dept of Experimental Surgery and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, Liver Transplantation Unit Cardarelli Hospital, Naples and St. Eugenio Hospital, Roma, Italy.

20.15 Acute upper gastrointestinal bleeding; did anything change? (p. 95) ME van Leerdam, EM Vreeburg, EAJ Rauws, AAM Geraedts, GNJ Tytgat. Dept of

Gastroenterology, Academic Medical Centre and Onze Lieve Vrouwe Gasthuis, Amsterdam.

20.30 Prospective first year evaluation of ileoanal pouch function with barostat. (p. 96) J Steens, C Penning, J Brussee, WA Bemelman, AAM Masclee. Dept of Gastro-

enterology-Hepatology, Leiden University Medical Center, Leiden, Dept of Surgery, Academic Medical Center, Amsterdam.

20.45 Clinical outcome of patients with combined Budd-Chiari Syndrome and portal vein

thrombosis. (p. 97) JAM Hopmans, PC Groen, EB Haagsma, B van Hoek, TJ Tang, HLA Janssen for

the Liver and Thrombosis Study Group. Dept of Gastroenterology and Hepatology University Hospital Rotterdam, Mayo Clinic and Foundation, Rochester, MN, USA, University Hospital Groningen, Leiden University Medical Center, The Netherlands.

21.00 BYK LECTURE: 'Gastroenterology - back to the future'. (p.) M.J.G. Farthing, Glasgow (p. 98) 21.30 Ledenvergadering Nederlandse Vereniging voor Gastroenterologie.

Voor alle congresdeelnemers: borrel in sport- en recreatievleugel 'De Dommelpoort', aangeboden door AstraZeneca.

15

Vrijdag 22 maart 2002 Casuϊstiek voor de klinikus Brabantzaal Voorzitter: W. Hameeteman 09.00 klinisch casuïstische patiëntenbespreking 09.30 einde casuïstiek

Sectie Gastrointestinale Endoscopie Brabantzaal Voorzitter: J.F.W.M. Bartelsman 09.30 Endoscopic augmentation of the lower esophagel sphincter. Pilot Study of the

Gatekeeper Reflux Repair System ™ in patients with GERD. (p. 99) P Fockens, MJ Bruno, DP Hirsch, A Lei, GE Boeckxstaens, GN Tytgat, Department

of Gastroenterology, Academic Medical Center, Amsterdam. 09.40 Molecular evidence for complete reversal of Barrett’s oesophagus with high-grade

dysplasia following argon plasma coagulation alone or in combination with photo-dynamic therapy. (p. 100)

M Hage, H van Dekken, CJ Vissers, W van de Vrie, J Haringsma, EJ Kuipers, PD Siersema. Depts of Gastroenterology & Hepatology and Pathology, Erasmus MC / University Medical Center, Rotterdam.

09.50 Re-intervention after self-expanding metal stent placement for palliation of eso-

phageal carcinoma. (p. 101) MYV Homs, M van Blankenstein, J Haringsma, EJ Kuipers, PD Siersema. Dept of

Gastroenterology & Hepatology, Erasmus MC/ Erasmus Medical Center Rotterdam. 10.00 Covered metal stents for the treatment of non-malignant perforations of the esopha-

gus. (p. 102) MYV Homs, HW Tilanus, J Haringsma, EJ Kuipers, PD Siersema. Dept of Gastro-

enterology & Hepatology and Surgery, Erasmus MC/University Medical Center Rotterdam.

10.10 Prior radiation and/or chemotherapy for esophageal carcinoma has no effect the out-

come of self-expanding metal stent placement. (p. 103) MYV Homs, BE Hansen, J Haringsma, M van Blankenstein, EJ Kuipers, PD

Siersema. Dept of Gastroenterology & Hepatology, Erasmus MC/University Medical Center Rotterdam.

10.20 Newly developing hiatus hernia (HH) in patients undergoing upper gastrointestinal

endoscopy. (p. 104) RJLF Loffeld, ABMM van der Putten. Dept of Internal Medicine, De Heel - Zaans

Medisch Centrum, Zaandam.

16

vrijdag 22 maart 2002

10.30 Prospective study on the impact of EUS-guided FNA of sub- and supracarinal lymph nodes in patients with distal oesophageal cancer. (p. 105) MA Brink, JJGHM Bergman, M Bruno, WA Marsman, ME Smits, JJB van Lanschot, P Fockens. Dept of Gastroenterology and Surgery, Academical Medical Center Amsterdam.

10.40 Transanal endoscopic microsurgery instead of endoscopic resection of benigne rectal tumours; is there an indication? (p. 106)

R Bakx, ICE Wesdorp, G Brutel, WF van Tets. Depts of Surgery, Gastroenterology and Pathology, Sint Lucas/Andreas Hospital, Amsterdam.

10.50 CT virtual colonoscopy versus conventional colonoscopy for the detection of

colorectal polyps. (p. 107) JM Jansen, MHJ Voormolen, GHA Dodemont, KH Schuur, WNHM Stuifbergen,

AWM van Milligen de Wit. Depts of Internal Medicine and Gastroenterology and Radiology, St. Elisabeth hospital, Tilburg.

11.00 Koffiepauze Symposium “Teaching in Endoscopy” 11.30 Basic Endoscopy Training: use of an improved endoscopic computer simulator.

(p. 108) J Haringsma, SPC Brouwers, EJ Kuipers. Dept of Gastroenterology & Hepatology, Erasmus MC/University Medical Center Rotterdam; Cook Nederland, Son, NL.

11.50 Animal Model in Endoscopy Training.

P Fockens, Dept of Gastroenterology, Academic Medical Center, Amsterdam 12.10 Discussie. 12.30 Lunchbuffet in expositiehal.

17

vrijdag 22 maart 2002 Sectie Experimentele Gastroenterologie Baroniezaal Voorzitters: J.G. Kusters / H.W. Verspaget 09.00 HNF-1α, GATA-4 and Cdx2 functionally interact to simulate sucrase-isomaltase gene

expression.* (p. 109) EHHM Rings, F Boudreau, HM van Wering, GP Swain, SD Krasinski, ER Suh, RJ

Grand, PG Traber. Division of Pediatric Gastroenterology, Dept of Pediatrics, University Hospital Groningen, The Netherlands, Division of Gastroenterology, Dept of Medicine, University of Pennsylvania, Philadelphia, USA, Division of Gastroenterology, Children Hospital of Boston, Harvard Medical School, Boston, USA.

09.10 Similair mechanisms of damage control in small and large intestine?* (p. 110) IB Renes, M Verburg, B de Koning, HA Büller, J Dekker, AWC Einerhand. Erasmus

Medical Center and Sophia Children’s Hospital Rotterdam. 09.20 Serine 60 residue phosphorylation within the Cdx2 activation domain mediates its

trans activation capacity.* (p. 111) EHHM Rings, F Boudreau, JK Taylor, J Moffett, ER Suh, PG Traber. Division of

Pediatric Gastroenterology, Dept of Pediatrics, Academic Hospital Groningen, The Netherlands, Division of Gastroenterology, Dept of Medicine, University of Pennsylvania, Philadelphia, USA.

09.30 Transcriptonal activation of the murine Muc5ac mucin gene by Sp1, Smad4 and

GATA-4.* (p. 112) I van Seuningen, M Sutmuller, A Velghe, M-P Ducourouble, M-P Buisine, J-P Aubert,

HA Büller, J Dekker, AWC Einerhand. Unité INSERM 377, Lille, France, Lab Pediatrics, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands.

09.40 Identification of Helicobacter pylori virulence factors by random mutagenesis. (p. 113) R de Jonge, D Bakker, SCL Langeveld, RGJ Pot, EJ Kuipers, AHM van Vliet, CMJE

Vandenbroucke-Grauls, JG Kusters. Dijkzigt University Hospital, Rotterdam, Vrije Uni-versiteit Amsterdam.

09.50 MUC5AC is the primary receptor for H. pylori in human stomach.* (p. 114) JHB van de Bovenkamp, AM Korteland-Van Male, T Boren, HA Büller, AWC

Einerhand, J Dekker. Laboratory Pediatrics and Sophia Children’s Hospital, Rotter-dam, The Netherlands and Dept Odontology/Oral microbiology, Umea, Sweden.

10.00 Proliferative kinetics and histological damage of the intestinal epithelium after rotavirus

infection in mice.* (p. 115) JA Boshuizen, J Reimerink, AM korteland-van Male, VJJ van Ham, M. Koopmans, HA

Büller, J Dekker, AWC Einerhand. Erasmus Medical Center, lab Pediatrics/Sophia Children’s Hospital, Rotterdam. National Institute of Public Health and the Environ-ment, Bilthoven.

10.10 MUC2 deficiency in IL10 knock out mice both before and after induction of colitis by

commensal bacteria.* (p. 116) MK Makkink, NJ Schwerbrock, M van der Sluis, HA Büller, RB Sartor, AWC

Einerhand, J Dekker. Lab Pediatrics, Erasmus University and Sophia Children’s Hospital, Rotterdam, The Netherlands, Division Digestive Diseases, University North Carolina, Chapel Hill NC, USA.

18


10.20 LPS Binding Protein (LBP) mediates LPS detoxification by Chylomicrons; a potential defense mechanism of the intensine against bacterial toxins. (p. 117)

A Vreugdenhil, C Rousseau, T Hartung, C van ‘t Veer, J-W Greve, W Buurman. Dept of Surgery, Maastricht University, The Netherlands, Dept of Biochemical Pharmacology, University of Konstanz, Germany.

10.30 Prevention of duodenal bacterial overgrowth decreases the rate of secondary

pancreatic infection in rats. (p. 118) ID van Felius, LMA Akkermans, A Verheem, W Harmsen, MR Visser, HG Gooszen. Universitair Medisch Centrum Utrecht, afdeling Heelkunde en Microbiologie. 10.40 In the absence of intestinal mucin MUC2 mice are more susceptible to dextran sodium

sulfate-induced colitis.* (p. 119) M van der Sluis, MK Makkink, M Sutmuller, HA Buller, J Dekker, LH Augenlicht, A

Velcich, AWC Einerhand. Laboratory of Pediatrics, Erasmus MC / Sophia Children’s Hospital, Rotterdam, The Netherlands, Dept Oncology, Albert Einstein College, New York, USA.

10.50 Improved survival from severe DSS-induced colitis of transgenic Cu/Zn-SOD

overexpressing mice. (p. 120) L Kruidenier, ME van Meeteren, I Kuiper, CBHW Lamers, HW Verspaget. Dept of

Gastroenterology-Hepatology, Leiden Universitary Medical Center, Dept. of Pharma-cology, Erasmus University Rotterdam.

11.00 Koffiepauze. 11.30 VAN FUNDAMENT TOT KLINIEK

NWO-MW Werkgemeenschap Darmfunctie ontmoet de Experimentele Gastroenterologie.

Voorzitters: J.B.M.J. Jansen en H.W. Verspaget Celiac Disease: a functional genomics approach to define molecular pathways. Dr. T.N. Wijmenga, Afdeling Medische Genetica, UMCU / WKZ, Utrecht.

Cystic Fibrosis and Secretory Diarrhea: search for pharmacological therapies. Dr. H.R. de Jonge, Afdeling Biochemie, EMCR / EU, Rotterdam.

12.30 Lunchbuffet expositiehal.

19

vrijdag 22 maart 2002 Nederlandse Vereniging voor Gastroenterologie Zaal 80 Voorzitter: J.W. Greve en J.H. Kleibeuker 09.00 Decision analysis in the surgical treatment of colorectal cancer due to a mismatch

repair gene defect. (p. 121) WH de Vos, E Buskens, P van Duijvendijk, JH Kleibeuker, FH Menko, G Griffioen, FM Nagengast, BG Taal, F. Slors, HF Vasen. Leiden University Medical Center, Dept of Clinical Epidemiology, Utrecht, Amsterdam Medical Center, Groningen University Hospital, VU Medical Center, Amsterdam, Nijmegen University Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands Foundation for the Detection of Hereditary Tumors, Leiden.

09.10 'Planned relaparotomy' or 'relaparotomy on demand' in secondary peritonitis: a meta-

analysis of observational studies. (p. 122) B Lamme, MA Boermeester, JWO van Till, JB Reitsma, H Obertop, DJ Gouma, Dept

of Surgery and Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam.

09.20 Small and multiple gallstones are major risk factors for acute biliary pancreatitis.

(p. 123) NG Venneman, MGH Besselink, PMNYH Go, K Bosscha, HG Gooszen, GP van Berge Henegouwen, KJ van Erpecum. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center Utrecht, Dept of Surgery, St. Antonius Hospital Nieuwegein.

09.30 PRS1 mutations in chronic pancreatitis: is the A16V mutation important? (p. 124)

M. Verlaan R Te Morsche, JBMJ Jansen, JPH Drenth; Dept. of Gastroenterology and Hepatology UMC St. Radboud, Nijmegen

09.40 Pancreaticoduodenectomy for palliative treatment of pancreatic cancer. (p. 125) KFD Kuhlmann, SMM de Castro, ORC Busch, TM van Gulik, H Obertop, DJ Gouma.

Academic Medical Center Amsterdam, Dept of Surgery. 09.50 Survival after surgical treatment of 402 patients with pathology proven pancreatic

adenocarcinoma and analysis of prognostic factors for survival. (p. 126) KFD Kuhlmann, SMM de Castro, ORC Busch, TM van Gulik, H Obertop, DJ Gouma.

Academic Medical Center Amsterdam. 10.00 Sporadic and syndromic fundic gland polyps: differences in proliferation, apoptosis

and expression of β-catenin. (p. 127) M Jalving, JJ Koornstra, W Boersma-van Ek, S de Jong, A Karrenbeld, H Hollema,

EGE de Vries, JH Kleibeuker. Depts of Gastroenterology, Medical Oncology and Pathology, University Hospital Groningen.

10.50 ECF-chemotherapy (epi-adriamycin, cisplatin and continuously 5-FU) in advanced

cancer of the stomach and gastro-esophageal junction (GEJ). (p. 128) SH Tonino, BG Taal, A Cats, R Dubbelman, HM Zuetenhorst, P Kuijer, H Boot. Dept

of Gastroenterology, Netherlands Cancer Institute / Antoni van Leeuwenhoek Hospital, Amsterdam.

20


10.20 Outcome of patients with esophageal carcinoma and suspicious truncal nodes as

determined by endoscopic ultrasonography. (p. 129) WA Marsman, M van Wissen, JJGHM Bergman, GNJ Tytgat, P Fockens. Dept of

Gastroenterology, Academic Medical Center Amsterdam. 10.30 The prognostic significance of elevated Cyclooxygenase-2 expression in patients with

adenocarcinoma of the esophagus. (p. 130) CJ Buskens, BP van Rees, GJA Offerhaus, PJ Bosma, A Ristimäki, JJB van

Lanschot. Depts of Surgery, Pathology and Experimental Hepatology, Academic Medical Center/University of Amsterdam, The Netherlands, Dept of Pathology, Helsinki University Central Hospital and Molecular and Cancer Biology Research Program, Finland.

10.40 Oesophageal cancer does not affect survival of patients with Barrett’s oesophagus. (p.

131) M Hage, H van Dekken, PD Siersema, EW Steyerberg, EJ Kuipers, J Dees. Depts of Gastroenterology & Hepatology, Pathology and Public Health, Erasmus MC / University Medical Center Rotterdam.

10.50 Staging procedures and treatment strategies for patients with esophageal carcinoma:

a survey in the Netherlands. (p. 132) MYV Homs, EW Steyerberg, HW Tilanus, A van der Gaast, J Haringsma, EJ Kuipers,

PD Siersema. Depts of Gastroenterology & Hepatology, Public Health, Surgery and Internal Oncology, Erasmus MC / University Medical Center, Rotterdam.

11.00 Koffiepauze Voorzitters: J.W. Greve en P.D. Siersema 11.30 Fas Ligand expression in sporadic and hereditary nonpolyposis colorectal adenomas

and carcinomas and the correlation with apoptosis. (p. 133) JJ Koornstra, FEM Rijcken, W Boersma-van Ek, H Hollema, EGE de Vries, S de Jong,

JH Kleibeuker. Depts of Gastroenterology, Pathology and Medical Oncology, University Hospital Groningen.

11.40 Germline mismatch repair gene mutations in patients with multiple HNPCC-related

tumors. (p. 134) MJW Brends, Y Wu, H Hollema, RH Sijmons, EGE de Vries, CHCM Buys, AGJ van

der Zee, RMW Hofstra, JH Kleibeuker. Depts of Gastroenterology, Medical Genetics, Pathology, Medical Oncology and Gynecology, University Hospital, Groningen.

11.50 SKY, chromosome CGH and array CGH analysis of two types of epithelial tumors:

squamous cell carcinoma versus adenocarcinoma. (p. 135) M Hermsen, A Snijders, MA Guervos, S Tanzer, J Baak, D Pinkel, D Albertson, G

Meijer, E Schrock. Dept Pathology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands, UCSF Comprehensive Cancer Center, San Francisco, CA, USA; Institut fur Medizinische Genetik, Humboldt University, Berlin, Germany.

12.00 Restriction of amplicon boundaries at 20q13 by microarray based comparative

genomic hybridization in human gastric cancer. (p. 136) MM Weiss, AM Snijders, EJ Kuipers, B Ylstra, D Pinkel, SGM Meuwissen, D

Albertson. GA Meijer. Depts of Gastroenterology, Pathology and Microarray Core Facility, VU University Medical Center, Amsterdam, The Neterlands, University of California San Francisco, California, USA, Dept of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.

21

vrijdag 22 maart 2002 12.10 Phenotypical differences in T-lymphocytes of non-coeliacs and refractory coeliacs;

association with Enteropathy Associated T cell Lymphoma. (p. 137) MS Goerres, CJJ Mulder, JAM Kerckhaert, H van Dijk. Dept of Gastroenterology and

Immunology, Rijnstate Hospital Arnhem, Dept of Immunology, Eemland Hospital Amersfoort.

12.20 Clinical and pathological features of pancreatic carcinomas in carriers of a specific 19

deletion of p16 (p16-Leiden). (p. 138) WH de Vos, GJA Offerhaus, M van Puijenbroek, E Caspers, N Gruis, F de Snoo, G

Griffioen, W Bergman, HFA Vasen, H. Morreau. Leiden University Medical Center, Dept of Gastroenterology, Pathology, Dermatology and Dept of Clinical Genetics, Academic Medical Center Amsterdam, Dept of Pathology, Netherlands Foundation for the Detection of Hereditary Tumours, Leiden.

12.30 Lunchbuffet Sectie Maag-darmmotoriek Parkzaal Voorzitter: A.A.M. Masclee 09.00 Effect of caffeine and nicotine on rectal tone and sensitivity. (p. 139) CEJ Sloots, RL West, RJF Felt-Bersma, EJ Kuipers. Dept of Gastroenterology and

Hepatology, Erasmus MC/University Medical Center, Rotterdam. 09.10 Fluoxetine (Prozac) for the treatment of Irritable Bowel Syndrome: a randomized,

controlled clinical trial. (p. 140) SD Kuiken, P Burgers, GNJ Tytgat, G Boeckxstaens. Dept of Gastroenterology and

Hepatology, Academic Medical Center, Amsterdam. 09.20 Studying gastrointestinal motility, allexythimia, psychological profile and quality of life

(QOL) in patients with irritable bowel syndrome (IBS). (p. 141) P Portincasa, A Moschetta, V Causarano, DF Altomare, G Palasciano. Chair of

Semeiotica Medica and Section of Internal Medicine, Section of Internal Medicine, Dept Internal and Public Medicine (DIMIMP), Section of Surgery, Dept Emergency Organ Transplant (DETO), University Medical School, Bari, Italy.

09.30 Effect of neurotensin on colo-rectal motor and sensory function. (p. 142) EDCM Schots, PPJ van der Veek, AAM Masclee. Dept of Gastroenterology-Hepa-

tology, Leiden University Medical Center, Leiden, The Netherlands. 09.40 In search of objective manometric criteria for colonic high-amplitude propagated

contractions. (p. 143) AMP de Schryver, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of

Gastroenterology and Surgery, University Medical Center Utrecht. 09.50 Fully automated analysis of prolonged ambulatory colonic manometry recordings.

(p. 144) AMP de Schryver, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of Gastroenterology and Surgery, University Medical Center Utrecht.

10.00 Functional Non-Retentive Fecal Soiling (FNRFS) in children: 10 years of follow up.*

(p. 145) WP Voskuijl, F de Lorijn, R van Ginkel, MP van Wijk, JA Taminiau, MA Benninga. Dept of Pediatric Gastroenterology and Nutrition, Academic Medical Center, Amsterdam.

22


10.10 The value of diagnostic tests in Hirschsprung’s disease.* (p. 146) F de Lorijn, WP Voskuijl, DC Aronson, FJ ten Kate, JB Reitsma, AM Smets, JA

Taminiau, MA Benninga. Depts of Pediatric Gastroenterology and Nutriton, Pediatric Surgery, Pathology, Clinical Epidemiology and Biostatistics, Radiology, Emma Children’s Hospital/Academic Medical Center, Amsterdam.

10.20 Maturation of the rectoanal inhibitory reflex in very premature.* (p. 147) F de Lorijn, TI Omari, JAJM Taminiau, MA Benninga. Dept of Pediatric Gastroentero-

logy and Nutrition, Emma Children’s Hospital/Academic Medical Center, Amsterdam, The Netherlands, Gastroenterology Unit, Women’s and Children’s Hospital, North Adelaide, Australia.

10.30 The effect of acute tryptophan depletion on gastric emptying and gastric myoelectrical

activity. (p. 148) MA van Nieuwenhoven, SDM Valks, WJ Riedel, R-JM Brummer. Depts of

Gastroenterology and Psychiatry & Neuropsychology, University Hospital Maastricht. 10.40 3-Dimensional ultrasonographic measurements of gastric volume in healty volunteers;

Gastric distribution in relation to sensations. (p. 149) MW Mundt, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of

Gastroenterology and Surgery, University Medical Center, Utrecht. 10.50 The effect of different drinks on the occurrence of gastrointestinal complaints during

running: A randomized controlled field study. (p. 150) MA van Nieuwenhoven, F Brouns, EMR Kovacs. Depts of Gastroenterology and

Human Biology, Maastricht University. 11.00 Koffiepauze 11.30 Octreotide affects gastric motor and sensory function after chemical but not after

mechanical stimulation. (p. 151) P Verbeek, PPJ van der Veek, C Penning, AAM Masclee. Dept of Gastroenterology-

Hepatology, Leiden University Medical Center. 11.40 Motor function of the proximal stomach in intestinal metaplasia of the esophagogastric

junction and in Barrett’s esophagus. (p. 152) YIP Ackermark, JMM Roelofs, R Timmer, C Wolf, CA Seldenrijk, R Breumelhof, AJPM

Smout. Dept of Gastroenterology, Pathology, St. Antonius Hospital, Nieuwegein. Dept of Gastroenterology, Diakonessenhuis, Utrecht. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center Utrecht.

11.50 Neuro-immune interaction in manipulated intestine triggers an adrenergic inhibitory

pathway maintaining prolonged postoperative ileus. (p. 153) WJ de Jonge, RM van den Wijngaard, RJ Bennink, SJ van Deventer, GE

Boeckxstaens. Dept of Gastroenterology and Hepatology & Dept of Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands.

12.00 Influence of motilin on the proximal stomach in patients with functional dyspepsia.

(p. 154) IMC Kamerling, AD van Haarst, I Biemond, H Heinzerling, R Jones, HC Schoenmaker, AF Cohen, AAM Masclee. Centre for Human Drug Research, Leiden, Dept of Gastroenterology, Leiden University Medical Center, The Netherlands, R.W. Johnson Pharmaceutical Research Institute, High Wycombe, United Kingdom.

12.10 Motor events underlying incomplete oesophageal bolus transport in healthy volun-

teers. (p. 155) BLAM Weusten, LMA Akkermans, AJPM Smout. Depts of Gastroenterology and

Surgery, University Medical Center Utrecht.

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vrijdag 22 maart 2002 12.20 The pressure inversion point revisted. (p. 156) AJ Bredenoord, A Baron, JMM Roelofs, BLAM Weusten, AJPM Smout. Gastro-

intestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht, The Netherlands.

12.30 Simultaneous gastroesophageal high-resolution manometry, pH metry and gastric

volume assessment by 3D ultrasound in healthy subjects. (p. 157) RCH Scheffer, M Samsom, GS Hebbard, AJPM Smout, HG Gooszen. Gastrointestinal

Research Unit, Depts of Gastroenterology en Surgery, University Medical Center Utrecht, The Netherlands, Dept of Medicine, Repatriation General Hospital, Daw Park, Australia.

12.40 Lunch Nederlandse Vereniging voor Hepatologie Auditorium

‘Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis’ Chairs: J.W. den Ouden-Muller, H.R. van Buuren. 09.30 The natural history of PBC; results of 10-yr Dutch follow-up study P.C.J. ter Borg, Erasmus MC, Rotterdam 09.50 Fatique and depression in PBC: major (neglected ) issues D.E.J. Jones, Centre for Liver Research, School of Clinical Med. Sciences, Newcastle upon Tyne, UK 10.15 PBC variant syndromes F.P. Vleggaar, Medical Center Haaglanden, Den Haag. 10.35 Coffee break 11.00 Medical treatment of PSC: what has been achieved? K.J. van Erpecum, University Medical Center, Utrecht. 11.20 Endoscopic treatment of PSC: who, why, when, how? A. Stiehl, University of Heidelberg, Germany. 11.45 PSC-like syndromes H.R. van Buuren, Erasmus MC, Rotterdam 12.05 Closure

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vrijdag 22 maart 2002 Sectie Experimentele Gastroenterologie Baroniezaal Voorzitters: I. Biemond, M.A.C. Meijssen 13.30 A Helicobacter pylori stress-induced locus shows genetic variation among clinical

strains. (p. 158) N de Vries, EJ Kuipers, EM van Ark, CMJE Vandenbroucke-Grauls, JG Kusters. Dept

of Gastroenterology and Hepatology, Dijkzigt University Hospital Rotterdam, Dept of Medical Microbiology, Faculty of Medicine, Vrije Universiteit Amsterdam.

13.40 Selective gene transfer into human gastric tumors using adenoviral vectors with

ablated native tropism targeted towards EpCAM. (p. 159) DAM Heideman, VW Beusechem, GJA Offerhaus, TJ Wickham, PW Roelvink, ME

Craanen, HM Pinedo, CJLM Meijer, WR Gerritsen. Dept of Medical Oncology, Division of Gene Therapy, Gastroenterology, Pathology, VU Medical Center, Amsterdam The Netherlands; Dept of Pathology, Academic Medical Center, Amsterdam, The Netherlands; GenVec Inc., Gaithersburg, MD, USA

13.50 Sphingomyelin offers protection against apoptosis and hyperproliferation induced by

the hydrophobic bile salt deoxycholate: potential implications for colon cancer. (p. 160) A Moschetta, P Portincasa, KJ van Erpecum, L Debellis, GP van Berge Henegouwen,

G Palasciano. Section of Internal Medicine, Dept of Internal and Public Medicine, University Hospital Bari, Italy, Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht The Netherlands; Dept of General and Ambiental Physiology, University of Bari, Italy.

14.00 Gene therapy for esophageal carcinoma: the use of an explant model to test

adenoviral vectors ex vivo. (p. 161) WA Marsman, CJ Buskens, GJA Offerhaus, JG Wesseling, JJGHM Bergman, GNJ

Tytgat, JJB van Lanschot, PJ Bosma. Dept. of Experimental Hepatology, Gastro-enterology, Pathology and Surgery, Academic Medical Center, Amsterdam.

14.10 Radioimmunotherapy for peritoneal carcinomatosis of colorectal origin; the cha-

racterisation of an experimental model. (p. 162) MJ Koppe, A Soede, WJG Oyen, RP Bleichrodt, OC Boerman. Depts of Surgery and

Nuclear Medicine, University Medical Centre Nijmegen. 14.20 High inducible nitric oxide synthase (iNOS) induction and increased FAS expression in

colonic enterocytes in the CD45RBhigh transfer model of colitis in monoassociated SCID mice. (p. 163)

NA Bos, G Dijkstra, JCAM Bun, GJ Geersing, H van Goor, HQ Jiang, N Kushnir, MC Thurnheer, JJ Cebra. Dept of Cell Biology, Histology and Immunology Section, University of Groningen, The Netherlands, Dept of Gastroenterology and Pathology, Academic University Hospital Groningen and Dept of Biology, University of Pennsylvania, Philadelphia.

14.30 Immunostimulated colonic explant cultures as a model for Inflammatory Bowel

Disease. (p. 164) MJW Meijer, MAC Mieremet-Ooms, W van Duijn, JM van der Zon, CBHW Lamers, HW Verspaget. Dept of Gastroenterology-Hepatology, Leiden University Medical Centre.

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vrijdag 22 maart 2002 14.40 A possible mechanism for the difference in efficacy of infliximab and etanercept in the

treatment of Crohn’s disease. (p. 165) JMH van den Brande, H Braat, GR van den Brink, I Hoedemaeker, MP

Peppelenbosch, SJH van Deventer. Academical Medical Center AMC, Amsterdam. 14.50 The response of TNF-α producing cells to infliximab exposure. (p. 166)

Q Gao, JM van der Zon, RA van Hogezand, MJW Meijer, CBHW Lamers, HW Verspaget. Dept of Gastroenterology and Hepatology, Leiden University Medical Center.

15.00 Theepauze 15.20 Concurrent Pseudomonas aeruginosa pneumonia aggravates acute cerulein-induced

pancreatitis in mice. (p. 167) DJ van Westerloo, M Schultz, S Knapp, SJH van Deventer, MJ Bruno, S Florquin, T van der Poll Intensive Care Geneeskunde, Experimentele Interne Geneeskunde, Maag-, Darm en Leverziekten; Academisch Medisch Centrum, Pathologie, Academisch Medisch Centrum, Amsterdam.

15.30 Expression of amidase- and urease-mediated ammonia production in Helicobacter

pylori is modulated by Fur. (p. 168) AHM van Vliet, J Stoof, SW Poppelaars, EJ Kuipers, JG Kusters. Dept of Gastro-

enterology and Hepatology, L-481, Academic Hospital Dijkzigt, Rotterdam. 15.40 Mucosal expression of motilin receptor mRNA and protein in humans. (p. 169)

WP ter Beek, ESM Muller, M van den Berg, I Biemond, CBHW Lamers. Dept of Gastroenterology-Hepatology, Leiden University Medical Center.

15.50 Incorporation of cholesterol in sphingomyelin-egg yolk phosphatidylcholine vesicles has profound effects on detergent-induced phase transitions: a time-course study by cryo-transmission electron microscopy. (p. 170)

A Moschetta, PM Frederik, P Portincasa, GP van Berge Henegouwen, KJ van Erpecum. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht, Section of Internal Medicine, Dept of Internal Public Medicine, University Hospital Bari, Italy; Dept of Electron Microscopy, Maastricht University, The Netherlands.

16.00 Acute cerulein-induced pancreatitis develops independently of Toll Like Receptor 4

(TLR4) in mice. (p. 171) DJ van Westerloo, S Florquin, JW van Till, SJH van Deventer, MJ Bruno, T van der Poll. Depts of Pathology, Surgery, Gastroenterology and Experimental Internal Medicine, Academic Medical Center, Amsterdam.

16.10 The Helicobacter pylori regulatory protein NikR is a nickel-responsive activator. (p.172) SW Poppelaars, J Stoof, EJ Kuipers, JG Kusters, AHM van Vliet. Dept of Gastro-

enterology and Hepatology, Academic Hospital Dijkzigt, Rotterdam. 16.20 Implications for decreased ion and water uptake and increased epithelial protection

and repair in experimental colitis.* (p. 173) IB Renes, M Verburg, DJPM van Nispen, HA Büller, J Dekker, AWC Einerhand.

Erasmus Medical Center and Sophia Children’s Hospital Rotterdam. 16.30 Einde programma.

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Symposium Nederlandse Vereniging voor Gastroenterologie Parkzaal

Chemotherapie en chemoradiotherapie in de gastrointestinale oncologie: controversieel of standaard?

Voorzitter: H. Boot / J.H.Kleibeuker 14.00 Aanvang programma Oesophagus carcinoom: de plaats van inductie/neoadjuvante chemo-/radiotherapie. Inleiders: Dr. K. Haustermans, Afd. Radiotherapie, Katholieke Universiteit Leuven, België Prof. dr. N.H. Mulder, Afd. Medische Oncologie, Academisch Ziekenhuis Groningen Colorectaal carcinoom: wanneer welke palliatieve chemotherapie. Inleiders: Dr. W.W. ten Bokkel Huinink, Afd. Medische Oncologie, NKI / Antoni van Leeuwen-

hoek Ziekenhuis, Amsterdam Prof. dr. C. Punt, Afd. Medische Oncologie, Universitair Medisch Centrum St. adboud,

Nijmegen 16.00 Einde symposium

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vrijdag 22 maart 2002 Maag Lever Darm Stichting Auditorium Eindpresentaties Wetenschappelijk Onderzoek Voorzitter: Dr. W. Dekker 14.00-14.20: The ontogeny of hepatobiliary copper transport in rats: involvement of a newly identified canalicular ATP-dependent transport system (cCOP).

Projectleiders: prof. dr. R.J. Vonk Presentatie: dr. H. Roelofsen Instelling: Institute for Drug Studies, AZG te Groningen Projectnummer: WS96-70

14.20-14.40 Helpt lichamelijke activiteit bij idiopathische obstipatie

projectleiders: prof. dr. G.P. van Berghe Henegouwen Presentatie: drs. A. de Schruyver Instelling: Universitair Medisch Centrum, afd. Maag darm leverziekten Projectnummer: 98-01

14.40-15.00 Identificatie van de genetische basis van aangeboren afwijkingen van de slokdarm en twaalfvingerige darm?

Projectleiders: dr. J.H.L.M van Bokhoven en prof.dr. H.G. Brunner Presentatie: Instelling: Academisch Ziekenhuis Nijmegen, afd. Anthropogenica Projectnummer: 97-81

15.00-15.20 Gentherapie voor de behandeling van cholangiocarcinomen door toediening vn adenovirus vectoren die Apoptin tot expressie geven

Projectleiders: dr. J.G. Wesseling / prof.dr.Huibregtse Presentatie: Instelling: Academisch Medisch Centrum afd. Gastroenterologie Projectnummer: 98-06

15.20-15.40 Coeliakie op weg naar immunotherapie

Projectleiders: dr. F. Koning en dr. M.L. Mearin Presentatie: Instelling: LUMC, VU Instituut Immunologie en Ontsteking Projectnummer: 98-24

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Sectie Endoscopie Assistenten Brabantzaal Voorzitter: T. Mestrom 13.30 Algemene ledenvergadering 14.00 Dr. J.J.J. de Sonnaville

Internist / Endocrinoloog Ziekenhuis Hilversum “Diabetes en endoscopie, een goede voorbereiding noodzakelijk”

14.20 Mw. C. de Jong Verpleegkundige endoscopieafdeling LUMC

"Oesophagus manometrie" 14.40 Theepauze 15.00 Mw. S. Lahey

Verpleegkundige endoscopieafdeling Rijnstate Ziekenhuis Arnhem “Endoscopische behandeling van het Zenkers divertikel “

15.20 Mw. M. van Wyk Voorzitter van de South African Gastro Intestinal Nursing Society.

"Endoscopy in Southern Africa”

15.40 Mw. M. Nooyen Leidinggevend endoscopie verpleegkundige AZ Dijkzigt Rotterdam “ Endoscopische Suture techniek, ervaringen uit de praktijk.”

16.00 Einde programma Sectie Endoscopie Assistenten

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Exercise tonometry for successfull treatment of suspected GI ischaemia; analysis of 152 cases. AS van Petersen, RH Geelkerken, AB Huisman, JJ Kolkman. Dept of Surgery, Radiology and Gastroenterology, Medisch Spectrum Twente, Enschede. Recently gastric tonometry during exercise (GTE) has been validated to diagnose chronic splanchnic ischaemia (CSI). In our clinic, the workup of CSI includes GTE, duplex and angiography. We investigated the additional value of GTE in our patient population. In the period July 1996 - August 2001, 176 patients with otherwise unexplained chronic abdominal complaints were referred. After independent evaluation by a gastroenterologist and vascular surgeon 152 patients remained in whom CSI was suspected. Using abdominal angiography and duplex ultrasound, 60 patients (pts) with a stenosis of more than 50% in the coeliac artery or superior me-senteric artery were identified. 3-vessel stenosis (3 pts): all 3 pts had an abnormal GTE (100%). Two pts died, quetelet index (QI) 16.2±0.9 shortly after vascular reconstruction. One patient (pt) was symptom free after PTA with stenting (QI 20.0). 2-vessel stenosis (25 pts): Fifteen had abnormal GTE and were revascularised. Three died postoperatively, 12 had disappearance of symptoms. Three of 10 pts with a normal GTE were revascularisated because of 'typical' history and angiography. In 1/3 the complaints persisted. 1-vessel stenosis (32 pts): Twenty pts had an abnormal GTE (66%). Fourteen of 20 pts are successfully revascularisated. In 1 pt abdominal complaints persisted because of inadequate stent placement. One of 12 pts with a normal GTE was revascularisated with no effect on abdominal complaints. No stenosis (92 pts): Nine pts had an abnormal GTE (10%). Seventy-eight pts had a normal GTE (85%). In 5 pts GTE could not be performed. None of the pts underwent revascularisation. In patients with an abnormal GTE, complaints disappeared in 96% (26/27 pts) of the cases after reconstruction. In pts with a normal GTE who underwent revascularisation abdominal complaints persisted in 50% (2/4 pts) of patients. Overall mortality after revascularisation was 16% (5/32 pts), which in retrospect can be partly explained by cachexia in these patients (in 3/5 pts, QI < 17). Conclusion: Selection of patients for revascularisation based on GTE resulted in high success rates with disappearance of abdominal complaints. The mortality after revascularisation in cachectic patients was high, PTA should be considered as an alternative. GTE has a role in preoperative analysis of patients suspect for CSI.

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Enhanced anti-tumor efficacy by combining conventional chemotherapy with angiostatin or endostatin in a murine liver metastasis model. EA te Velde, JM Vogten, M. Gebbink, EE Voest, IHM Borel Rinkes. Dept of Surgery and Medical Oncology, University Medical Center Utrecht.

Strategies targeting both tumor cells and vasculature have not been thoroughly investigated in models of early metastatic colorectal disease. We have studied the efficacy of combinations of con-ventional chemotherapy with endostatin or angiostatin (both currently tested in clinical trials) in a murine model of early colorectal liver metastases. Control mice received solvent (PBS or citrate). Conventional chemotherapy consisted of adriablastin in a suboptimal dose of 10mg/kg iv.. Angiostatin, generated from human plasma, was given continuously in high and low dose (HD-A 100mg/kg/d and LD-A 10mg/kg/d, respectively). Endostatin (Entremed®) was given sc. (500 mg/d). Sixty-two mice were subjected to intrasplenic injection of C26 tumor cells to induce colorectal liver metastases. Treatment was initiated 6 hours postoperatively and consisted of single agent, or chemotherapy combined with either angiostatin or endostatin (n>5 per group). Clinical appearance was scored daily using a semi-quantitative scale. Liver weight, macroscopic and histological tumor involvement (hepatic replacement area, HRA) were measured upon sacrifice at day 12. ANOVA was performed to calculate the interaction effects between agents. A multiplicative effect was defined as an enhanced effect of anti-angiogenic therapy in the presence of chemotherapy, or visa-versa. Mice treated with either drug displayed significantly better clinical scores than controls, except for LD-A or its com-bination with chemotherapy. All single agent drugs were superior in anti-tumor efficacy compared to no treatment (p<0.001).The treatment of liver metastases with adriablastin mono-therapy resulted in a decrease in hepatic replacement area from 42.3±2.0% (non-treated controls) to 29.1%±0.9% (p<0.001). HD-A resulted in a HRA of 8.6±2.6% (p<0.001). LD-A resulted in a hepatic replacement area of 27.2±0.98% (p<0.001). The addition of HD-A and LD-A to the conventional chemotherapy resulted in HRA’s of 3.3±1.4% and 8.7±0.7%, respectively. HD-A added to conventional chemotherapy was not significantly more effective than HD-A alone. However, LD-A combined with conventional chemotherapy significantly enhanced anti-tumor efficacy when compared to LD-A alone (p<0.001). When compared to chemotherapy alone the effect of addition of

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angiostatin was multiplicative. Endostatin mono-therapy resulted in a HRA of 12.4±1.4%. Addition to the conventional chemotherapy further reduced hepatic tumorload ta a HRA of 3.8±1.1% (p<0.001). Again, the effect of co-administration of the anti-angiogenic agent and conventional chemotherapy was multiplicative (p=0.017). Conclusion: The addition of angiostatin or endostatin to conventional chemotherapy enhances anti-tumoral efficacy in a multiplicative manner in a murine model of early colorectal liver metastases.

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Endoscopic balloon dilatation of symptomatic intestinal strictures in Crohn's disease: a long-term analysis. G Dijkstra, FTM Peters, JH Kleibeuker, HM van Dullemen, AJ Limburg. Dept of Gastroenterology and Hepatology, University Hospital, Groningen.

Background: Intestinal stricture formation is a common complication of Crohn's disease. Especially fibrous strictures do not respond to anti-inflammatory therapy and can be an indication for resection or strictureplasty. However, strictures commonly recur leading to repeated operations. Endoscopic balloon dilatation has been advocated as an efficacious and safe alternative for surgery. Aim: To study the long-term efficacy and safety of endoscopic balloon dilatation of symptomatic intestinal strictures in Crohn's disease. Methods: From 1992 till 2001 we performed 32 "through the scope" balloon dilatations (rigiflex/ c.r.e, balloon diameter 15-20 mm, balloon length 5-8 cm) of 20 intestinal strictures (colonic strictures 8, ileocolonic anastomosis 9, colocolonic anastomosis 3) in 16 Crohn's disease patients (9 male, 7 female, mean age 40 yr. (range 22-66). The dilatations were performed as an outpatient procedure using conscious sedation. Results: Endoscopic balloon dilatation was technically successful in 30 of the 32 procedures (94%), with scope passage in 87 % of the cases. One patient (3%) had an acute operation because of a perforation. Another 44 % (7/16) needed surgery because of persistent or recurrent symptoms (mean follow up 11 months (range 0-24)). Long-term relieve of symptoms without surgery was seen in 56 % (9/16) of the patients (mean follow up 46 months (range 19-91)). Five patients were asymptomatic after 1 and 4 patients after 2-3 dilatation sessions. Conclusion: Endoscopic balloon dilatation can offer long-term relieve in 56 % of Crohn's disease patients with symptomatic intestinal strictures with a low risk (3% perforations) of procedure related complications.

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Outcome of surgery for peptic ulcer hemorrhage ME van Leerdam, HI Bax, EAJ Rauws, GNJ Tygat, JJB van Lanschot. Dept of Gastroenterology and Surgery, Academic Medical Centre, Amsterdam Peptic ulcer hemorrhage remains an important medical emergency. The role of surgical intervention has dramatically changed. This study analysed the outcome of surgical intervention among ulcer hemorrhage patients. The records of patients with surgery for non-malignant ulcer hemorrhage in the Academic Medical Centre in the period 1988-2001 were retrospectively reviewed. Sixty-three patients were identified, 41 male, median age 69 years (range 25-91). Eleven patients (17%) had a gastric, 51 (81%) a duodenal and one an anastomotic ulcer. Sixteen patients (25%) used NSAID´s prior to the bleeding and 33 patients (52%) had severe or life-threatening comorbidity. Twenty-one patients (33%) underwent surgery for a first bleeding episode, 41 patients (65%) because of rebleeding. Semi-elective surgery was performed in one patient (2%). In 58 patients (92%) conservative (intraluminal stitch ligatures and/or extraluminal ligation) was performed, 5 patients (8%), had conventional surgery (Billroth I or II). Rebleeding after surgery occurred in 17 patients (27%) and 13 patients (21%) needed a second operation. There was no difference in rebleeding between different types of surgery. Mortality rate was 37%. Comorbidity and spurting bleeding at initial endoscopy were factors significantly contributing to mortality by multivariate analysis. Age, shock at the time of surgery, ulcer size, type of surgery, number of rebleeds and endoscopies prior to surgery did not contribute significantly to mortality. In only 10 of the surviving patients (26%) diagnostic tests for H. pylori infection were performed. Conclusions Conservative surgery was most frequently performed for ulcer hemorrhage. Rebleeding after surgery and mortality were substantial. Comorbidity and spurting bleeding at initial endoscopy were factors significantly contributing to mortality. Only a minority of the patients was tested for H. pylori infection.

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Feasibility of early closure of diverting ileostomies. R Bakx, ORC Busch, D van Geldere, WA Bemelman, JFM Slors, JJB van Lanschot. Dept of Surgery, Academic Medical Centre / University of Amsterdam, Amsterdam. Dept of Surgery, Amstelveen General Hospital, Amstelveen.

A diverting ileostomy is sometimes constructed for the protection of a distal anastomosis. This ileostomy does not prevent leakage but reduces its septic complications. When the distal anastomosis has heeled, the ileostomy has lost its protective function. It is difficult to identify the group of patients who really require an ileostomy and therefore its routine application has been proposed by some authors. Elective closure of diverting ileostomies is mostly performed after 2-3 months, although this time-span is not supported by solid data. In this period stoma related complications are reported in up to 40% of the patients. Earlier closure might effectively protect the distal anastomosis and at the same time reduce stoma related complications, reduce stoma related costs and improve quality of life. The aim of this pilot study was to investigate the feasibility of closure of a diverting ileostomy in an early stage, i.e. during the same hospital admission as the primary operation. Sixteen patients were entered in this pilot study. Informed consent was obtained from all patients. Water-soluble contrast enema radiographic examination was performed preferably 7-8 days after the primary operation to check the distal anastomosis. If patients recovery was uneventful and without clinical or radiographic signs of leakage, patients were planned for ileostomy closure as soon as possible. The 16 patients had a median age of 58 year, five were female, 11 were male. In 12 of the 16 patients early ileostomy closure was performed after 7-21 days (median 13 days). In 4 patients early ileostomy closure was not performed (2x anastomotic leakage, 1x prolonged recovery after first operation, 1x irradicality/radiotherapy) There were 3 complications after early ileostomy closure; 2 superficial wound infections and 1 i.v. catheter sepsis. No leakage of the proximal anastomosis nor of the distal anastomosis was seen. Conclusion: In 75% of the cases it was feasible to close a diverting ileostomy shortly after the primary operation. This was done with low morbidity and without mortality. A larger prospective study is currently performed to establish its feasibility and safeness as a routine procedure.

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Robot assisted thoracoscopic long esophageal myotomy for diffuse esophageal spasm (”nutcracker” esophagus).

JP.Ruurda, IAMJ Broeders, BLAM Weusten, RPM Simmermacher,

AJPM Smout, J Oors, HG Gooszen. Dept of Surgery and Gastrointestinal Motility Research Centre, University Medical Centre Utrecht.

The “nutcracker esophagus” (NE) and diffuse esophageal spasms (DES) are esophageal motility disorders of unknown etiology. Diagnosis is based on the combination of disabling non-cardiac chest-pain, with or without dysphagia, and simultaneous con-tractions associated with >10 % of wet swallows and a mean simultaneous contraction amplitude of >30 mm Hg (DES) or a peristaltic amplitude greater than 180 mm Hg (NE). The relation between symptoms and motility events is substantiated, based on a symptom index >50%. Medical treatment is often not successful and surgical long esophageal myotomy, through thoracotomy has been attempted with variable results. With the introduction of 24-hr manometry with scoring of symptom association and minimally invasive surgery, the surgical approach has gained renewed interest. Especially with the help of robot-assisted, 3-dimensional approach, long myotomy can be performed with the scrutiny needed to safely perform such an operation. The purpose of this study is to demonstrate the feasibility of performing a safe and effective thoracoscopic long myotomy with the use of a robotic system. For this purpose 6 patients with DES or NE (5 F,1 M) were operated with the da Vinci robotic system, which consists of a master-console and a 3 armed robotic telemanipulator. A double optic system provides a 3D image, integrated in the console. The length of the myotomy varied according to the findings at manometry, with the upper level of the azygos vein and the lower esophageal sphincter as extremes. Three months follow-up has been completed in 4/6 patients. One conversion occurred because of pulmonary adhesions. There were no intra-operative complications and one postoperative pneumothorax. Blood loss was 100 cc (10-250). Operating time mediated 120 minutes (95-150). Hospitalization ranged from 3 to 9 days (median 5,5). Manometry showed a median decrease in peristaltic pressures from 138 before to 19 mm Hg after myotomy. Symptoms decreased substantially in all patients, al-though one patient reports mild dysphagia. In conclusion, thoracoscopic myotomy seems a useful and safe technique for the treatment of this disabling and rare disease.

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Two years clinical outcome and costs of a randomised study comparing conventional and laparoscopic Nissen.

JE Bais, E Buskens, HG Gooszen, on behalf of the Netherlands AntiReflux Surgery Study Group: JE Bais, JFWM Bartelsman, JH Bonjer, MA Cuesta, PNMYH Go, HG Gooszen, Y van der Graaf, EC Klinkenberg, JJB van Lanschot, JHSM Nadorp, AJPM Smout. University Medical Centre Utrecht, Depts of Surgery and Julius Centre. Hundred-three patients with refractory gastro-esophageal reflux disease (GERD) were included in a randomised clinical trial (RCT) comparing conventional (CNF: 56) with laparoscopic Nissen fundoplication (LNF:47). Inclusion was stopped after an interim analysis after inclusion and 3 months follow-up, because in the LNF group significantly more patients had reached a study end point (dysphagia, recurrent GERD and wrap herniation, p < 0.001). All but nine patients were followed up by a mailed questionnaire - general health, reflux symptoms and quality of life - for two years. A cost-effectiveness analysis was performed including all direct and indirect costs from the pre-operative visit to two years of follow-up onwards. Sixteen patients (6 CNF, 10LNF) were reoperated - dysphagia (5), recurrent GERD (5), epigastric pain (3), rec. GERD and dysphagia (2) and cicatricial hernia (1) - within the first two years after the initial procedure, two of them were reoperated twice. After two years 93% of the CNF patients had complete cure or significant improvement of their reflux symptoms, and 96% in the LNF group. Success (improvement in both general health and reflux symptoms) was obtained in 38/41 (93%) after CNF and in 46/53 (87%) patients after LNF. Quality of life and reflux symptoms were equally improved in both groups. Average total costs were € 14,189 for LNF and € 12.8096 for CNF. The higher costs for LNF were partly compensated by lower costs of productivity loss, € 5,738 for LNF compared to € 6,281 for CNF. Reduction in operating time, costs of disposable equipment, reoperation rate or hospitalisation could not cancel out the higher direct costs for LNF. With a reduction of sick leave days from 71.8 to 52.2 for LNF, both procedures would become equally expensive. Conclusions: If reintervention was included, both procedures were equally successful at two years, but the laparoscopic approach was 10 % more expensive. The possibility of earlier return to work after LNF is not fully exploited by medical officers in the Netherlands yet. There is no other reason then “patient’s preference”, to favour LNF over CNF.

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Laparoscopic hand assisted transhiatal esophagus resection with cervical esophagogastrostomy for esophageal cancer.

WT van den Broek, A Houdijk, S Meijer, MA Cuesta. VU Medical Centre, Dept of Surgery, Amsterdam Several attempts have been made to perform the same resection for malignant diseases of the esofagus as conventional, but lowering the high morbidity. Problems may be overcome with the use of the hand assisted procedure in which the same incision can be used for retrieval of the specimen. Fifteen patients with tumors of any resectable stage localized in the infracarinal segment of the esophagus have been included in the prospective laparoscopic esophageal resection program.The surgi-cal procedure was started completely laparoscopic, the moment for introducing the hand assisted device was determined by the surgical difficulty. Using a five trocars approach, dissection of the distal esophagus with the tumor was performed up to the margins of aorta, pericard sac and both pleurae. In 12 patients a piece of pleura was taken with the specimen. Dissection followed up to the superior limit of the pulmonal veins. Thereafter the stomach was dissected with pre-servation of the gastroepiploic vessels along the greater curvature. The left gastric vessels were taken down by means of endostaplers. Another team dissected the cervical esophagus and thereafter the entire esophagus was stripped towards the abdomen. The specimen was exteriorized through the small incision of 7 cm, the specimen was resected and the gastric tube passed through the mediastinum and anastomosed to the cervical esophagus.Three patients were converted. Operative time was 260 min (230-300min). Postoperative complications included four recurrens nerve palsy and one evisceration that resulted in reintervention. There was no mortality. Hospital stay was 10 days (SE 7-14 days). One patient had locally recurrence in the abdomen and another one brain metastases. From this preliminary prospective study it seems that laparoscopic hand assisted esophageal resection for cancer, transhiatally performed, is not only feasible but also associated with low morbidity.

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Major delayed haemorrhage after pancreatic and biliary sur-gery. SMM de Castro, KFD Kuhlmann, NT van Heek, ORC Busch, H. Obertop, TM van Gulik, DJ Gouma. Academic Medical Center, Amsterdam. Despite the decrease in morbidity for pancreatic and biliary surgery during the past years, anastomotic leakage, infection and major bleeding are still of great concern because they are responsible for 80% of the postoperative mortality. In a previous study we found a high mortality in patients with major delayed haemorrhage (MDH). The purpose of this study is to analyse the management of MDH after pancreatic and biliary surgery and compare results to historical controls to evaluate if non-surgical treatment (embolisation) increased. MDH was defined as necessitating 5 or more packed cells within 24 hours in patients with a bleeding more than 24 hours after initial surgical procedure. Patients with various causes of MDH were compared to identify differences in diagnostic procedures, non-surgical and surgical intervention and mortality. The present study consists of 805 consecutive patients (group 1) who underwent pancreatic or biliary surgery (cholecystectomy excluded) between 1994 and 2001. The historical controls consisted of 686 patients (group 2) from the period of 1983 until 1993 previously reported. MDH occurred in 13 patients (1.6%) in group 1 compared to 22 patients (3.2%) in group 2. Mortality occurred in 4 patients (31%) and 6 patients (27%) respectively. Conservative treatment was performed successfully on nil patients in both groups. Radiological and/or endoscopic intervention was performed successfully on 1 of 1 patients (100%) in group 1 and 2 of 4 patients (50%) in group 2. Mortality occurred respectively in nil patients and 2 patients. Surgical treatment was performed successfully on 8 of 10 patients (80%) in group 1 and 14 of 18 patients (78%) in group 2. Mortality of surgical intervention occurred respectively in 2 patients and 4 patients. Overall in hospital mortality for all patients was respectively 4 of 805 (0.5%) and 6 of 686 (0.9%). Conclusion: The incidence of MDH is around 2% and did not change dramatically throughout the years. Conservative treatment is not useful in patients with MDH. Non-surgical intervention has relatively limited success. Early aggressive surgical intervention is still mandatory when confronted with MDH after pancreatic or biliary surgery.

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Increased hepatobiliary cholesterol transport by activation of the liver X-receptor LXR is independent of ABCA1 in mice. T Plösch, T Kok, VW Bloks, R Havinga, MJ Smit, G Chimini, AK Groen en F Kuipers. Dept of Pediatrics, University Hospital Groningen; Centre de Immunologie, INSERM-CNRS, Marseille, France; Dept of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands. The ATP binding cassette transporter ABCA1 is essential for HDL formation and therefore considered rate-controlling for reverse cholesterol transport (RCT). Recently, we demonstrated that hepatic cholesterol synthesis and hepato-biliary transport are not affected in mice lacking ABCA1, findings incompatible with current concepts of RCT. ABCA1 is highly expressed in peripheral tissues, including macrophages, but also in liver and intestine: its function in these organs is unclear. Expression of the Abca1 gene is controlled by the liver X-receptor (LXR). We have evaluated the physiological effects of LXR activation on hepatic cholesterol metabolism, with special reference to hepatobiliary transport. For this purpose, Abca1-/- and wildtype mice were treated with the LXR agonist T0901317 (10 mg/kg, 5 d). Plasma cholesterol levels increased in Abca1-/- mice (1.11 vs. 0.50 mM) and in control mice (1.64 vs. 1.12 mM) upon treatment. In Abca1-/- mice, the increase was exclusively in VLDL-sized fractions, whereas in wildtype mice both VLDL and HDL cholesterol increased. Hepatic triglycerides were massively elevated in both strains after treatment, presumably related to induction of lipogenic genes. LXR activation strongly affected bile composi-tion. Bile flow was identical in both strains, but bile salt excretion was diminished in treated wildtype (-22 %) and in Abca1-/- (-46 %) mice. Likewise, biliary phospholipid output decreased upon treatment in both strains, in spite of unaffected expression of Abcb4, encoding the hepatic phospholipid translocase. In contrast, cholesterol output was significantly induced by treatment, leading to increases in cholesterol:phospholipid ratios from 0.13 to 0.46 and from 0.12 to 0.42 in wildtype and Abca1-/- mice, respectively. Expression of Abcg5 and Abcg8, recently implicated in cholesterol transport, was induced in livers of treated mice. In conclusion, chronic activation of LXR in mice leads to enhanced hepatobiliary cholesterol removal independent from (ABCA1-mediated) elevation of HDL and the presence of ABCA1 in the liver. Supported by NWO grant 902-23-193.

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Hepatitis B vaccination with a pre-S1 and pre-S2 containing vaccine (Biohep) in previous non-responders to at least two courses of standard vaccination. RA de Man, R van den Dorpel, B Zietse, M Kemmeren, RA Heijtink. Dept of Gastroenterology & Hepatology, Internal Medicine and Virology, Universital Hospital Rotterdam. Present recommendations for HBV vaccination denominate antibody titers > 100 IU/l anti-HBs as protective levels. There is no solution for persons responding with anti-HBS titers below 100 IU/l after two courses of recombinant HBs vaccine (Engerix-B or HBvax). We evaluated the response to Biohep vaccine containing pre-S1, pre-S2 and surface antigen in previous vaccine non-responders. All parti-cipants received a dose of 20 microgram i.m in the deltoid region at 0,1 and 6 months. Anti-HBs was determined at 0,1,6,7 months. Side effects were monitored using structured questionnaires. The protocol was approved by the medical ethics committee. Included were dialysis patients (n=15; median age 63 years, range 42-81 years), partners of infected patients (n=4; median age 56 years, range 56-60) and health care workers (HCW) (n=10; median age 30 years, range 25-59 years). Response to vaccination was expressed as percentage of patients with anti-HBs titers above 10 IU/l, 100 IU/l and median titers per group respectively. Eighty percent of dialysis patients and HCW and 100% of partners had a complete follow-up. Anti HBs >10,100 IU/l respectively was obtained in 66%,50% of dialysis patients, 88%,50% of HCW and 100%, 75% of partners. Median anti-HBs at month 7 was 72 IU/l, 391 IU/l and 478 IU/l respectively. No significant side effects were documented. In conclusion a preS1 and preS2 containing vaccine was able to induce protective antibody titers in the majority of persons not responding to two courses of standard vaccination. This vaccine should be further explored in non-responders to standard vaccination schedules.

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Inter mixed-micellar/vesicular fractions of conjugated cholates in model biles are strongly increased by acidification: potential implications for reflux esophagitis and Barrett’s esophagus. W Renooij, MB de Smet, HG Gooszen, KJ van Erpecum. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht. Esophageal bile salts are currently considered a major contributing factor in reflux diseases. The inter mixed-micellar/vesicular bile salt fraction (IM: i.e. non-phospholipid associated fraction: bile salt simple micelles and monomers) is held responsible for cytotoxic effects of the detergent (J Lipid Res 2000;41:916-24). We therefore examined effects on IM bile salts of diluting and acidifying model biles, thus mimicking gastro-esophageal passage of bile in vivo. Model biles were prepared containing phosphatidylcholine, cholesterol and a pathophysiologically relevant bile salt mixture (taurine- and glycine-conjugated cholate, chenodeoxycholate, deoxycholate and lithocholate; TLConc. 8 g/dL; EYPC/(EYPC+BS)=-0.3; CSI 1.1 or 0.8). Aliquots were diluted 10- or 100-fold in buffers of varying pH ranging from pH 7 to pH 1) and incubated for 0.5-4 hrs at 37 0 C. IM and mixed-micellar fractions were isolated by established centrifugation/filtration techniques (Biochim Biophys Acta 2001;1532:15-27). Glycine conjugates and lithocholates were insoluble in buffers at acid pH. When the bile salt mixture was solubilized as part of model biles, mixed-micellar and IM bile salt concentrations and compositions were not affected by acidification to pH 4; below pH 2-3 concentrations and compositions decreased considerably due to precipitation of glycine conjugates and lithocholic acid. The initial IM fraction comprised 6-9 % of total bile salts, but increased to 25-28% upon acidification to pH 4 at 10-fold dilution and to 50-60% at 100-fold dilution. The composition of the IM fraction was more hydrophilic than that of the mixed-micellar fraction from pH 7 down to pH 4, culminating in taurocholate and glycocholate becoming the predominant bile salts in the IM fraction at pH 2-3, with virtual depletion of glyco(cheno)deoxycholates and lithocholates. Conclusion: The dramatic increase of conjugated cholates in the inter mixed-micellar/vesicular fraction at acid pH indicates an important role for this bile salt in cytotoxicity.

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Lamivudine treatment during pregnancy to prevent perinatal transmission of hepatitis B virus infection. M van Zonneveld, AB van Nunen, HGM Niesters, RA de Man, SW Schalm, HLA Janssen. Dept of Gastroenterology & Hpatology and Virology, University Hospital Rotterdam. Vertical transmission of hepatitis B virus (HBV) can occur despite vaccination of the child. This vaccination breakthrough has been associated with high maternal viremia. We treated seven highly viremic (HBV DNA = 1,2 x 109 geq/ml) mothers (median age 21 years) with lamivudine 100 mg daily during the last month of pregnancy. Duration of lamivudine treatment was 5 to 40 days. HBV-DNA, HBsAg, anti-HBs and anti-HBc of the offspring were measured at birth and at 3, 6 and 12 months, respectively. Twenty-four children, born to untreated HBsAg positive mothers with HBV DNA-levels above 150 pg/ml (=1,2x109 geq/ml) served as controls. All children received standard passive-active immunization and were followed for 6-12 months. In the lamivudine group HBV DNA levels dropped below 1.2 x 108 geq/ml in five women. Median percentual decrease in HBV DNA was 98,9%. Four children were HBsAg positive at birth. One of the seven children (14%) was still HBsAg and HBVDNA positive at the age of six months. All other children seroconverted to anti-HBs and remained anti-HBs positive until the last visit. In one child HBV DNA was detectable at birth, in two other children until the age of 3 months, but not at later visits. No side effects were found in mothers and their offspring. In the untreated control group perinatal transmission occurred in 7 of the 24 children (29%; relative risk for infection 2.1). We conclude that treatment with lamivudine appears to decrease the risk of perinatal transmission. In highly viremic HBsAg positive mothers reduction of viremia by lamivudine therapy in the last month of pregnancy may be an effective and safe measure to reduce the risk of vaccination breakthrough. This approach should be evaluated in a large controlled trial.

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Combined polymorphisms in UDP-glucuronyltransferases 1A1 and 1A6; implications for patients with Gilbert's syndrome. WHM Peters, RHM te Morsche, HMJ Roelofs. Dept of Gastro-enterology, University Medical Center St. Radboud, Nijmegen. UDP-glucuronyltransferases (UGTs) are a family of enzymes that metabolise endogenous and exogenous compounds such as bilirubin, steroid hormones, drugs and carcinogens. The variability of three UGT enzyme activities was determined in 39 human liver specimens. These activities were associated with each other and with two genetic polymorphisms in UGT1A1 (UGT1A1*28) and UGT1A6 (UGT1A6*2). In Caucasians, UGT1A1*28 is associated with Gilbert's syndrome, whereas UGT1A6*2 may result in a reduction of glucuronidation of several drugs, such as ß-blockers, coumarins and aspirin. UGT enzyme activity towards bilirubin (B), 4-nitrophenol (NP) and 4-methylumbelliferone (MB) was measured by HPLC, spectrometry and fluorometry, respectively. After isolation of genomic DNA, genetic polymorphisms were measured by PCR-RFLP. An association was found between UDP-glucuronyltransferase (UGT) enzyme activities of bilirubin (B) and 4-nitrophenol (NP; R= 0.47, p= 0.0024), B and 4-methylumbelliferone (MU; R= 0.54, p= 0.0003), and NP and MU (R= 0.89, p< 0.0001). In addition to an association between B-UGT enzyme activity and UGT1A1*28 (R= 0.45, p= 0.0034) as reported earlier, a similar association between B-UGT and UGT1A6*2 (R= 0.43, p= 0.007) was found. No associations were found between NP- or MU-UGT activity and UGT1A1*28 or UGT1A6*2. In addition, 253 Dutch Caucasians from the general population were tested for the co-occurrence of the UGT1A1*28 and UGT1A6*2 polymorphisms, and a strong association was found (R= 0.78, p<0.0001). In Caucasians, approximately 90% of the patients with Gilbert's syndrome, in addition to a disturbed bilirubin metabolism, may have abnormalities in the glucuronidation of several drugs such as ß-blockers, aspirin, coumarin- and dopamine-derivatives, as a result of the combined UGT1A1*28 and UGT1A6*2 genotypes.

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Paired measurements of quantitative hepatitis B virus DNA in saliva and serum: implications for saliva as infectious agent in selected patients. AA van der Eijk, HGM Niesters, SD Pas, RA de Man. Dept of Gastroenteroloy & Hepatology, Virology, University Hospital Rotterdam. Up to 50% of acute hepatitis B virus (HBV) infections remain unexplained after intensive source and transmission studies. In addition horizontal transmission between children is well docu-mented and estimated at 1% per year of exposure. Saliva may be an unexpected vehicle of transmission. To further explore this hypothesis we evaluated the quantitative levels of HBV DNA in saliva and compared these with the HBV DNA levels measured in serum. Serum and saliva were collected from 19 chronic HBsAg carriers attending our outpatient clinic. There were 11 men and 8 women; nine patients were HBeAg positive, anti-HBe negative and nine patients were HBeAg-negative, anti-HBe positive. One patient was HBeAg and anti-HBe negative. Samples of serum and saliva were collected on the same day. All saliva samples were clear on inspection. For the accurate measurement of HBV DNA in serum the Digene Hybrid Capture II microplate assay (Digene Diagnostics), the HBV Monitor assay (Roche Diagnostics) as well as an in-house developed HBV DNA TaqMan assay were used. The HBV DNA TaqMan assay was used for the quantitative measurement of HBV DNA in saliva. The HBV DNA concentrations were calculated through interpolation of the Ct values from a standard curve. Median HBV DNA levels in serum were 5,10 E3 geq/ml and ranged from =1,0 E3 geq/ml to 4,9 E9 geq/ml; Median HBV DNA levels in saliva were 2,66 E3 geq/ml and ranged from =1,0 E3 geq/ml to 9,25 E6 geq/ml. A clear correlation was shown between HBV DNA in serum and saliva (n=10); log HBV DNA in saliva=2,719 + 0,374 * log HBV DNA in serum. In conclusion: this is the first report of precise quantitative measurements of HBV DNA levels in saliva and the relationship with HBV DNA levels in serum. Horizontal transmission of HBV without apparent sexual or parenteral exposure is common in hyperendemic areas. Saliva is not considered as an important mode of HBV transmission nowadays. However our findings suggests that saliva is a source of HBV DNA and this finding may have implications in selected patients for the infectivity of saliva and insight in the routes of transmission of HBV DNA.

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Copper-induced apical trafficking of an ATP7B-EGFP fusion protein in polarized MDCK cells correlates with kinetics of apical copper excretion. H Roelofsen, JR Forbes, H Wolters, DW Cox and RJ Vonk. Center for Liver, Digestive and Metabolic Diseases, Dept of Pediatrics, University Hospital Groningen, Dept of Medical Genetics University of Alberta, Edmonton, Canada. Mutations in the ATP7B gene, encoding a copper-transporting P-type ATPase, lead to excessive hepatic copper accumulation due to impaired biliary copper excretion in Wilson disease. In human liver, ATP7B is predominantly localized to the trans-Golgi network (TGN), which appears incompatible with a role of ATP7B in biliary copper excretion. We have shown that ATP7B redistributes from the TGN to the apical membrane in polarized HepG2 hepatoma cells when the extracellular copper concentration is raised. The aim of the current study is to relate the location of ATP7B to the kinetics of copper efflux over the apical membrane. Direct assessment of the relation between ATP7B-localization and copper efflux is not possible in HepG2 cells due to the inaccessibility of apical vacuoles formed by this cell line. Therefore, we switched to Madin Darby Canine Kidney (MDCK) cells. Confocal microscopy was used to study effects of excess copper on ATP7B-localization in MDCK cells, stably transfected with a cDNA-construct of ATP7B coupled to enhanced green fluorescent protein (EGFP). Cells were cultured on filter inserts. Copper efflux was measured using an assay based on copper-induced quenching of the fluorescent indicator calcein. Results indicate that in polarized MDCK cells, in the absence of copper, the ATP7B-EGFP fusion protein is predominantly located between the nucleus and the apical membrane, probably representing a TGN localization. No clear labeling of basal and apical membranes was observed. ATP7B-EGFP redistributed to apical membranes of MDCK cells within 2 hrs after the addition of 20 µM copper to the basolateral compartment. Apical copper transport followed similar kinetics: copper efflux into the apical compartment started to increase 1 hr after the addition of 20 µM copper to the basolateral compartment. Conclusion: Copper-induced apical trafficking of ATP7B correlates with the onset of apical copper excretion. Ligand-induced apical sorting of ATP7B provides a novel mechanism for biliary copper excretion and the control of hepatic copper homeostasis. Supported by the Digestive Disease Foundation, projectno WS 96-70

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The effect of recombinant bactericidal/permeability-increasing protein (rBPI21) on circulating Interleukin-6, Vascular Endo-thelial Growth Factor (VEGF) and Endostatin in patients undergoing major liver resection. FPK Wu, PG Boelens, PAM van Leeuwen, K Hoekman, AHG Hansma, MJ Wiezer, C Meijer, S Meijer, M Scotté, MA Cuesta. Dept of Surgery, VU Medical Center, Amsterdam. Dept. of Medical Oncology, VU Medical Center, Amsterdam. Background. Bactericidal/Permeability-Increasing protein (BPI) is found in human neutrophils and neutralizes lipopolysaccharide (LPS). Exogenous BPI has shown to reduce postoperative infectious complications. Since BPI showed to inhibit angiogenesis by inducing apoptosis of endothelial cells, we investigated the effect of rBPI21 on angiogenic factors before, during and following liver surgery. Methods. A total of 18 patients with liver metastasis of colorectal carcinoma were randomised to receive either a 48-hour continues perioperative rBPI21 or placebo administration (double-blind). The effect of liver surgery and rBPI21 on the pro-angiogenic factors interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) and the inhibitory angiogenic factor, endostatin was investigated by ELISA technique. Results. The highest IL-6 levels were found during the first 24 hours and reached peak levels at 2 hours postoperatively in both groups, the placebo group had significantly higher IL-6 levels at 2 hours after the liver resection. In both groups VEGF levels decreased sharply in the postoperative hours and increased significantly at day +1 observed in both groups. In both groups an immediate decrease in endostatin levels was observed and remained significantly low up to day +3. Conclusions. Perioperative infusion for 48 hours of RBPI21 resulted in a significantly lower IL-6 levels (2 hours postoperative) and significant higher levels of VEGF (day +1). These results show that exogenous BPI can modulate the liver surgery-induced immune response. Liver surgery induced an immediate immune response (IL-6) and an immediate angiogenic response, reflected in a paradoxal VEGF decrease and a longer lasting decrease of endostatin. This emphasizes the dynamics of angiogenesis in the first phase of wound healing.

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Early differentiation between rejection and infection in liver transplant patients by serum and biliary cytokine patterns. MC Warlé, HJ Metselaar, IC Gyssens, GJ Bouma, HW Tilanus. Depts of Surgery and Gastroenterology & Hepatology, Medical Microbiology & Infectious Diseases, University Hospital Rotterdam. Differentiation between acute liver graft rejection and infection remains a clinical challenge during the early post-transplant period. Although cytokines play a pivotal role in mediating allograft rejection, previous studies demonstrate that most cytokines are not specific for liver graft rejection or infections. However, other studies suggest that adhesion molecules and cytokines in bile reflect the immunological activity within the liver more closely. Therefore we postulated that by combining cytokine patterns in serum and bile, early recognition of acute liver graft rejection and differentiation from infectious complications can be improved. We performed a prospective study in 45 patients, who were monitored daily for clinical events and cytokine patterns in serum and bile during the first month after liver transplantation. Soluble ICAM-1 in serum and IL-8 in bile were specifically increased at the onset of acute rejection (P<0.001), whereas serum sTNF-RII was also significantly increased in patients with infectious complications and serum IL-6 only in patients with rejection during infection. In 68% of patients with increased sICAM-1 acute rejection was diagnosed within 10 days, whereas rejection occurred in only 26% of patients with low serum levels of sICAM-1. In patients with increased sICAM-1 the relative risk for rejection was 4.8 (P=0.009). Conclusions: Cytokine patterns in bile do not provide rejection markers with higher specificity as compared to serum cytokines. Daily monitoring of sICAM-1 in serum could identify patients at risk for rejection, therefore in those patients acute liver graft rejection may be recognized earlier.

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Association of donor-recipient sharing of HLA-DR antigens and severity of HCV recurrence after liver transplantation. LB Koppert, PE Zondervan, HJ Metselaar, WCJ Hop, JNM IJzermans, G Kazemier, HW Tilanus, GJ Bouma. Dept of Surgery, Pathology, Gastroenterology & Hepatology, Epidemiology and Biostatistics, University Hospital Rotterdam. Worldwide, Hepatitis C Virus (HCV) infection is becoming the leading cause of chronic liver disease requiring liver transplantation. The time-period between transplantation and the first symptoms of damage to the allograft induced by HCV re-infection and also the severity of damage vary between patients. HLA-DR mismatched grafts lead to stronger allo-responses than HLA-DR matched grafts. Our hypothesis is that the allo-response will interfere with the response against HCV. We set up a histologic scoring system to detect and discriminate damage of the allograft caused by HCV re-infection from other causes like rejection. Retrospectively, in ten patients we performed a blind analysis of all liver biopsies taken according to protocol or on indication. HLA-DR matching or mismatching between patient and donor was correlated with time to HCV recurrence. In addition, from 113 patients, 23 patients transplanted for HCV and 90 control patients transplanted for non-viral causes, alanine aminotransferase (ALT) levels in week 4 to 8 posttransplantation were analyzed. Histologic HCV recurrence appeared earlier in HLA-DR-matched patients, than in HLA-DR-mismatched patients and did not appear in two of the HLA-DR mismatched patients. ALT-levels in week 4 to 8 were significantly increased in HLA-DR matched patients transplanted for HCV compared to HLA-DR mismatched patients. These results suggest that the allo-response, induced by mismatched HLA-DR antigens, may aid in the anti-HCV response, thereby delaying HCV recurrence. The results warrant a larger study to evaluate whether HCV-liver transplant recipients should receive HLA-DR mismatched liver grafts, in face of the scarcity of the donor pool.

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Detection of Helicobacter species in the non-cirrhotic liver of patients with hepatocellular carcinoma. K Verhoef, RGJ Pot, R de Man, P Zondervan, JNM IJzermans, EJ Kuipers, JG Kusters. Depts of Surgery, Gastroenterology and Hepatology, and Pathology, Erasmus Medical Center, Rotterdam. Although the causative agent of hepatocellular carcinoma (HCC) is unknown, there is a clear association with hepatitis B/C infections, alcoholic liver disease, haemachromatosis, tyrosinaemia, aflatoxin and long term use of oral contraceptives. In addition there are many HCC patients that without known risk factor. Here the role of Helicobacter species as a potential co-factor in the hepato-carcinogenesis in patients with HCC in a non-cirrhotic liver is investigated. Fifty-three liver specimens were studied (20 from patients with HCC in a non-cirrhotic liver and 32 from patients with colorectal liver metastasis). All liver samples were obtained through surgery. In eleven patients with HCC, a gastroscopy was done to obtain tissue samples of the stomach. DNA was isolated from the liver and stomach samples and used in a Helicobacter species specific PCR that when positive generates a 360bp 16S rDNA product. To exclude that the absence of PCR products is due to inhibition, all samples were also tested in a Beta-Globulin based PCR. Amplified products were sequenced to determine the genus and species of the bacteria. PCR performed with the 16S rDNA primers, and and subsequent sequence analysis revealed the presence of bacteria from the genus Helicobacter in 9 out of the 20 liver samples from patients with HCC (45%), but only in 3 out of the 32 liver samples from patients with colorectal liver metastasis (9.4%) (p< 0.005) The PCR performed on the gastric samples revealed the presence of bacteria from the genus Helicobacter in 5 out of the 11 stomach samples (45.5%). The presence/absence of Helicobacter species in these gastric samples did not correlate with the Helicobacter status of the corresponding liver samples. Conclusion: The incidence of Helicobacter species in the liver of patients with HCC in a non-cirrhotic liver is significantly higher than the incidence of Helicobacter species in the liver of patients with colorectal liver metastasis. This suggests that the presence of Helicobacter is associated with the occurrence of HCC. (Supported by a grant from Gastrostart, Haarlem, the Netherlands).

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The role of intrahepatic immune effector cells in inflammatory liver injury and viral control during chronic hepatitis B infection. TJ Tang, J Kwekkeman, J Laman, HGM Niesters, PE Zondervan, RA de Man, SW Schalm, HLA Janssen. Dept of Gastroenterology & Hepatology, Immunology, Virology and Pathology, University Hospital Rotterdam Cytotoxic T lymphocytes (CTL) and Kupffer cells play an important role in the immune control of hepatitis B virus (HBV), but also may induce liver injury during infection. We investigated the immune response in liver biopsies of chronic HBV patients in relation to inflammatory liver injury and viral control. Cross-sectional liver biopsies of chronic HBV patients were selected according to predefined ALT levels: ≤50 (n=29) and >50 (n=19); 54% were HBeAg+. Acute hepatitis and normal liver specimens served as controls. Immune effector cells [CTL (CD8mAb), NK/NKT cell (CD56mAb), macrophage/Kupffer cell (CD68mAb), plasmacytoid dendritic cell (CD123mAb)], cytotoxic effector molecules (Fas-L and granzyme), and cytokine (IFNγ and TNFα) producing cells were quantified after immunohistochemical staining in lobular and portal areas of the biopsies. The intralobular number of CTL's was significantly decreased in biopsies of patients with high ALT (r=-0.52;p=0.001). Higher ALT-values were correlated with increased numbers of granzyme+ cells in portal areas (r=0.73;p=0.02) and higher numbers of intrabolular Fas-L+ cells (r=0.32;p=0.05). Fas-L was expressed on Kupffer- and lymphoid cells. In patients with low ALT more intralobular CTL's were found in HBeAg- than in HBeAg+ patients (p=0.001). In these patients, the numbers of intralobular CTL's and granzyme+ cells were equal, suggesting that all these CTL's were functionally activated. NK/NKT cells and plasmacytoid dendritic cells were scarcely present and not enhanced in comparison to normal liver. IFNγ and TNFα producing cells were observed sporadically in chronic HBV patients, whereas in controls with acute HBV infection these cells were abundant. Low viral replication, as indicated HBeAg negativity, is related to an increased presence of intralobular CTL's. Persistence of the virus may be due to the absence of cells producing anti-viral cytokines in the liver. Inflammatory liver injury during chronic HBV infection is probably not the result of increased numbers of infiltrating CTL's, but of Fas-L expression by Kupffer cells and increased cytolytic activity of cells in portal areas.

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Rapid HCV Rna Decline After Daily 18 Mu Interferon Induction Combined With Ribavirin And Amantadine In Chronic HCV Patients. R Sentjens, M Beld, CJ Weegink, HW Reesink. Academical Medical Center, Dept of Gastroenterology and Hepatology, Dept of Calinical Virology, University of Amsterdam. Objectives: To study viral decline in HCV patients treated with high dose induction combination therapy during the first 6 weeks of therapy. Methods: 24 treatment-naïve patients with chronic hepatitis C received IFN according to the following schedule: week 1 and 2 8 hourly 6 MU, week 3 and 4 8 hourly 3 MU, week 5 and 6 12 hourly 3 MU, subsequently genotype non-1 patients were treated with 3 MU IFN daily uptill 26 weeks and genotype-1 patients uptill 52 weeks. All patients received also Ribavirin 1000-1200 mg and Amantadine 100 mg daily. Serum samples were obtained once weekly. HCV RNA levels were determined by bDNA (Bayer) or qualitative PCR (Roche) Results: 15 patients had genotype non-1 (11 patients genotype 2 or 3, 4 patients genotype 4), 9 patients had genotype 1. Mean pre-treatment viral load in genotype non-1 was 5.6 Log IU/ml vs. 5.6 log IU/ml in patients with genotype 1. The viral load decline after one week of treatment for patients with genotype non-1 and genotype 1 was 2.9 log IU/ml and 2.6 log IU/ml respectively. Between week 1 and 4 the viral load decline for patients with genotype non-1 and genotype 1 was 1.0 log IU/ml and 1.2 log IU/ml respectively. All patients (n=24) were HCV PCR negative at week 4. Conclusions: A rapid HCV RNA decline induced by high dose IFN induction therapy combined with Ribavirin and Amantadine in all patients independent of genotype. After 4 weeks of treatment all patients were HCV RNA negative.

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A Population-Based Study of the Effects of HFE C282Y and H63D Mutations on Liver Function. BZ Alizadeh, OT Njajou, JJ Houwing-Duistermaat, N Vaessen, G de Jong, JM Vergeer, A Hofman, HA Pols, CM van Duijn. Dept of Epidemiology & Biostatictics and Dept of Internal Medicine, Erasmus Medical Centre, Rotterdam. Accumulation of iron in carriers of the mutations in hemochromatosis gene (HFE) may result in liver damages at old age. We studied the effects of HFE mutations and body iron indexes on liver function in the elderly. We genotyped 2095 subjects for the C282Y and H63D mutations whom were randomly derived from the Rotterdam Study, a population based study of elderly people. For 1576 of people genotyped serum liver function tests (LFT) were available. Serum iron, ferritin and transferrin saturation were measured in 346 sub-jects selected within each genotype category. There was no difference in the mean of alanin aminotransferase, alkaline phospha-tase and total protein by HFE genotypes. Men (heterozygous and homozygous) and women (homozygous) for the H63D mutation had significantly higher bilirubin compared to carriers of the wild type allele. Serum alanin aminotransferase increased significantly with increasing serum ferritin. Increased total bilirubin was associated significantly (p=0.001) with high serum iron and transferrin saturation levels and in women also with higher serum ferritin levels. Conclusions: There is no evidence that HFE mutations affect liver function. However levels of serum iron indices are associated with LFT suggesting that in addition to HFE other determinants of iron metabolism may be important. In the general population, the H63D mutation may induce higher hemoglobin synthesis and/or reduce uptake of bilirubin by the liver that result in higher serum bilirubin level.

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HCV-specific immunity after Extracorporeal Whole Body Hyper-thermia in patients with chronic hepatitis C infection. GJ Boland, H van Soest, T van Bommel, C Huijben, S Moschatsis, AM van Loon, J van Hattum. Dept of Gastroenterology, dept of Virology, University Medical Centre Utrecht. Extracorporeal Whole Body Hyperthermia (EWBH) is used as a treatment for several forms of malignancies. In AIDS-patients, the treatment has also been used, and in some patients an antiviral effect was observed. We apply EWBH to patients with chronic hepatitis C virus (HCV) infection to study the safety, early viral effect and immunity pattern of EWBH. It is known that HCV-specific T-cell immunity to HCV antigens is high in acute HCV-infection, but it is diminished in chronic HCV-infected patients. Since the antiviral effect of EWBH might start weeks or even a few months after the procedure, it is assumed that after EWBH, the HCV specific T-cell immunity is (one of) the effector mechanisms in the antiviral effect of EWBH. We conducted an open-label pilot study in chronic HCV patients. 9 Patients with HCV genotype 1 and previous non-response to antiviral therapy underwent a single session of EWBH with their core temperature raised to 41,80C ± 0,20C for 2 hours. The device used is the TemetTM (First Circle Medical, Minneapolis, MN, USA). The HCV-specific immunity was measured by T-cell proliferation assay at different time points using the following antigens: recombinant p22 (a 16 kDa HCV nucleocapsid protein, [[), and latex beads coated with HCV antigens from the core-, NS3, NS4 and NS5 regions (Abbott, Ill, USA). As controls and to study in vitro general T-cell reactivity after EWBH, T-cell proliferation to diphtheria and tetanus toxoid (DTT, mixture), Candida and Pokeweed mitogen were measured. In 8 patients, the T-cell proliferation of the cells, stimulated with HCV antigen-coated latex beads, increased as compared to the pretreatment level. This increase occurred 1 to 4 weeks after the EWBH with an optimum at 2 or 3 weeks. In addition, in 4 of those patients the T-cell reactivity to DTT and candida increased. No increase in T-cell activity was observed in one patient. The same pattern was found in the T-cell immunity to p22, although less pronounced. These preliminary results show that EWBH induces both HCV-specific and general T-cell immunity. This may be a clue to reveal the mechanism of action of EWBH.

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Vaccination with SBAS4-adjuvanted vaccine against hepatitis B. G Boland, T van Loon, T van Bommel, A Baars, B Vroom, J van Hattum. Dept. of Gastroenterology and Virology, UMC Utrecht. The current vaccination schedule with the hepatitis B vaccine includes 3 injections, at T=0, T=1 or 2, and T=6 months, but alternative schedules are investigated. In recent years, new and more potent adjuvants have been developed and applied for human vaccination. We investiga-ted one of them, SBAS4, which contains 3-deacylated monophosphoryl lipid A and alum (Al(OH)3), for safety and immunogenicity in humans. Increasing the immunogenicity of the hepatitis B vaccine may lead to a reduction of the number of injections. In this study we compared the safety and immunogenicity of a 2-dose schedule of SBAS4-adjuvanted hepatitis B vaccine with the current 3-dose schedule of Al(OH)3-adjuvanted vaccine (Engerix-B). A total of 375 subjects were included. In a single-blind, random design the subjects received either Engerix-B at T=0, T=1 and T=6 months, or one of three batches of SBAS4-adjuvanted hepatitis B vaccine at T=0 and T=6 months. At T=1 month a placebo-injection was given. Blood was drawn at T=0, T=1, T=2, T=6 and T=7 months. Adverse reactions were recorded and antibodies to hepatitis B surface antigen (anti-HBs) were measured in the serum. The subjects were checked for hepatitis B markers in the first serum sample at T=0. Of the 375 inclusions, 21 subjects were not included in the data evaluation. Of the 354 e-valuable subjects, 235 had received SBAS4-adjuvanted hepatitis B vaccine, and 119 had received Engerix-B. Anti-HBs titers after one and after two injections with the SBAS4-adjuvanted vaccine were significantly higher as compared with Engerix-B. Even, anti-HBs titers one month after two injections with SBAS4-adjuvanted hepatitis B vaccine were significantly higher (p=0.003) than those one month after three injections with Engerix-B. The percentage of responders after two injections with SBAS4-adjuvanted vaccine were similar than the percentage of responders after three injections with Engerix-B. Local side effects were similar or sometimes slightly more serious with SBAS4-adjuvanted hepatitis B vaccine as compared to Engerix-B. Conclusion: Two doses with SBAS4-adjuvanted hepatitis B vaccine are at least as immunogenic as three doses of the current Al(OH)3-adjuvanted vaccine.

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Preoperative fasting dramatically increased the permeability of the intestinal wall. A rat model of ischemia/reperfusion injury PG Boelens, H Bouritius, MC Middelaar, RJ Nijveldt, DEC van Hoon, AA Lambalgen, K van Norren, PAM van Leeuwen. Dept of Surgery, VUMC, Amsterdam and Numico Research, Wageningen. Background: During major aortic aneurysm repair (AA) the superior mesenteric artery (SMA) is clamped resulting in ischemia/-reperfusion injury to the intestine. This study investigated the effect of nutritional status on the integrity of the intestinal wall in a rat model clamping the SMA and measuring the permeability of the intestinal wall. Methods: Male Wistar rats were divided in four experimental groups. Two groups were fed until the operation and two groups fasted the night before the operation. Rats underwent a laparotomy and SMA clamping of either 20 minutes or 40 minutes (ischemia) followed by 180 minutes of reperfusion. Directly after sacrifice the ileum was removed and the stripped epithelium mounted in Ussing-chambers. Permeability was determined by measuring the mucosal to serosal flux of HRP at four time points and the transepithelial resistance (Rt). Results: Fasting prior to surgery in combination with 40 minutes of ischemia resulted in a significant increase in HRP flux and a significant decrease in transepithelial resistance (Rt). No significant changes were seen between the other groups. Conclusions: Fasting followed by 40 minutes of ischemia and 180 minutes of reperfusion of the intestine resulted in severe damage to the intestinal epithelium in rats. In fed rats the integrity of the mucosal wall was preserved completely. Fasting before an operation as an AA repair, results in substantial damage to the intestinal wall. Patients should be fed overnight prior to aortic surgery in order to preserve the intestinal wall and so reduce complications related to ischemia/reperfusion injury.

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Enteral glutamine reverses the Th1/Th2 shift in severe trauma patients. A Randomised, double-blind controlled study. PG Boelens, APJ Houdijk, JCM Fonk, BME Blomberg, S Meijer, HJThM Haarman, PAM van Leeuwen. VUMC, Depts of Surgery & Pathology, Amsterdam. Background: Severe trauma leads to a Th2 immune response, which is associated with an impaired cellular immune response and subsequent increased susceptibility for infectious complications. Glutamine is the preferred fuel for immunocompetent cells. This study was designed to investigate the effect of enteral glutamine-enriched nutrition (>5 days) as compared to an iso-caloric, iso-nitrogenous control feeding on the Th1/Th2 response towards primary antigen KLH following severe trauma (ISS>20). Methods: Trauma patients were sensitised with KLH (within 12 hours) and received enteral nutrition within 48 hours after the trauma. Cellular and humoral immune responses were determined. Healthy subjects were used to determine the reference values. Results: IFN-gamma production of stimulated PBMCs (PHA) was significantly reduced after trauma on day 1 in both study groups. On day 14 the IFN-gamma production was significantly increased in the glutamine group as compared to the control group (p<0,018). IL-4 production was significantly depressed (p<0,045) following trauma in the control group while the glutamine group had an intact IL-4 production on day 1 and 14. Significantly less KLH specific IgG, IgG2 on day 9 was measured in the glutamine fed patients. Specific IgM, IgA, IgG1 and IgG3 was similar in both study arms. Conclusions: Trauma caused a suppressed cellular immune response, as was observed by an impaired IFN-gamma production (day 1). Glutamine partially restored IFN-gamma production (day14), preserved IL-4 production and part of the humoral immune response to KLH was less, suggesting a shift to Th1 by glutamine. Enteral glutamine might therefore play an important role in reversing the trauma-induced Th1/Th2 shift.

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Antithrombin III substitution inhibits local intravascular coagulation and fibrin deposition following intestinal ischemia and reperfusion in rats. IG Schoots, EHP Roossink, PB Bijlsma, M Levi, TM van Gulik. Dept of Surgery and Internal Medicine, Academic Medical Center, Amsterdam. The aim of this study was to investigate the effect of systemic heparin and antithrombin III (ATIII) administration upon local intravascular coagulation and thrombotic obstruction in the splanchnic microvasculature following intestinal ischemia and reperfusion (I/R). Rats (n=60) were divided into 3 groups: control, heparin and ATIII. Intestinal ischemia was induced by superior mesenteric artery occlusion (SMAO) for 0, 20 or 40 min. Saline, heparin (375IU/kg) or ATIII (250IU/kg) were administered 15 min before reperfusion. Portal (local) and systemic blood samples were analysed for activation of coagulation and fibrinolysis. SMAO resulted in mild to moderate intestinal injury as assessed by histological analysis, biochemical markers and absorptive capacity. 20 and 40 min of intestinal ischemia and 3 hours reperfusion resulted in local thrombin generation and fibrinogen to fibrin conversion, reflected by a 2.9- and 4.1-fold increase in thrombin-antithrombin (TAT) complex levels and a 2.9- and 2.8-fold elevation of fibrin degradation products (D-dimer), respectively. Administration of ATIII, but not of heparin, resulted in reversion of I/R-induced activation of coagulation, as shown by a 1.9- and 2.1-fold reduction of portal TAT levels and in a 1.5- and 3.2-fold decrease of portal D-dimer levels. In the control group, plasminogen activator activity was suppressed after 20 and 40 min ischemia, as a result of an almost 4-fold increase in portal plasma levels of plasminogen activator inhibitor-1 during reperfusion. Both, heparin and ATIII administration did not change fibrinolytic activity or its inhibition. Activation of coagulation and depression of fibrinolysis resulted in fibrin formation in the control group, as confirmed by intravascular fibrin deposition at histological examination. No such fibrin deposition could be detected in the ATIII-treated rats. Conclusion: Intestinal I/R result in local intravascular coagulation and fibrin deposition that may further compromise the intestinal microcirculation. Systemic substitution of ATIII inhibits local acti-vation of coagulation and reduces fibrin deposition.

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Twenty-four hours gastric tonometry testing: a new promising diagnostic tool for chronic mesenteric ischemia PBF Mensink, RH Geelkerken, AB Huisman, JJ Kolkman. Dept of Internal Medicine/ Gastroenterology, Surgery and Radiology, Medisch Spectrum Twente, Enschede. Gastric tonometry exercise testing (GTET) has become a standard procedure in our hospital for the work-up in patients suspected of chronic mesenteric ischemia (CMI). Some patients are unfit for GTET due to physical conditions. Other patients have a normal vascular anatomy but do have an abnormal result on GTET despite acceptable acid suppression. These patients may suffer from abdominal arterial spasm. Pitfalls in prolonged gastric tonometry are the influence of feeding and acid production on PCO2 measurement in the stomach. In the work-up of patients suspected of CMI prolonged gastric tonometry during feeding has never been used. Methods: Twenty-four hours gastric tonometry with standard meals: breakfast (B), lunch (L) and diner (D). Gastric PCO2 values were collected every 30 minutes. The 24 hours were divided in to 4 periods: 90 minutes after each meal (respectively B, L and D) and empty stomach (ES). Acid suppression was administered intra-venously during registration, 24 hours gastric pH measurement was performed. Patients were kept in resting condition. Results: 16 patients were enrolled in this study, 10 female and 6 male, mean age 54 years. Patients were divided into 4 groups: (1) normal anatomy, retrospective no ischemia, (2) stenotic, retro-spective no ischemia, (3) normal anatomy and ischemia (4) stenotic and ischemia. The groups 3 and 4 show a significant increase of PCO2 levels at ES, group 4 also on period D, compared to group 1. No differences in mean pH were found between the groups. The significant higher PCO2 level at empty stomach in group 3, adds to the notion that these patients may suffer from arterial spasm. Conclusion: 24 hours gastric tonometry with meals can be used in the diagnostic follow-up in patients suspected for chronic mesenteric ischemia. Elevated values of PCO2 after meals and/or at empty stomach may indicate gastric ischemia.

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Jejunal tonometry. Feasibility, normal values and comparison of jejunal with gastric tonometry exercise testing. JA Otte, AB Huisman, RH Geelkerken, JJ Kolkman. Dept of Internal Medicine, Ziekenhuis Zeeuws-Vlaanderen, Terneuzen. Depts of vascular surgery, radiology and gastroenterology, Medisch Spec-trum Twente. Gastric tonometry (GT) exercise testing is a diagnostic function test for chronic GI ischemia. Although often the celiac artery (CA) is involved, doubt remains whether testing in the stomach alone is sufficient if CA is not or not the only vessel involved. Jejunal tonometry (JT) -in the flow region of the superior mesenteric artery (SMA)- could have additive value in patients with (isolated) SMA stenosis. We investigated the feasibility of JT, determined its normal values and compared the results of JT with GT exercise testing. One healthy volunteer (M; 25 yrs) and 26 patients (12 M, 14 F; age 51 (34-75) yrs.) with suspected chronic GI ischemia were tested. Two standard tonometry catheters were used. Under fluoroscopic guidance, one was positioned in the stomach, the other in the jejunum. Automated air tonometry was used to measure intragastric and intrajejunal PCO2 (PgCO2 resp. PjCO2) and intraluminal-arterial PCO2 gradients (∆gPCO2 resp. ∆jPCO2) before, during, and after (submaximal) exercise. All patients were referred to the multidisciplinary working group on GI ischemia in our hospital. Selective splanchnic angiography was used for diagnosing stenosis. A panel decision of the working group was used for diagnosing ischemia. In 25 subjects combined GT/JT was performed successfully. Total insertion time was 12 - 20 min., with a transillumination time of 2 - 5 min. In one patient proper jejunal placement was not possible. In one subject a leaking jejunal catheter yielded unreliable tonometry results. Subjects with normal splanchnic vasculature. The normal resting PgCO2 was 5.0 ± 0.7, PjCO2 5.9 ± 0.9, ∆gPCO2 -0.5 ± 0.5 and ∆jPOC2 0.4 ± 0.5 kPa. The calculated upper threshold of normal ∆jPCO2 was 1.4 kPa. The normal upper thresholds for ∆gPCO2 of 0.8 and for ∆jPCO2 of 1.4 kPa were not exceeded after submaximal exercise. Patients with splanchnic artery stenosis or symptomatic chronic GI ischemia. In 4 subjects both CA and SMA were stenotic; all had symptomatic ischemia. In two only GT was abnormal, in one both GT and JT were abnormal, in the fourth only ∆jPOC2 was borderline elevated. Five subjects had isolated CA stenosis. Both ∆gPCO2 and

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∆jPOC2 were lower compared to the subjects with CA and SMA stenosis: 0.4 and 0.8 kPa vs. 1.0 and 1.6 kPa for ∆gPCO2 and ∆jPOC2 resp. Three patients with isolated CA stenosis had ischemia; in two only GT was abnormal, in the third JT but not GT showed ischemia. One subject had isolated SMA stenosis without ischemia; both GT and JT were normal. In one subject with ischemia due to vascular spasms GT but not JT was abnormal. Other disorders. Two subjects were hemodynamically unstable. They had gastric and jejunal ischemia after submaximal exercise. In one subject with Crohn's disease a marked increase of an already elevated resting ∆jPCO2 of 3.2 kPa was observed, while GT was normal. Conclusion. Combining GT and JT in exercise testing is a feasible procedure that is easy to perform. Normal resting PjCO2 was 0.8 kPa higher than PgCO2. The calculated normal upper threshold of ∆PjCO2 of 1.4 kPa was not exceeded during exercise in subjects with normal splanchnic vasculature. Apart from having additional value in demonstrating jejunal ischemia in chronic GI ischemia, the technique can be used to demonstrate ischemia in other disorders such as hemodynamic instability and Crohn's disease.

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Enteral nutrition protects against hemorrhagic shock induced bacterial translocation. MDP Luyer, ACE Vreugdenhil, JA Jacobs, M Hadfoune, CHC Dejong, WA Buurman, JW Greve. Dept of Surgery and Dept of Medical Microbiology, University of Maastricht. Lipopolysaccharide (LPS) is an important mediator in the patho-genesis of the sepsis syndrome after major trauma or hemorrhage. Translocation of endotoxin into the systemic circulation leading to failure of the gut barrier is probably one of the important initiating events. Therefore, the capacity to neutralize LPS is essential in this group of patients. Triglyceride-rich lipoproteins like LDL, VLDL and especially chylomicrons bind bacterial endotoxin and can inhibit and neutralize the toxic effects of LPS. Chylomicrons are only formed after enteral feeding, however starvation is common in traumatized and hypotensive patients. Therefore, the goal of this study is to upregulate the formation of chylomicrons by enteral feeding in order to increase neutralization of LPS and thereby to decrease the effects of endotoxin like bacterial translocation leading to failure of the gut barrier and sepsis. Anaesthetized male Sprague Dawley rats weighing 300 – 400 gram were subjected to a non-lethal hemor-rhagic shock without resuscitation by withdrawing 2.1 ml/100 gram blood. Rats were monitored for 50 minutes and twenty-four hours later mesenteric lymph nodes, liver and spleen were evaluated for bacterial translocation by using a quantative microbiological culture technique. Rats in the fed group received tube feeding before and just after hemorrhage whereas rats in the unfed group were starved overnight. Control rats were starved overnight and underwent a sham operation. Mesenteric lymph nodes, spleen and liver con-tained mean 535 (0-998) colony forming units (cfu’s) in 8/8 of the unfed hemorrhagic shock rats compared with 22 (0-95) cfu in 3/8 rats of the unfed sham operated group. Enteral feeding decreased the amount of bacterial translocation dramatically; in 4/8 rats no pathogenic bacteria were cultured. In the remaining rats cultures grew pathogenic bacteria with a mean of 69 cfu’s (0-144), p = 0.01. Levels of bacterial translocation in the fed hemorrhagic shock group were comparable with those found in the unfed sham shock group. This study demonstrates that enteral nutrition before and just after hemorrhage improves gut barrier function reflected by a decrease in bacterial translocation.

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The high metabolic cost of a functional gut.* SRD van der Schoor, JB van Goudoever, B Stoll, DG Burrin, JF Henry, JF Rosenberger, PJ Reeds. Sophia Kinderziekenhuis; neonatologie; Baylor College of Medicine, Houston, Texas; Pediatrics, University of Illinois, Urbana IL, USA; Department of Animal Sciences. Protein metabolism in the gut contributes up to 35% of whole-body protein turnover. Previous studies in adequately nourished animals have shown that more than 50% of the dietary protein intake is utilized by the gut and that a large portion of intestinal amino acid utilization is devoted to (glyco)protein synthesis. Subsequently these (glyco)proteins are secreted into the intestinal lumen. Therefore, the degree to which the amino acids in these secretions are recycled could have a substantial impact on their availability for the support of extravisceral amino acid requirements. We determined the net systemic availability of dietary amino acids during a 12-h continuous feeding period followed by a 12-h fasting period in piglets. The simultaneous use of intravenous and intraduodenal infusions of different stable isotopically labeled tracers of lysine and threonine allowed the calculation of their total utilization and recycling. Approximately 70% of the dietary protein was utilized by the portal-drained viscera during the first 6-h of feeding. Over 24-h 48% of the dietary intake was utilized by the portal-drained viscera. Of this, one-third of the amino acids reappeared in the portal vein via recycling, a process that continued for at least 8 h after the cessation of feeding. Thus, intestinal recycling of amino acids contributes significantly to their overall systemic availability and may be a critical factor in amino acid nutrition.

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Orlistat treatment of Gunn rats, especially when combined with phototherapy, decreases plasma bilirubin levels by enhancing the fecal excretion and turnover of bilirubin.* AM Hafkamp, PPE van Lierop, R Havinga, L Pascolo, C Tiribelli, JD Ostrow, HJ Verkade. Dept. Pediatrics, Univ. Hospital, Groningen, The Netherlands; Dept. BBCM, University of Trieste, Italy; Research Svc., Seattle VA Medical Centre, Seattle, WA USA We have shown that, in the Gunn rat model of unconjugated hyperbilirubinemia, dietary supplementation with the lipase inhibitor orlistat (Orl), decreased plasma levels of unconjugated bilirubin (UCB), parallel to an increase in fecal fat excretion (Gastro. 2000;118:1173A). Aim of this study was to determine whether Orl is as effective as phototherapy (PT) in decreasing plasma UCB, and whether Orl enhances turnover and fecal excretion of UCB. Adult male Gunn rats (4-5 per group) were treated for 2 weeks with dietary Orl supplementation (200 mg/kg chow), PT (380-480 nm, 9 µW/cm²/nm), or both (Orl+PT). Plasma UCB was measured by HPLC. In control, Orl and Orl+PT Gunn rats (3-4 per group), ³H-UCB was given i.v. to assess steady-state UCB turnover after 2 weeks of treatment (T0). Plasma ³H and UCB were then measured every 12 hr for two days; turnover was calculated from semilog plots of ³H-UCB sp. act. vs. time. In 4 Gunn rats, fecal UCB was measured by HPLC before and for 2 days after starting Orl treatment. Plasma UCB declined by 34% in Orl (mean±SD; 159±16 µM to 105±13 µM, p<0.01), 28% in PT (135±7 µM to 97±10 µM, p<0.01) and 48% in Orl+PT (145±14 µM to 76±4 µM, p<0.001). Orl+PT was more effective than either Orl or PT (p<0.01). There was a negative linear correlation between plasma UCB at T0 and fractional turnover of ³H-UCB (r= -0.65, p<0.05). UCB pool sizes were similar, but total UCB turnover (nmol/hr per 100g), compared with controls (16±1), was increased in Orl (20±3, p<0.05) and Orl+PT (23±2, p<0.001). Within 48 hr of starting Orl, fecal UCB excretion increased from 0.6±0.2 to 1.3±0.5 µmol/24 hr (p<0.05). Conclusions: Orlistat is as effective as phototherapy in decreasing plasma UCB in Gunn rats; the combination is more effective than either treatment alone. Orlistat increases UCB turnover, apparently by enhancing fecal UCB excretion.

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The effect of equicaloric amounts of medium-chain and long-chain triglycerides on pancreas enzyme secretion. T Symersky, MK Vu, M Frölich, I Biemond, AAM Masclee. Dept of Gastroenterology-Hepatology and Clinical Chemistry, Leiden, University Medical Center, Leiden. It has been shown previously that medium chain triglycerides (MCT) in contrast to long chain triglycerides (LCT) are readily absorbed and do not affect cholecystokinin (CCK) release and gallbladder motility. Use of MCT is considered in conditions where "intestinal rest" is required, for instance "pancreatic rest" after pancreatitis. However, the effect of MCT on exocrine pancreas secretion in humans is unknown. We have therefore compared the effect of enteral administration of MCT versus LCT on exocrine pancreatic secretion. Eight healthy subjects (3 female, 5 male; mean age 22+/-2 years) participated in two experiments, performed in random order. Duodenal contents, obtained by aspiration with recovery marker (PEG 4000) were used to calculate the output of pancreatic enzymes (lipase, amylase) and bilirubin. An equicaloric amount of either MCT or LCT oil (2 kCal/min) was continuously administered in the proximal jejunum for two hours. Gallbladder volume was measured by ultrasonography and blood samples were drawn for determination of CCK (RIA). The experiments consisted of 1-hour basal secretion, 2 hours of continuous oil administration and 1 hour post-stimulation. Results: Lipase output (basal: 61+/-10 KU/h) increased sign. during LCT but not during MCT: 137+/-25 KU/h (p<0.01) and 88+/-21 KU/h resp. Amylase output (basal 15+/-2 KU/h) increased significantly during LCT but not during MCT: 39+/-5 KU/h (p<0.01) and 14+/-3 KU/h resp. Bilirubin output during MCT (15+/-3µmol/h) was not different from basal (14+/-4 µmol/h) whereas LCT significantly increased bilirubin output (51+/-8 µmol/L; p<0.01). Gallbladder emptying during LCT was sign increased over MCT: 61+/-5% vs 6+/-3% (p<0.05). MCT did not affect CCK levels in contrast to LCT: 114+/-30 pM.180min. We conclude that enteral administration of MCT in the proximal jejunum does not stimulate exocrine pancreatic secretion nor gallbladder contraction or CCK release, in contrast to an equicaloric amount of LCT.

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Effect of oral Lactobaccillus rhamnosus supplementation on IL-2 production and IL-2 receptor expression in healthy indivi-duals and patients with Crohns Disease. H Braat, H Kroes, DW Hommes, JMH van de Brande, A te Velde, EAF van Tol, SJH van Deventer. Dept of Experimental Internal Medi-cine, Academic Medical Center, Amsterdam and Numico Research BV, Wageningen. Aim: Determine the effect of oral Lactobacillus rhamnosus supplementation on systemic cytokine production and interleukin 2 receptor expression by naive and memory T lymphocytes. Methods: Five healthy individuals and five patients with Crohns disease gave informed consent for a two week daily oral intake with 1x1010 CFU Lactobacillus rhamnosus. CD4+ PBMC were sorted before and directly after the regimen in CD45RBhigh and CD45RBlow subsets. After 72 hours stimulation with CD3/CD28 supernatants were harvested and tumour necrosis factor alpha, interleukin 2, interleukin 4, interleukin 5 and interleukin 10 were measured by Cytometric Bead Array. Interleukin 2 receptor expression was determined by FACS analysis in the CD4+CD45RB+ cells. Results: Oral supplementation with Lactobacillus rhamnosus resulted in inhibition of cytokines involved in T cell proliferation, in patients with Crohns Disease cytokines that were upregulated compared to normal controls were also decreased. The expression of the interleukin 2 receptor was decreased after probiotic supplementation. Conclusion: Lactobacillus rhamnosus appears to have a suppres-sive effect on systemic immune responses. This effect was not accompanied by the generation of regulatory cells. Patients with Crohns Disease may benefit from these effects of Lactobacillus rhamnosus.

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Study on the occurrence of dysplasia and intestinal metaplasia in longstanding achalasia. GE Boeckxstaens, JJ Bergman, CB Verkleij, F ten Kate, GNJ Tygat. Divisions of Gastroenterology & Hepatology and Pathology, Aca-demic Medical Center, Amsterdam. In a recent retrospective study, we observed a relatively high mortality rate due to esophageal carcinoma in a cohort of patients with longstanding achalasia. This finding raises the issue of screening for premalignant lesions such as intestinal metaplasia and dysplasia. Therefore, the present study was designed to evaluate the presence of these abnormalities in patients with longstanding achalasia. Patients with achalasia, treated for the first time with pneumodilation > 5 years ago, were invited to undergo an upper endoscopy, combined with lugol staining and/or fluorescence endoscopy. During endoscopy, biopsies were taken for routine histological investigation at the level of the esophagogastric junction and in each quadrant every 2 cm over the entire length of the esophagus. In addition, biopsies were taken from areas suspicious for dysplasia, as indicated by lugol staining or fluorescence endoscopy. 35 patients (21 M, 32-86 yr.) participated in the study. 20 patients were diagnosed and treated > 15 yr. ago, 12 patients between 10 and 15 yr. ago, and 7 patients between 5 and 10 yr. ago. All patients underwent fluorescence endoscopy combined with lugol staining in 17. At the esophagogastric junction, 9 out of 35 patients showed endoscopic and/or microscopic signs of inflammation, whereas intestinal metaplasia was present in 4 patients. Lesions with abnormal fluorescence were observed in 4 patients, but microscopic investigation did not show dysplasia. In contrast, 3 of the 17 patients who underwent lugol staining had a suspicious lesion, of which one showed low-grade dysplasia. This lesion was not detected by fluorescence endoscopy. Repeat endoscopy one year later revealed again low grade dysplasia. Conclusions: Intestinal metaplasia is present in 11 % of patients with longstanding achalasia. Although most patients were treated more than 10 years ago, mild dysplasia was present in only 3 %, questioning the need for endoscopic screening. Further follow-up of this cohort will be important to confirm this conclusion.

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Longterm results of pneumatic dilatation in achalasia; a pros-pective study P Scholten, E Ong, EJ Kuipers. Department of Gastroenterology and Hepatology, Erasmus MC / University Medical Center, Rotterdam Between 1975-2001 392 patients were referred to our hospital with a clinical suspicion of achalasia. All patients were studied by means of complete history, physical exam, barium esophagography, upper GI endoscopy and esophageal manometry.If achalasia was confirmed patients were treated on 3 consecutive days with pneumodilatation (PD) using 30-35-40 mm balloons, positioned under fluoroscopy.In case of pain or fever, a control esophagogram was made. All patients were diagnosed, treated and followed according to a strict protocol with repeated esophagography, upper GI endoscopy (including esophagus biopsy sampling) and esophageal manometry after 3 months and yearly for 7 years. After 7 years follow up was restricted to 2-yearly endoscopy with biopsies of the distal esophagus. Either recurrence of complaints or progressive dilation or elongation of the esophagus was a reason for re-PD. Out of 392 patients, 378 were diagnosed with primary achalasia. >From these 378, those who have died and those with a minimal follow up of 5 years were selected for this study, resulting in 276 patients (136 men, mean age 52 years, mean follow-up 131 months, range 0 to 311) of whom 41 were lost, 97 died and 138 still in follow up. The first PD was succesfull in 189 patients (68%); 87 needed retreatment (80 PD, 7 myotomy) after an average of 41 months. This 2nd PD led to persistent remission in 54 pts (67%), 33 needed a 2nd retreatment (25 PD, 8 myotomy) at an average 57 months later. The succes of this 3rd PD was 64%, 9 patients needed a 3rd retreatment (all PD) after an average of 21 months. These patients showed no relapse after an average follow up of 91 months after the last treatment.In the first 276 PD there were 9 perforations, all treated conservatively. With re-PD there were overall 4/130 perforations (3%), all succesfully treated conservatively. PD for primary achalasia is safe and effective, both initially and for re-treatment. Success rates for 1st and later treatments remain consistently 60-100%. PD is therefore the 1st treatment in primary achalasia, both initially and with retreatment.

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Increased deoxycholic acid bile concentrations correlate with longer columnar-like epithelium segments in the esophagus of rats RR Sital, FWM de Rooij, RWF de Bruin, JG Kusters, JLD Wattimena, EJ Kuipers, PD Siersema. Depts of Gastroenterology & Hepatology, Internal Medicine and Surgery, Erasmus MC / University Medical Center Rotterdam. Bile acid reflux is implemented in the pathogenesis of Barrett’s esophagus (BE). In this study we used a rat-model to induce bile acid reflux. Wistar rats (n=46) were divided in 2 groups. Group I was Sham operated, group II received an esophagojejunostomy with gastrectomy (EJG). All rats received acidified drinking water (pH 1.8) supplemented with 500 U/ml pepsin and were fed a standard diet. In subgroups, either glycine was added to drinking water, or glyco-deoxycholic acid (GDCA) was added to the diet for 6 months. Bile was collected by cannulating the common bile duct. Concentrations of cholic acid (CA), chenodeoxycholic acid (CCA), deoxycholic acid (DCA) were measured with gas chromatography. The length of columnar-like epithelium (CLE) was determined. GDCA supplemen-tation resulted in a two-fold increase in DCA content (from 0.4 to 0.8 mmol/L) in group I (p<0.02). After EJG, in all subgroups a further increase in DCA content was observed (p<0.01), however this increase was more pronounced in the GDCA supplemented group (3.4 mmol/L) than in the standard diet group (2.3 mmol/L) and glycine supplemented group (2.4 mmol/L). While none of the animals of group I had CLE, 19/20 animals of group II had de-veloped esophageal CLE. Linear regression analysis was performed taking into account the length of the CLE segment and the different DCA, CCA and CA concentrations in bile in the different EJG groups. Of these, only DCA in rats supplemented with GDCA displayed significant correlation with CLE length (R2= 0.96; p<0.03). Conclusions: Dietary supplementation with GDCA changes the bile pool in rats. EJG results in CLE and in a dramatic increase of DCA in bile. The observed relationship between length of CLE and concentration of DCA in bile of rats suggests that bile acid com-position plays a role in the pathogenesis of Barrett’s esophagus. The elevated DCA levels in bile must be the result of increased bacterial dehydroxylation. Bacteria normally only reside in the colon, but as result of an EJG induced loss of acid production a significant number of bacteria will now be present in the small intestine as well. This may have implications for individuals with bacterial overgrowth, e.g., as induced by long term use of PPIs. (Supported by a grant from AstraZeneca BV).

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Duodenal juice, but not human bile alone affects the growth of Helicobacter pylori. RR Sital, JG Kusters, FWM de Rooij, JLD Wattimena, EJ Kuipers, PD Siersema. Depts of Gastroenterology and Hepatology and Internal Medicine, Erasmus MC / University Medical Center Rotterdam. Barrett’s esophagus (BE) is a premalignant condition caused by chronic duodenogastro-esophageal reflux. Based on the lower prevalence of Helicobacter pylori in BE patients, it has been sug-gested that individuals infected with H. pylori may be protected against the development of BE. We investigated the effect of bile and duodenal juice components on H. pylori. Inhibition of bacterial growth by human bile was tested with a disc diffusion test on Columbia agar plates with four CagA-positive (G27, 26695, HV 89, and 151) and four CagA-negative (2022, 2025, 2047, and 2074) H. pylori strains. Human bile was obtained from patients with drains for obstructive bile duct disease, or aspirated from the duodenum after administration of CCK (Kinevac®). As controls, synthetic cholic acid (10 mmol/L) and deoxycholic acid (0.5 mmol/L) were used. Bile samples (15 µl) were applied to discs and inhibition zones (IZ) were determined after 48 hours of incubation. Human bile obtained from liver drains and cholic acid or deoxycholic acid did not affect H. pylori growth (all strains had IZ’s of 0 mm), whereas growth of both CagA-positive and -negative H. pylori strains was substantially affected by duodenal juice (IZ: 2.5 ± 1.2 mm). Heat treatment of the duodenal juice samples (30 min, 100º C) decreased the growth-inhibiting effect (IZ: 1.1 ± 1.2 mm). No significant differences in growth reduction between CagA-positive and CagA-negative strains were found. Elastase was determined in the bile samples as a marker of pancreatic enzymes. As expected, only low amounts of elastase (< 0.04 g/L) were present in the drain samples, whereas significant amounts of elastase were present in all duodenal samples (0.18 - 0.50 g/L). Conclusions: Bile from extrahepatic biliary drains or synthetic unconjugated bile acids did not affect growth of H. pylori, whereas duodenal juice (containing bile and pancreatic enzymes) was toxic. The observation that H. pylori protects against BE is based on the lower incidence of H. pylori in these patients. Our in vitro observation that duodenal juice affects growth of different H. pylori strains might explain the lower incidence of H. pylori in BE patients rather than the claimed protective effect of H. pylori in BE. (Supported by a grant from AstraZeneca BV).

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Metronidazole (MET) and Clarithromycin (CLAR) resistance of H.pylori: a survey RJLF Loffeld, C Feijen Dept of Internal Medicine and Microbiology, De Heel Zaans Medisch Centrum Zaandam. Successful eradication of H.pylori significantly decreases if resis-tance to MET or CLAR exists. The occurrence of antibiotic resis-tance is described to vary between people of different countries. Not many data are present on the yearly incidence of resistance, and results of antibiotic sensitivity testing are seldom related to people of different ethnic origin living in the same region. A cross-sectional study was done in order to assess primary resistance of MET and CLAR and relate the results to ethnicity. All consecutive cultures in a 5.5-year period were included. Three groups of patients were present: people of Turkish descent, people originating from Africa and the Middle East, and authentic Dutch. Resistance was tested using E-test. Of 3010 cultures 976 (32%) were positive for H.pylori. MET resistance was seen on 25.8% of strains, CLAR resistance in 4.8%. The number of MET resistant strains showed a gradual decrease during the studied period of time, while the number of CLAR resistance showed a slight increase. In the population 269 people were of Turkish descent (group I), 52 patients originated from the Middle East or Africa (group II), the remainder 634 patients (group III) were authentic Dutch. There was no statistically significant difference in gender between the groups. However, the native Dutch were significantly older (p<0.001). Resistance to MET and CLAR in patients from groups I and II was 35% and 9.1% respectively, while this was 21% and 2.9% in cultures from patients of group III. Resistance to MET and CLAR was significantly more often present in patients from group I and II, p=0.003 and p=0.002 respectively. There was no difference in antibiotic resistance between men and women for either of the populations. It is concluded that it is important to take ethnicity into account when studying antibiotic resistance. The number of primary MET resistant strains shows a gradual decrease in the Zaanstreek region while the number of CLAR resistant strains increases slightly.

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A triple basepair mutation in 16S rRNA causes tetracycline resistance in Helicobacter pylori MM Gerrits, MR de Zoete, NLA Arents, EJ Kuipers, JG Kusters. Dept of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Regional Public Health Laboratory Groningen / Drenthe, Hoogeveen. Tetracycline is a commonly used antibiotic for the treatment of Helicobacter pylori infections. Most H. pylori strains are susceptible to tetracycline, but recently an increase in the prevalence of tetracycline resistance has been reported. To our knowledge in the Netherlands the first stable tetracycline-resistant (TetR) H. pylori strain (MIC 8 mg/L) was isolated in 2000 from a 72-year-old male dyspeptic patient. The aim of this study was to identify the molecular mechanism of tetracycline resistance of this Dutch TetR strain. In order to determine the molecular mechanism responsible for this resistance, twelve putative tetracycline resistance genes were selected from the genome of H. pylori, based on homology with TetR genes from other bacteria. The selected genes were amplified from the genome of the TetR strain, and used for the genetic transformation of the tetracycline-sensitive (TetS) strain 26695. As controls for the transformation experiments total DNA of the TetR strain, water, or DNA from the TetS strain 26695 were used. Tetracycline resistance of the TetR strain could easily be transferred to TetS H. pylori strains by genetic transformation. Only the 16S rRNA genes were able to confer tetracycline resistance. None of the other putative tetracycline resistance genes resulted in tetracycline resistance. Genetic transformation of the TetS strain 26695 with smaller overlapping PCR fragments of the 16S rRNA genes, revealed that a 361 bp fragment that spanned nucleotides 711 to 1071 (numbering according to 16S rrnA of H. pylori strain 26695) was sufficient to result in tetracycline resistance. Comparison of the sequences of the TetR strain, the TetS strain 26695 and four TetR 26695 transformants only revealed a triple basepair substitution (AGA927-929->TTC) within this 361 bp fragment. Site direct mutagenesis provided independent proof for the involvement of this triple basepair substitution in tetracycline resistance. In conclusion, a triple basepair substitution, AGA927-929->TTC in 16S rRNA, is responsible for tetracycline resistance in this H. pylori strain. In H. pylori this triple basepair replacement may contribute to an increase in therapy failure.

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Relevance of the IL-1B-511 and the IL-1RN gene polymorphism and their genotypes in peptic-ulcer-disease (PUD) and non-ulcer-dyspepsia (NUD) in relation to the Helicobacter pylori cagA subtype infection. SA Morré, L Murillo, JBA Crusius, Y Pannekoek, RWM van der Hulst, AS Peña, A van der Ende. Dept of Gastroenterology and Laboratory of Gastrointestinal Immunogenetics, Vrije University Medical Centre Amsterdam. Dept. of Microbiology, Academic Medical Center, Amsterdam, Kennemer Gasthuis, Location Johannes de Deo, Dept of Gastroenterology Haarlem. Genetics differences in susceptibility to infection are important, and specific defects in cytokine genes have been reported. Poly-morphisms within the IL-1B and IL-1RN genes are associated with altered protein production and certain haplotypes have been linked to inflammatory disease. People with peptic-ulcer-disease (PUD) and non-ulcer-dyspepsia (NUD) are infected with Helicobacter pylori (HP) but the clinical severity of disease in quite different. We hypothesize that the host genetic factors IL-1B and IL-1RN are involved in the outcome of infection with HP. Since bacterial virulence factors are involved in the course of infection one of the important virulence genes of HP the cagA gene status was also determined. Aim: We investigate whether the IL-1B-511 and IL-1RN gene polymorphism are differently distribuited between PUD and NUD patients in relation to the Helicobacter pylori cagA subtype. Methods: 55 out of 120 consecutive patients were diagnosed with PUD and 65 with NUD. The HP cagA status was determined used PCR and serology. DNA was isolated from sera to analyse IL-1B-511 and IL-1RN gene polymorphisms. Results: 42 out of the 65 NUD patients had a cagA positive HP infection while in the PUD patients 51 out of 55 were cagA positive (P<0.001). The genotype distribution and allele frequency for the IL1B–511 and IL-1RN gene polymorphisms were not statistically significant between the PUD and NUD patient groups: IL1B–511: 1.1=38 vs 46%, 1.2= 33 vs 28%, 2.2=29 vs 26% for IL-1RN : 1.1= 67 vs 66%, 1.2= 24 vs 23%, 2.2= 7 vs 11%, 1.3= 7 vs 0%. Finally, the cagA status within the PUD and NUD patient groups was not linked to the genotype distribution or allele frequency. Conclusions: The polymorphisms in the IL1B–511 and IL-1RN genes were not differently distributed between the HP positive PUD and NUD patients. However, the cagA status of HP was positively associated with PUD.

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Acid-inhibitory effects and pharmacokinetics of pantoprazole 40 mg and omeprazole 20 mg during repeated oral administration: effect of CYP2C19 polymorphism N Srivastava, DJ Touw, CBHW Lamers, WP Geus. Leiden University Medical Centre, The Hague Central Pharmacy and Leyenburg Hospital. The major metabolic pathway of omeprazole (OPZ) is the formation of 5-hydroxyomeprazole by CYP2C19. Pantoprazole (PPZ) undergoes O-demethylation by CYP2C19, which is followed by sulphate conjugation to form PPZ sulphate. The aim of the study was to compare the effect of genotype status on the acid-inhibitory effects and pharmacokinetics of PPZ with that of OPZ. Randomized two-way crossover study in 16 H. pylori-negative healthy Caucasian subjects, whose intragastric pH was below pH 4 for more than 70% of the time during a 24-hr baseline period. CYP2C19 genotype was determined by a PCR-RFLP method. Gastric pH and plasma levels of PPZ 40 mg and OPZ 20 mg were measured at day 1 and 6 of drug administration. CYP2C19 genotype was determined in 14 subjects, 11 were homozygous extensive metabolizers (homEMs) and 3 were heterozygous extensive metabolizers (hetEMs). There were no significant differences in gastric pH and percentage of time spent above pH 4 between hetEMs and homEMs during the baseline period (1.6 vs. 1.6 and 13% vs. 11%). At day 1 of drug ad-ministration median 24-hr gastric pH and median percentage of time with pH > 4 in hetEMs were significantly higher than in homEMs for both PPZ (4.0 vs. 2.0 and 51% vs. 23%) and OPZ (3.8 vs. 1.8 and 49% vs. 18%). At day 6 the differences in median pH and median percentage of time pH > 4 between hetEMs and homEMs were not significant for both PPZ and OPZ. At day 1 and 6 median AUCs (area under the concentration time curve) of PPZ and OPZ in hetEMs were significantly greater than in homEMs. This study shows that at day 1 of administration the acid-inhibitory effect of PPZ and OPZ and median AUCs are significantly affected by CYP2C19 genetic polymorphism. Median AUCs of PPZ and OPZ also are significantly affected by genetic polymorphism at day 6, but that is not attended with a significant difference between hetEMs and homEMs in acid-inhibitory effect.

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A prospective study to determine the value of HLA-DQ typing and serological tests (AGA, EMA, AtTG) in screening for coeliac disease (CD), a step forward to select patients for jejunal biopsy. M. Hadithi, JBH Crusius, M von Blomberg, E Bloemena, CDA Stehouwer, AS Peña. Vrije Universiteit Medical Center, Amsterdam. The gold standard for diagnosis of CD is jejunal biopsy. However, small intestinal biopsy is invasive, costly, time-consuming, and is not free of complications. Because the HLA-DQ2 and HLA-DQ8 confer the primary susceptibility to develop CD, an initial HLA-DQ typing may help to select patients for endoscopy and biopsy. A combination of serology and HLA-typing may increase the detection rate of CD yet spare others the endoscopical examination. The aim of our study is to define the value of HLA-DQ typing in the diagnostic strategy of CD, to identify its relation to histopathological findings and serological tests commonly implemented in daily practice. We present an interim analysis of a study started in January 2001. Adult subjects suspected to have CD were referred for small intestinal biopsy from the outpatient department of internal medicine were requested to participate. In blood samples from 90 biopsied subjects AGA, EMA, tTG antibodies and DQ2/8 typing by PCR-SSCP were performed. Histopathological examination was considered the gold standard. 176 duodenum biopsies were carried out till January 2002. Blood tests were obtained from 112 thus far. CD was found in eight (4.6%) patients: 4 Marsh III, and 4 Marsh I. DQ2 and/or DQ8 was present in a total of 45 subjects, including 4 CD patients. Positive serological tests were identified in a total of 7,3 CD with Marsh III, and 4 with normal small intestine mucosa architecture; PPV and NPV: 42% and 96% respectively). Antibodies were not detected in 4 CD patients (Marsh I) (42% and 96% sensitivity and specificity respectively). 67 patients could have been spared the endoscopy and biopsy. This is the first ongoing prospective study of all biopsied subjects to test the usefulness of DQ typing in the initial diagnostic strategy of coeliac disease. A negative serological test does not exclude the disease but our results so far suggest that a Caucasian patient without the DQ2DQ8 does not have CD. This subgroup of patients will not need the endoscopy and biopsy. Further con-clusions will be more clarifying once study group enlarges.

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Intestinal current measurement (ICM) on rectal biopsies in cystic fibrosis (CF) patients and controls.* M Sinaasappel, I Bronsveld, HR de Jonge. Dept of Pediatric Gastro-enterology, Sophia Childeren’s Hospital, Rotterdam, and Dept of Biochemistry, Erasmus University Rotterdam. In the diagnostic proces of CF the first test performed is the sweat test. However, since CF patients have presented with sweat chloride levels in the borderline (30 - 60 mmol/l) or normal range (< 30 mmol/l) additional approaches are necessary. With the ICM we are able to measure the chloride transport capacity in rectal tissue. To evaluate the value of the ICM as a diagnostic method for CF, we compared the results in patients suspected with CF by characteristic clinical features with previously reported ICM results in CF and control groups (Veeze et al, Gastroenterology 1991; Bronsveld et al, Gastroenterology 2000). In the ICM method a rectal suction biopsy is mounted in an Ussing chamber which surrounds the tissue with salt solution. By adding secretagogues and inhibitors of different chloride secretory pathways to the mucosal and/or serosal side of the rectal tissue, chloride currents can be determined and separated into cAMP and Ca2+-mediated chloride currents. Fourty-nine patients with clinical symptoms varying from chronic upper airway infections, nasal polyps, steatorrhoea or pancreatic insufficiency were investigated by ICM. On the basis of their sweat chloride levels (39.6 ± 20.1) CF diagnosis could not be determined. Therefore, we compared their ICM values with the reported ICM values, which were 43.9 ± 18.9 µA/cm2 (range 11.9 - 110.2) for controls and -4.6 ± 7.4 µA/cm2 (-35.2 - 8.43) for the CF group. In our 49 patients 14 had ICM values in the CF range (1.6 ± 6.9 µA/cm2), while the other ICM results were consistent with control values (37.3 ± 18). In conclusion, patients with a clinical presentation suspected for CF but with inconclusive sweat test results can be identified with abnormal intestinal chloride currents by their ICM results, which support the diagnosis of CF.

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Interleukin-1ß (IL-1ß) stimulates Fos expression in specific subsets of enteric neurons through a cyclooxygenase-depen-dent pathway. ETTL Tjwa, JM Bradley, CM Keenan, ABA Kroese, KA Sharkey. Neurosciene Research Group, University of Galgary, AB Canada; Dept Med Physiology, University of Utrecht, The Netherlands. Pro-inflammatory cytokines may act on the enteric nervous system (ENS) and so alter function through activation of enteric neural circuitry. In this study we examined whether the prototypic inflammatory cytokine IL-1ß causes Fos expression in the ENS, as an indicator of neuronal activation. Isolated segments of ileum and colon were incubated in Krebs buffer (37C) containing IL-1ß (0.1,1 or 10ng/ml) for 60 min in the absence or presence of the cyclooxygenase inhibitor, indomethacin (10uM). After a 60min incubation in Krebs buffer, segments were then processed for immunohistochemistry using an anti-Fos antibody (1:200) together with markers for subsets of enteric neurons. Freshly removed tissue, or tissues incubated in Krebs alone had virtually no Fos expression in neurons of the ENS. IL-1ß caused a concentration-dependent increase in neuronal Fos expression in the ileal (6-61% of total neurons, P<0.05) and colonic submucosal plexus (4-73% of neurons, P<0.001). In the ileal myenteric plexus, Fos expression was restricted to a small proportion of neurons (11-15%, P<0.05) at any concentration, but in the colonic myenteric plexus there was a concentration-dependent increase in Fos expression (16-43% of neurons, P<0.05). All responses to IL-1ß were entirely blocked by indomethacin. In the ileal and colonic submucosal plexus, Fos expression was largely restricted to VIP neurons (about 55% of Fos cells in colon and 80% of Fos cells in ileum) and was totally absent from NPY neurons. In the colonic submucosal plexus, Fos was also found in NOS neurons (35%). In the ileal and colonic myenteric plexus, 46-53% of the Fos cells were NOS neurons, 15-30% were enkephalin neurons. About 35% of neurons expressing Fos could not be accounted for with these markers in the colonic mesenteric plexus. Conclusions: IL-1ß causes neuronal activation in the ENS through a cyclooxygenase-dependent pathway. There are differential effects of IL-1ß in different regions of the GI tract and specific subsets of enteric neurons are activated in these regions.

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Effect of depot long-acting octreotide (oct-lar) on clinical symptoms and quality of life in dumping syndrome. AAM Masclee, C Penning, J Vecht, CBHW Lamers. Dept of Gastro-enterology-Hepatology Leiden University Medical Center, Leiden, Dept of Gastroenterology, Isala-klinieken Zwolle. Background: About 10% of patients after gastric surgery suffer from postprandial symptoms known as dumping syndrome. The long-acting somatostatin analog octreotide effectively reduces symptoms of early and late dumping, however side effects and repeated subcutaneous administration limit its long-term clinical use. Aim of the present study was to evaluate the clinical efficacy of depot long-acting octreotide (OCT-LAR) on dumping symptoms (abdominal, systemic) and quality of life. Methods: Twelve patients after gastric surgery (6F, 6M; age 37-76 yr) suffering from severe, invalidating dumping symptoms requiring daily use of octreotide s.c. (50-300 ìg) were included in an open study and changed from octreotide s.c., after a 4 week washout to OCT-LAR 10 mg i.m. every 4 weeks. At regular intervals the following parameters were scored: abdominal and systemic dumping symptoms (7 days questionnaires), body weight, fecal fat excretion, food intake and gastrointestinal specific quality of life (GIQLI). Results (mean+/-SEM): Systemic and abdominal composite symp-tom score (score 0-10 for 9 items) was 44+/-6 during OCT, 45+/-7 during washout and decreased significantly (p<0.02) to 30+/-5 and 30+/-4 resp. at 1 and 6 months after OCT-LAR. Quality of life (GIQLI; maximum score 144) during OCT-LAR after 1 and 6 months was sign. (p<0.05) higher with values of 93+/-5 and 90+/-4 vs OCT and washout: 74+/-4 and 75+/-6 resp. Body weight at 1 and 6 months use of OCT-LAR was sign (p<0.05) higher versus washout (OCT: 66+/-4 kg, washout 65+/-4 kg, OCT-LAR 1 and 6 months: 69+/-4 and 69+/-3 kg). Fecal fat excretion during OCT-LAR was sign. (p<0.05) lower compared to OCT (27+/-5 vs 48+/-18g/24 h) but remained significantly increased over washout (13+/-5g/24 h). It is concluded that depot octreotide LAR is more effective than octreotide s.c. in 1) reducing dumping symptoms, and fecal fat excretion, and 2) in increasing body weight and quality of life in patients with severe dumping syndrome.

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Comparison between oral ingestion and intake via nasogastric tube to assess drinking capacity. BDJ van den Elzen, GNJ Tytgat, GEE Boeckxstaens. Dept of Gastroenterology, Academic Medical Center, Amsterdam. We recently developed a drinking test and reported impaired drinking capacity in patients with functional dyspepsia (Gastro-enterology 2001;121:1054-1063). Subjective factors however could significantly affect the maximal ingested volume, making the test rather unreliable. Therefore, the drinking capacity assessed by oral ingestion was compared with the maximal volume load via a nasogastric tube. 16 healthy volunteers (27, 20-54 yr.) were invited to undergo a drinking test (water (n=8) or a caloric liquid (Nutridrink, 1.5 Kcal/ml, n=8)) and to receive intragastric infusion of the same liquid (water or Nutridrink) until maximal tolerance on two separate days. The drinking rate and the infusion rate was 100 ml/min. In addition to maximal volume, symptoms (bloating, nausea, pain, satiety, fullness, hunger, burning) were scored at the end of the test, and after 1 and 2 h. The maximal ingested volume of water was 1220 + 104 ml, which was not significantly different from the maximal volume infused via the nasogastric tube (1263 + 102 ml). There was a good correlation between the volumes administered by the two different routes (r = 0.90, p=0.003, Pearson correlation). The mean maximal ingested volume of Nutridrink (1075 + 100 ml) was not significantly different from that infused via the nasogastric tube (1109 + 149 ml), however the correlation between the two methods was not significant (r = 0.64, p=0.09). The symptoms reported after oral intake or intragastric infusion did not differ for both water and Nutridrink. 14 out of 16 healthy volunteers preferred the oral ingestion to the infusion by nasogastric tube. Conclusions: In healthy volunteers, there is very good correlation for water, but not for Nutridrink, between the maximal volume ingested and that infused via a nasogastric tube. These findings suggest that the water drinking test is a more reliable tool than the caloric drinking test to assess drinking capacity, at least in HV. Most likely taste preferences may interfere with the caloric drinking test. Our data however need confirmation in patients.

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3D Transanal ultrasonography: better imaging with an extra dimension. RL West, RJF Felt-Bersma, CEJ Sloots, EJ Kuipers. Dept of Gastroenterology & Hepatology, Erasmus MC/University Medical Center Rotterdam. Transanal ultrasonography (TU) is a well established technique to visualize anorectal disorders. 3D images can be reconstructed with a 2D setup connected to a frame grabbing computer. This extra dimension can provide information on anatomical disorders. Here we determined to what extend 3D transanal ultrasonography provides extra visualization of anorectal disorders. In total 260 consecutive patients (95 males, mean age 50 years, range 15-82) were examined for anorectal disorders using a B&K type Hawk 2102 transanal ultrasound unit connected to a computer with 3D software (Life Imaging Systems Inc.). The anorectal disorders were fecal incontinence (86), perianal fistulas (80), rectal tumors (13), constipation (28) and miscellaneous perianal lesions (53). The procedure is easy to perform. It takes 30 seconds to withdraw the probe slowly and a 3D view is constructed. Better review of images is possible. The sagittal and coronal plain of the anal canal can be visualized. More information on sphincter defects in incontinent patients can be obtained. The position of fistulas in relation to the sphincters and the internal opening of fistulas can be determined. The extent of a rectal tumor in the anal canal can be studied. A new possibility is the measurement of volume. This could be used to study sphincter atrophy (smaller volumes) in patients with fecal incontinence as well as tumor masses. Conclusions: The use of 3D images provides more information on the anatomy of anorectal disorders. Volume measurements of sphincter defects and rectal tumors can be performed.

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Hypnotherapy in irritable bowel syndrome: impact on symptoms, quality of life and visceroperception. M Vidakovic-Vukic, PPJ van der Veek, J Steens, M Steenvoorden, AAM Masclee. Dept of Internal Medicine, Lucas-Andreas Hospital Amsterdam and Dept of Gastroenterology-Hepatology, Leiden University Medical Center, Leiden. Background: Several studies have shown that hypnotherapy is able to improve symptoms of patients with irritable bowel syndrome (IBS) but the mechanism of action is poorly understood. IBS patients have increased visceroperception as demonstrated by rectal barostat studies. Aim of the present study was to explore the effect of hypnotherapy on symptoms, quality of life and rectal motor and sensory function. Methods: Thirteen patients (5 males, 8 females), mean age 40 yrs (range 24-61 yrs) with diarrhea-predominant type IBS (Rome II criteria) and a more than 2 year history of symptoms participated in a prospective open study to evaluate the effect of hypnotherapy. They completed a 10-session standardized hypnotherapy protocol supplemented by home use of audiotapes. Both before and 3 months after hypnotherapy abdominal symptoms, quality of life by SF-36 and rectal motor and sensory function by barostat were recorded. The barostat procedure consisted of a double random staircase procedure with intermittent distensions from 5-33 mmHg. Symptom perception (urge, pain) was scored with visual analog scales (VAS). Results: Hypnotherapy significantly (p<0.05) improved 14 day symptom rating (scale 0-10) of abdominal pain from 5+/-1 to 3.3+/-0.8 and bloating from 4.1+/-0.8 to 3.1+/-0.6 but stool consistency was not affected. Quality of life improved significantly (p<0.05) for the subscales of physical limitations, bodily pain and social functioning. Rectal compliance was not affected by hypnotherapy: 6.9+/-0.8 vs 7.0+/-0.9 ml/mmHg (post vs pre). First sensation of urge was not different post vs pre hypnotherapy: 19+/-2 vs 17+/-1 mmHg but first sensation of pain occurred at significantly higher pressures post therapy: 27+/-2 vs 19+/-1 mmHg (p<0.05). The intensity of urge and pain at highest distension pressures was significantly (p<0.05) lower post therapy. Conclusion: Hypnotherapy significantly improves symptoms and quality of life in IBS patients. Hypnotherapy significantly reduces visceroperception without affecting motor characteristics.

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Effects of anti-TNF therapy on the quality of life in Crohn's disease. BPJ van Balkom, EJ Schoon, RW Stockbrügger, FL Wolters, RA van Hogezand, SJH van Deventer, B Oldenburg, HM van Dullemen, MGVM Russel. Dept. of Gastroenterology & Hepatology, University Hospital Maastricht, Leiden Medical University Center, University Hospital Amsterdam, University Medical Center Utrecht University Hospital Groningen. Infusion of anti-TNF alpha appears to be highly effective in patients with Crohn's disease. The aim of this study was to assess the effect of Infliximab on the quality of life in patients with active or fistulizing disease as measured by the inflammatory bowel disease questionnaire (IBDQ), and to examine the impact on its four dimensions. An open label trial was conducted in 65 patients. An infusion of 5 mg/kg Infliximab was given at week 0 in patients with active disease and at week 0, 2 and 6 in fistulizing disease. Changes from baseline of the total and dimensional IBDQ scores were calculated and compared between both patient groups. Potential predictors of change in the quality of life were identified. In the active disease group, at week 4, mean total and dimensional IBDQ scores improved compared to baseline (P < 0.001). In the fistulizing group, at week 10, all scores changed from baseline (P < 0.01). Improvement of the total IBDQ score correlated well with the improvement of CDAI (R = 0.62). Systemic and social scores improved more than bowel and emotional scores. Active Crohn's disease and young age at diagnosis were predictors for better response to Infliximab therapy. Conclusions: Infliximab therapy improves all dimensions of the quality of life in patients with Crohn's disease.

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Infliximab treatment for Crohn's disease: what have we learned after 500 infusions? DW Hommes, M Hermans, GJ Sterringa, BH van Heisteeg, JFWM Bartelsman, SJH van Deventer. Dept of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam. The aim of this study is to report our clinical experience with infliximab for Crohn's disease (CD) after its registration in the Netherlands in 1999. Infliximab (Remicade) is a monoclonal antibody with specificity for tumor necrosis factor (TNF), a pivotal cytokine in the inflammatory response of Crohn's disease (CD). It has proven to be highly efficacious in healing both ulcerations as well as fistulae. However, it is not known whether the response- and complication rates in the published controlled trials are representative for the clinical efficacy and safety observed in the setting of routine patient care. All 132 consecutive CD patients receiving infliximab infusions were prospectively followed after the drugs' registration in the Nether-lands. Clinical response and adverse events were assessed for both active luminal disease as well as fistulous disease. Associations between response rate and concurrent maintenance therapy were made, and steroid withdrawal was recorded. A total of 579 infusions were administered to 106 patients with active luminal CD and 26 patients with fistulous CD. 45% of patients received more than 3 infusions, 11% more than 10 infusions. The mean duration between infusions was 49 days. In 25% of patients, adverse events were recorded. The response rate was 76% in active luminal CD and 83% in fistulous disease. Response rates were highest in patients receiving concomitant methotrexate as maintenance therapy. Steroids could successfully be tapered off in 73% of responding luminal CD patients and 97% of responding CD patients with fistulae. 16 patients showed a loss of response to continuous infliximab re-administration. Conclusion: Experience with infliximab for active luminal- and fis-tulous CD showed that administration is safe, effective and has high steroid-sparing efficacy. Loss of infliximab response is seen in 12% of patients. Higher response rates were seen with methotrexate as concomitant medication.

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Effect of tumour necrosis factor alpha antibody on circulating gastrin in patients with Crohn’s disease. WPM Hopman, AHJ Naber, DJ de Jong, JBMJ Jansen. Dept of Gastroenterology and Hepatology, UMC, Nijmegen. Tumour necrosis factor-alpha (TNF-alpha) stimulates gastrin release from gastrin producing cells in vitro. Therefore, increased circulating gastrin in patients with H pylori positive gastritis has been attributed to enhanced production of cytokines including TNF-alpha in the stomach. Infliximab, a chimeric monoclonal antibody to TNF-alpha, is an effective treatment for Crohn’s disease. The aim of this study was to determine the in vivo effect of TNF-alpha binding on circulating gastrin in patients with Crohn’s disease and to determine whether this effect is related to the presence of H pylori infection. 25 consecutive patients with Crohn’s disease (10 M, 15 F; median age 39 y, range 22-66 yr) were treated with a single intravenous infusion of 5 mg/kg infliximab. Basal and bombesin stimulated plasma gastrin was measured after an overnight fast immediately before and 2 weeks after infliximab. Results are presented as medians with interquartile ranges. Basal plasma gastrin was 21(16-26)pmol/L before and 19(15-25)pmol/L after infliximab (NS).Infliximab induced a significant decrease of bombesin stimulated plasma gastrin from 49(40-62)pmol/L to 36(33-59)pmol/L (p<0.005). H pylori infection was absent in 22 patients as determined by serology. Bombesin stimulated gastrin decreased from 50(37-62) pmol/L to 36(33-59) pmol/L (p<0.005) in these H pylori negative patients. Conclusion. Neutralization of TNF-alpha with infliximab in Crohn’s disease is accompanied by a decrease of gastrin release in response to bombesin, even when H pylori infection is absent. The data support the hypothesis that TNF-alpha is involved in the in vivo regulation of this gut hormone.

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Methotrexate therapy for Crohn's disease: long-term efficacy and safety. DW Hommes, M DeLey, GJ Sterringa, JFW Bartelsman, SJH van Deventer. Dept of Gastroenterology and Hepatology, Amsterdam. The goal of this study was to report the clinical response and adverse events of MTX in a large cohort of Crohn's disease patients. Methotrexate (MTX) has been shown to induce clinical remission and prevent relapse of disease in patients with Crohn's disease. However, its widespread clinical use is hampered by potential side-effects including hepatotoxicity. A total of 83 patients receiving MTX subcutaneously were followed prospectively from 1998. Disease activity and adverse events were assessed at least quarterly. A questionnaire, addressing feasibility of self-administration, patients' experience and preference over other immunomodulatory drugs was completed. Reasons for initiation of MTX were active disease (82%) and azathioprine intolerance (26%). The majority of patients were treated with 25mg/week for remission induction and 15mg/week for maintenance therapy. Clinical remission was achieved in 80% of patients. Seventeen patients discontinued MTX during follow-up (mean 9.2 months) because of lack of response (10), side-effects (5) or other reasons (2). Of the 33 patients that continued MTX during an average period of 21.2 months, 70% maintained clinical remission, 24% suffered from moderately active disease, and 6% from active disease. A response rate (96%) was observed in 25 patients receiving infliximab concomitantly. 77% said to have had adequate information and instructions about MTX administration, and 36% were taught self-administration in the outpatient clinic. Side-effects, occurring in 72% of patients, included nausea, loss of appetite, abdominal pain, coughing, shortness of breath and arthralgia. Pain and hematoma around the injection site was reported in 40% of patients. Asymptomatic elevation of liver enzymes occurred in 30%. Patients treated with both immunosuppressive drugs preferred MTX (49%) over azathioprine treatment (41%). Conclusion: MTX is efficacious for Crohn's disease, side-effects occur frequently but only result in discontinuation in 10%. Patients treated with combination of MTX and infliximab show a high rate of response.

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6-Thioguanine seems promising in azathioprine intolerant patients DJ de Jong, LJJ Derijks, LGJB Engels, JBMJ Jansen, PM Hooymans, CJJ Mulder. Dept of Gastroenterology, University Medical Center Nijmegen, Dept of Clinical Pharmacy and Gastroenterology, Maasland Hospital Sittard, Dept of Gastroenterology, Rijnstate Hospital Arnhem. 6-Mercaptopurine (6-MP) and its prodrug azathioprine (AZA) have proven efficacy in the treatment of inflammatory bowel disease (IBD). However, adverse-events (AE) leading to discontinuation may occur in 10-20% of patients. Most common AE are nausea, vomiting and myelosuppression. The efficacy of AZA and 6-MP correlates with blood levels of active 6-thioguaninenucleotides. Aim of the study was to assess the short-term safety of 6-thioguanine (6-TG), administered orally in AZA/6-MP intolerant patients. 31 IBD patients with AZA/6-MP related AE and prolonged indication for immunosuppressive therapy were treated with 6-TG tablets (Lanvis, Glaxo-Welcome) in a dose of 20mg (n=20) or 40mg (n=11) once daily. Before (t=0), and after onset of 6-TG (t= between 2 and 12 weeks), AE were reported, laboratory parameters were obtained and 6-TG levels in erythrocytes were assessed. Within 12 weeks, 5 patients in the 20mg group (25%) and 2 in the 40mg group (18%) discontinued 6-TG due to AE. The following AE were observed: hepatitis (n=1), nausea and vomiting (n=2) and fever/chills (n=1), which resolved after discontinuation of 6-TG. In 3 patients, the relation of the AE with 6-TG was unclear (arthralgia (n=1) and malaise (n=2)). 6-TG blood levels (in pmol/8x108 RBC) were higher in the 40mg group, compared with the 20mg group (20mg: 790 ± 374; 40mg: 1393 ± 752; p<0.05). The mean dose of 6-TG in mg/kg body weight was 0.40 ± 0.03 mg/kg. A positive correlation was observed between the weight-corrected dose and the 6-TG bloodlevels (correlation coefficient 0.45; p<0.05). No myelotoxicity of 6-TG was observed. Leukocyte counts, platelets and hemoglobin levels did not decrease after onset of 6-TG (respectively from 11.5 ± 3.9 x109/l to 11.2 ± 4.5, 343 ± 86 x109/l to 347 ± 89 and 7.8 ± 1.8 mmol/l to 8.0 ± 0.9). Conclusion: 6-TG administered orally is a promising alternative in AZA/6-MP intolerant patients. Overall, in 23% of these patients 6-TG was discontinued due to possibly related AE. The 6-TG blood levels on 20 to 40mg once daily were high compared to levels observed in AZA or 6-MP treated patients. However, despite high blood levels of 6-TG, no myelotoxicity was observed.

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NOD2 and Crohn's disease: healthy homozygous carriers of 3020insC mutation. K van der Linde, PPC Boor, JJ Houwing-Duistermaat, EJ Kuipers, JHP Wilson, FWM de Rooij. Depts of Gastroenterology and Hepatology, of Internal Medicine and of Epidemiology & Biostatics, Erasmus MC / University Medical Center, Rotterdam. Genetic susceptibility plays an important role in chronic inflammatory bowel disease (IBD). A major step forward has been the discovery of the 3020insC mutation in exon 11 of the NOD2 gene within the IBD1 locus, which was highly associated with Crohn's disease (CD). This frameshift mutation is thought to result in an altered monocytic response to bacterial components. The goal of this study was to evaluate NOD2 3020insC in Dutch multiple affected families with IBD. Ninety-three Caucasian multiple affected families with IBD were recruited by interviewing patients attending the University Hospital Rotterdam. Sixty-one probands had CD, and 32 probands ulcerative colitis (UC). The diagnosis of probands and affected family members was verified according to standard criteria. In addition, 81 healthy unrelated controls were included. Genomic DNA was isolated from venous blood of all participants to determine the NOD2 3020insC mutation by using an allele-specific PCR, followed by agarose gel electrophoresis. Fourteen probands with CD, one proband with UC, and 3 healthy controls were positive for the mutation. In 3 families, CD-affected probands were found who were homozygous for the NOD2 3020insC mutation. The genotype frequencies in the controls were in Hardy-Weinberg equilibrium proportions (p=0.87). The allele frequency was 14% among patients with CD, and almost 2% in UC and controls. The frequency of the frameshift mutation was significantly higher in CD cases than controls (allelic odds ratio of 8.6; p<0.0001, Fisher exact test). No association was found with UC. In one of the families of the homozygous probands, 4 relatives (45-82 years) were identified as homozygous for NOD2 3020insC but without symptoms or signs of IBD. CONCLUSIONS: This study confirms the association of NOD2 3020insC with CD. However, homozygous carriage does not always lead to CD. Other mechanisms must be involved in the pathogenesis of CD.

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More severe course of Crohn's disease in affected sib-pairs. S Bekkers, J van Dieren, K van der Linde, EJ Kuipers. Dept of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, Rotterdam. Epidemiological studies have shown that genetic susceptibility plays an important role in Crohn's disease (CD) and ulcerative colitis (UC). Several studies suggested a more severe course of inflammatory bowel disease (IBD) in familial cases, with lower age of disease onset, and more extensive bowel involvement. The aim of this study was to evaluate the severity of IBD in familial cases within a Dutch population. Eighteen CD- and 19 UC-affected Caucasian probands with one or more siblings affected with IBD were included in this study. The probands were evaluated via a standard interview, and review of their medical records for date of first symptoms and diagnosis, number of symptoms and signs, location of the disease, surgical history, fistulas, smoking, and medication. For each proband an unrelated control with IBD was selected, matched for sex, age, and disease type. Student's t-test, Wilcoxon rank sum test, chi-square test, and chi-square trend test were used for statistical analysis. Compared with matched sporadic cases, familial CD patients had a more extensive disease involvement as colon and small bowel were significantly more often affected simultaneously (p=0.01). Familial CD patients also presented with symptoms at earlier age (p=0.05), and the use of azathioprine was more common in familial cases (p=0.03) compared to controls. There was a trend for an earlier diagnosis of disease in familial CD patients (p=0.06). All other evaluated parameters were not significantly different. In UC no difference was found between familial and sporadic cases for any parameter. Comparing all familial IBD patients with controls, familial cases had more often undergone resection (p=0.03). CONCLUSIONS: CD but not UC is more severe in patients with a positive family history than in sporadic patients. The results suggest that genetic factors play a more important role in CD than in UC.

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Relation between CARD15 (NOD2) frameshift mutation and Vienna Classification in Crohn’s disease. RC Mallant-Hent, L Murillo, AM Sambuelli, BZ Alizadeh, S Negreira, J Bai, JBA Crusius, AA van Bodegraven, AS Peña. Dept of Gastro-enterology, VU Medical Center, Amsterdam, Laboratory of Immuno-genetics, VU Medical Center, Amsterdam, Laboratory of Cilincal Immunology, VU Medical Center, Amsterdam The Netherlands, Bonorino Udaondo Gastroenterology Hosp Buenos Aires, Argentina. The CARD15 3020InsC frameshift mutation, a major factor for the susceptibility to Crohn’s disease (CD), is thought to lead to LPS hypo responsiveness. Vienna Classification subdivides patients with CD according to age at onset, localization and behavior of disease. We established the frequency of the mutation and investigated its relation with subgroups of both Argentinean and Dutch patients with CD and the relation with the Vienna Classification. 130 Dutch and 116 Argentinean unrelated patients with CD were analyzed for the presence of the CARD15 3020InsC frameshift mutation by multiplex PCR. Ki2 statistics and logistic regression were used for statistical approach. The strength of associations is expressed as OR.14 (12%) of the Argentinean and 16(12.3%) of the Dutch patients were heterozygous; 3(2.3%) of Dutch patient but none of the Argentinean patients were homozygous for the CARD15 frameshift mutation. In the Dutch patients, the frequency of being carrier for the rare variant was 15/111 (13.5%) for early onset (<40 years) CD (P=0.39). The prevalence of carriership was not different among stricturing (11/59), inflammatory (4/47) and penetrating (4/24) behavior of CD (P=0.32). No significant differences were found among different intestinal locations of the disease (P=0.6). Only colonic involvement was significant predictor of more sever penetrating behavior of the disease (P=0.009). The risks of the Argentinean were 2.81 (95%CI 0.87-9.05) for presenting with colonic involvement and 1.68 (95%CI 0.5-5.5) for early onset CD. In these cases, the stricturing form of the disease had significant higher carrier rate (31.0%) compared to other behavior of the disease (P=0.001). Adjusting for ethnicity and other characteristics of the all patients (n=246), carriers of the mutation had a significantly (P=0.03) higher risk for stricturing behavior of the disease (OR=2.5, 95%CI 1.1-5.6). In spite of low number, in our Dutch and Argentinean patients, carriership of the CARD15 frameshift mutation may not be a significant determinant to clinically defined subgroups of CD. However, the association of stricturing behavior of CD defined by the Vienna Classification emerges the need for further investigations.

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The FAS (TNFRSF6) gene polymorphism at position -670 plays a role in ulcerative colitis but not in Crohn's disease J Wu, B Xia, AA van Bodegraven, JBA Crusius, AS Peña. Laboratory of Immunogenetics and Dept. of Gastroenterology, VUMC, Amsterdam, the Netherlands, the Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, China, and the Wuhan University Zhongnan Hospital, Wuhan, China. An abnormal regulation of apoptosis, involving CD4+ T lymphocytes seems to play a role in the immunopathogenesis of IBD. This could contribute to the intense infiltration of T lymphocytes in the lamina propria of the intestinal mucosa and the skewing of the inflammatory balance towards a TH1 response. It has been recently found that in UC patients, CD45RO+CD4+ T cells are less sensitive to apoptotic signals mediated by Fas, thus suggesting that the Fas-FasL system may contribute to the pathogenesis of UC. We determined whether the G-670A polymorphism in the promoter of the FAS gene is associated with IBD and its phenotypes using a PCR-RLFP method with restriction endonuclease Mval. 234 unrelated Dutch Caucasian IBD patients (124 ulcerative colitis (UC) patients, 58 men/66 women; 110 Crohn's disease patients (CD) 43 men/67 women were compared with two groups of 211 and 88 ethnically matched healthy individuals. No significant difference in allele frequency or genotype frequency of the FAS-670 gene polymorphism was observed between UC or CD patients and healthy controls. Furthermore, the distribution of this polymorphism did not differ among the three variables, age at diagnosis, location and behaviour categorised to the Vienna Classification in Crohn's disease. However, a significant association of this polymorphism with extent of UC was found. Allele A and AA genotype frequencies in left-sided colitis (n=61, 28 men/33 women) were higher than in pancolitis (n=51, 24 men/27 women), 61% vs. 45%, p=0.02, OR 1.88 (1.10-3.20); 38% vs. 14%, p=0.005, OR 3.8 (1.47-9.85). Conclusion: In the Dutch population the FAS G-670A polymorphism does not seem play a role in the susceptibility to UC and CD. However, this polymorphism may contribute to determine the extent of UC since the data show that allele A may protect UC patients from extensive lesions. Some data suggests that this may be due to the possible role of allele A leading to less transcription of Fas. Functional studies will be pursued.

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Severe fatigue in patients with IBD in remission. IM Minderhoud, B Oldenburg, GP van Berge Henegouwen. Dept of Gastroenterology, University Medical Center Utrecht. Many patients with inflammatory bowel disease (IBD), which comprises ulcerative colitis (UC) and Crohn’s disease (CD), complain of fatigue, even when the disease is in remission. Given the high impact on daily life and inability to work as consequences of fatigue, insight in this symptom is important. We studied the prevalence and severity of fatigue in healthy controls and IBD patients, and the correlation with disease activity, quality of life, and biochemical and hematological parameters. Cortisol levels were assessed to evaluate the role of hypoadrenalism in this respect. 74 subjects (39 male) with proven IBD (43 CD) were included. Mean age (± SEM) was 43.5 (± 1.62) years. Subjects with comorbidity known to cause fatigue were excluded, as were subjects on steroid therapy (within 12 months prior to study entry). Disease activity was assessed using the clinical activity index for ulcerative colitis (CAIUC) and the Crohn’s disease activity index (CDAI). Quality of life was measured by the IBDQ, while fatigue was assessed using the multidimensional fatigue inventory (MFI), a 20 item question-naire, which comprises five fatigue dimensions. Routine biochemical and hematological determinations were performed and basal cortisol was determined. Healthy age-and sex matched subjects (n=58) were asked to fill out the MFI to serve as controls. The MFI scores of both UC patients and CD patients in remission were significantly higher than those of controls (both p<0.001), while UC patients in remission tended to be more fatigued compared to CD patients in remission (p=0.05). Patients with moderate disease activity (n=12) were significantly more fatigued compared to IBD patients in remission (p< 0.001). The IBDQ showed a negative correlation with the MFI. No correlation between fatigue and basal cortisol levels or other laboratory parameters was found. Conclusions: IBD patients in remission are more fatigued compared to sex-and age matched controls. We found impressive MFI scores, comparable to MFI scores reported in cancer patients. UC patients in remission tend to be more fatigued than CD patients in remission. These results underscore the need for further research into the pathogenesis of fatigue in IBD patients.

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Work disability and sick leave in Dutch patients with Inflam-matory Bowel Disease: results of a population sampled case-control study. A Bonen, PS Dagnelie, A Feleus, MA Hesselink, JW Muris, RW Stockbrügger, M Russel. Depts of Rheumatology and Gastroenterology University Hospital Maastricht; Epidemiology and General Practice University Maastricht. Inflammatory bowel diseases (IBD) are chronic conditions that might cause a severe impact on social life. To assess possible differences in employment, chronic work disability and sick leave, a postal questionnaire was sent to 984 patients with inflammatory bowel disease and 1504 population controls, unknown with IBD. Age- and gender- adjusted employment and chronic work disability ratios and rates were calculated using indirect standardisation. In subjects in paid employment, proportions of those having an episode of sick leave and lost workdays were analysed. Logistic regression was used to assess the contribution of age, gender, education and course of disease. The results of 680 (69%) patients and 715 (48%) controls could be analysed. For the entire group of patients, employment was 6.5% lower compared to controls (95%CI: 4.0-9.0). Chronic work disability was 17.1% higher than expected (95%CI: 15.1-19.1). In those in paid employment, 60% of patients compared to 53% of controls had experienced one or more episodes of sick leave during the past year (p=0.002). This resulted in 19.2 versus 11.8 days of sick leave per subject per year for patients and controls respectively (p=0.002). Relative to controls, the risk of chronic work disability was more increased in younger (p=0.02) and higher educated (p= 0.02) patients. Course of disease contributed to chronic work disability and sick leave. Conclusion: Work disability and sick leave are significantly more prevalent in inflammatory bowel disease. Relative to controls, the younger and more highly educated patients were especially at risk to be chronic work disabled. Amongst patients, the course of disease is an important determinant of chronic work disability and sick leave.

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Cytomegalovirus in Inflammatory Bowel Disease: prevalence and consequences for therapy. DW Hommes, GJ Sterringa, JFL Weel, JFW Bartelsman, WR Boom, SJH van Deventer. Dept of Gastroenterology and Hepatology, Amsterdam. The goal of this study was to investigate the prevalence and relevance of CMV infection in inflammatory bowel disease (IBD). CMV is known to complicate IBD and to alter the course of the disease predisposing a fulminant outcome. IBD patients visiting the outpatient clinic were analysed for CMV DNA in blood and fecal specimens using a quantitative CMV-PCR. Disease activity was assessed using accepted indices, comedication was reported. Patients hospitalised for steroid refractory UC, were also analysed. Subsequently, CMV copy numbers were followed in time until colectomy or recovery. Of 98 consecutive IBD patients, 38% of UC patients were IgG positive versus 61% CD patients. 40% of UC patients had active disease versus 47% CD patients. Only in 7% of UC, CMV-DNA could be detected in stool specimens versus 3% in CD. No correlation was found between disease activity or comedication. Surprisingly, the prevalence of CMV IgG in 22 hospitalised steroid refractory UC patients was 68%. 77% of patients suffered from pan-colitis, 23% from left-sided colitis. All patients received immunosuppressive therapy concomitant with steroids during viral detection (azathioprine, cyclosporine or combination). All patients had detectable faecal CMV levels, ranging from 1000 and 450.000 copies/ml. In 4 patients sequential analysis was performed. Two patients had high baseline levels of CMV copies both in blood (14.000 resp. 34.000) and in faeces (65.000 resp. 110.000). Ganciclovir (bid 5mg/kg) treatment led to disappearance of CMV DNA in both blood and faeces but colitis continued and colectomy was performed. In samples of two other steroid refractory patients that were not anti-virally treated, levels of fecal PCR copies diminished with improvement of the colitis. Conclusion: The prevalence of CMV reactivation in IBD is low. High CMV copy numbers are found in steroid refractory UC and eradication is not associated with clinical improvement. CMV infection can subside spontaneously with improvement of the colitis. These data suggest that CMV reactivation mainly occurs in steroid refractory IgG positive UC patients and is an epiphenomenon rather than a cause of refractory UC.

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Clinical application of the AMC-bioartificial liver; A phase I clinical study. M-P van de Kerkhove, E Di Florio, V Scuderi, A Mancini, M Dauri, F Calise, RAFM Chamuleau. Dept of Experimental Surgery and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, Liver Transplantation Unit Cardarelli Hospital, Naples and St. Eugenio Hospital, Roma, Italy. Recently a bio-artificial liver (BAL) system has been developed at the Academic Medical Center (AMC) of Amsterdam to bridge patients with acute liver failure (ALF) to orthotopic liver trans-plantation (OLT). The AMC-BAL is based on 10.109 freshly isolated porcine hepatocytes attached as micro-aggregates to a non-woven polyester matrix with oxygenation fibers at site. The BAL is extra-corporally connected to the patient’s circulation by a plasmapheresis circuit. Inside the AMC-BAL there is a direct contact between the porcine hepatocytes and patient’s plasma. After successful testing of the AMC-BAL in small and large animals with ALF, a phase I study in ALF patients waiting for (OLT) has been started in Italy. Here we present the results of the first 7 patients. The age of the patients (2 male and 5 female) ranged from 21 to 55 years. Cause of ALF: Acute HBV infection 3, Acute HAV 1, Acute fatty liver of pregnancy 1, unknown 2. All patients had coma grade 3 or more. The total AMC-BAL treatment time ranged from 8 to 35 hours. Three patients received 2 treatments with two different BAL's within three days. Six of the 7 patients were successfully bridged to OLT. One patient showed improved liver function after two treat-ments and did not need OLT. The patients showed improved neurological condition, more stabile hemodynamics and improved diuresis. Mortality 1/7 due to primary non-function of the graft. No severe adverse events were seen. In two patients a short period of hypotension was observed shortly after starting the system. This was easily corrected by volume repletion and temporary dopamine administration. Follow-up of possible Porcine Endogenous Retro-virus (PERV) infection was tested in five patients (follow-up 1 to 9 months). No active PERV infection was found. Conclusion: Treatment of ALF patients with the AMC-BAL is safe and is able to bridge the waiting time for an adequate liver-graft.

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Acute upper gastrointestinal bleeding; did anything change? ME van Leerdam, EM Vreeburg, EAJ Rauws, AAM Geraedts, GNJ Tytgat. Dept of Gastroenterology, Academic Medical Centre and Onze Lieve Vrouwe Gasthuis, Amsterdam. Eradication of H. pylori, the use of proton pump inhibitors and the beneficial effect of endoscopic therapy all might have influenced the incidence and outcome of upper gastrointestinal bleeding. We conducted a time trend analysis of upper gastrointestinal bleeding in the Amsterdam region, including 13 hospitals and serving a catch area of 1.6 million persons. In 1993/1994 and in 2000 all patients presenting with melena or hematemesis were prospectively collected using a standard case record form. Patient’s demographics, comorbidity, endoscopic data, therapy and outcome were recorded. The incidence of acute upper gastrointestinal bleeding decreased from 59 in 1993/94 to 48 cases per 100.000 persons per year in 2000. The mean age was 67 years for both time-periods. There was no difference in severity of comorbidity. The rebleeding and mortality rate did not change; rebleeding rate was 16% versus 15% and mortality 14% versus 13% respectively for 1993/94 and 2000. In the multivariate analysis, age, in-hospital bleeding and comorbidity significantly contributed to mortality in both time-periods. Peptic ulcer hemorrhage (PUH) was the most frequent cause of bleeding. Among PUH patients there was a small increase in the use of NSAIDs, from 46% to 51% in 2000. Among patients with a history of ulcer disease, NSAID use increased from 34% (1993) to 47% (2000). Endoscopic therapy was performed in ulcer patients with active bleeding or non-bleeding visible vessel in 74% (1993) versus 81% (2000). The use of proton pump inhibitors as additional therapy increased from 42% to 91% (2000). However, rebleeding and mortality rate did not differ for PUH between the two time-periods. Conclusions: There was a small decrease in incidence of upper gastrointestinal bleeding between 1993/94 and 2000. Rebleeding and mortality did not decline during the past 6 1/2 years despite a wider use proton pump inhibitors.

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Prospective first year evaluation of ileoanal pouch function with barostat. J Steens, C Penning, J Brussee, WA Bemelman, AAM Masclee. Dept of Gastroenterology-Hepatology, Leiden University Medical Center, Leiden, Dept of Surgery, Academic Medical Center, Amsterdam. Proctocolectomy with ileal pouch anal anastomosis (IPAA) is surgical therapy of choice for severe ulcerative colitis and colonic polyposis. Up to 50% of patients with IPAA may experience functional impairment. Clinical pouch function improves during the first postoperative year. Our aim was to evaluate prospectively pouch sensory and motor characteristics during the first postoperative year and to compare the results with rectal characteristics of control subjects. Twelve patients with an ileoanal J-pouch (39+/-3 yr; 6 men, 6 women, ulcerative colitis N=12) were studied at 3 and 12 months postoperatively. The results were compared with those obtained in 12 healthy controls (age 42+/-3 yr). Visceral compliance was assessed using an electronic barostat by a pressure distension procedure, during which also sensitivity was scored by visual analogue scales (VAS). The response to a meal was assessed during set pressure (MDP + 2 mmHg). Results: during the first postoperative year pouch compliance increased significantly (p<0.01) from 7.2±0.6 to 10.7+/-0.9 ml/mmHg (rectal compliance 10.6+/-1.1 ml/mmHg). The increase in pouch compliance correlated significantly with a reduction in 24-hr stool frequency (r=0.66, p<0.01). Visceroperception increased during stepwise distensions but was not different between 3 and 12 months or between patients and controls. Postprandial decrease in intra-bag volume was more pronounced in patients (45+/-13% at 3 months, 32+/-15% at 12 months) than in controls (9+/-6%, p<0.05), and residual postprandial pouch volumes were significantly lower in patients at 3 months compared to patients at 12 months (58+/-14 vs 106+/-20 ml; p<0.05). Conclusions: ileoanal pouch compliance increases significantly during the first postoperative year to values in the range of rectal compliance and is related to a decrease in 24-hr stool frequency. Postprandial bag volumes in the pouch increase during the first postoperative year, but remain significantly smaller than those in the rectum. Pouch sensitivity does not change.

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Clinical outcome of patients with combined Budd-Chiari Syn-drome and portal vein thrombosis. JAM Hopmans, PC Groen, EB Haagsma, B van Hoek, TJ Tang, HLA Janssen for the Liver and Thrombosis Study Group. Dept of Gastroenterology and Hepatology University Hospital Rotterdam, Mayo Clinic and Foundation, Rochester, MN, USA, Univ Hospital Groningen, Leiden University Medical Center, The Netherlands. Clinical outcome of patients with combined Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT) is largely unknown. Therapy in these patients is hampered by the fact that portosystemic shunting is difficult due to PVT. We studied the determinants of survival and the influence of portosystemic shunting (PSS) in patients with combined BCS-PVT. In an international multicenter survey 32 patients with combined BCS and PVT were identified. Outcome measures and patient characteristics of the 32 patients were collected by means of a standardized review of the medical chart by one single investigator. Survival was compared to patients with BCS only (n=165). Subgroup analysis was performed for patients with a complete PVT (n= 26) and those with incomplete PVT (n=6). The most important risk factors for combined BCS-PVT were myeloproliferative disease (28%) and hepatic cancer (25%). Median Child-Pugh score was 8 (range 5-12). Median follow-up was 1.57 years (range 0-15). Sixteen patients (50%) died during follow-up.The causes of death were liver failure in 44%, malignancy in 38%, cardiopulmonal in 12% and variceal bleeding in 6%. The 1 and 5-year survival rate was 55% and 43%. Survival was significantly decreased as compared to patients with BCS only (1 and 5-year survival was 80% and 65%; p=0.012). Univariate analysis in patients with combined BCS-PVT showed that age (p=0.01), creatinin (p=0.003) and platelet count (p=0.04) were significantly associated with survival. PSS was performed in 7 patients and liver trans-plantation in 3 patients. PSS nor liver transplantation influenced survival significantly. Patients with incomplete PVT exhibited a better survival (1 year 83%) than those with complete PVT (1 year 50% p=0.28). Outcome in patients with combined BCS-PVT is poor and treatment options are limited. Patients with BCS but without PVT or with incomplete PVT have a better prognosis than patients with complete PVT. Thus, patency of the portal vein appears of major importance for beneficial clinical outcome of patients with BCS. Immediate anticoagulant therapy appears therefore warranted in patients with BCS, not only to improve hepatic outflow, but also to prevent PVT.

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BYK - LECTURE Gastroenterology – Back to the Future M.J.G. Farthing, Glasgow, U.K. The science and clinical practice of Gastroenterology began to develop rapidly in the 19th century with an unprecedented explosion of knowledge in the 20th century. The early anatomical studies prompted the inevitable question, “how does it work?”. Despite expansion of our knowledge of the physiological principals of digestion and absorption few new therapies emerged. However, in the middle of the 20th century drug development for gastrointestinal disease gained momentum and the technological revolution which allowed the abdominal organs to be imaged from within and without brought a reality to the statement, “seeing is believing”. These developments dominated clinical gastroenterology for the re-mainder of the 20th century and lead the rapid expansion of the discipline in most countries worldwide. It has been argued by some that the industry-lead development of drugs to inhibit acid secretion, cure peptic ulcers, to treat chronic viral liver disease and control inflammatory bowel disease have left a void in the further de-velopment of our understanding of the basic biology of the alimen-tary system. Similarly clinicians may have been diverted by the wonders of the imaging world and neglected the wider research agenda. With the exception of cancer, gastrointestinal and liver diseases have a relatively minor impact on mortality in western countries. The public health agenda has demanded that increasing research resources are directed towards cardiovascular diseases and cancer, leaving gastrointestinal disorders relatively under resourced. If the science of gastroenterology is to continue to develop then clinical academics must explore the new biology of the post genomic era, stem cell research, proteomics and bioengineering. Gastroenterologists must interface with the politics of health, recog-nising the increasing expectations from health care services, the expanding requirement for accountability and the absolute require-ment to place the practice of medicine within the social context. Gastroenterologists in Europe need to organise themselves better as it is unlikely that these major issues can continue to be satis-factorily managed at a national level.

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Endoscopic Augmentation of the Lower Esophageal Sphincter. Pilot Study of the Gatekeeper Reflux Repair System(TM) in Patients with GERD P Fockens, MJ Bruno, DP Hirsch, A Lei, GE Boeckxstaens, GN Tytgat, Department of Gastroenterology, Academic Medical Center, Amsterdam. BACKGROUND: Endoscopic treatment of GERD seems to be an attractive alternative to long-term medical treatment. The Gate-keeper Reflux Repair System(TM) (Endonetics, San Diego, CA) is a new endoscopic system allowing the introduction of expandable hydrogel prostheses in the submucosa of the esophagus. After placement the prosthesis swells in 24 hours to its maximum volume. This pilot study was designed to evaluate the feasibility of the Gatekeeper System to place prostheses and demonstrate perfor-mance in treating patients with GERD. METHODS: Patients with reflux symptoms responsive to PPI treatment were invited to participate. After baseline manometry, a 24h pH-metry was per-formed. Only patients with increased acid exposure were included. Between 10/2000 and 6/2001, 10 patients (5M; age 27-63yr) under-went endoscopy for placement of 3 prostheses in the esophagus at the GE-junction. The procedure was performed under conscious sedation. RESULTS: Procedures lasted between 11 and 22 min and were tolerated well by all subjects. Two pts underwent a second procedure to place additional prostheses. Of the total number inserted prostheses, 33/34 (97%) were correctly placed with one prosthesis re-entering the lumen of the esophagus which was endoscopically removed. One patient complained of post-prandial nausea starting 1 week post-placement. No cause was found. All 3 prostheses were endoscopically removed at 3 wks. In the remaining patients, 4 prostheses migrated into the lumen of the esophagus within 1 month. In 1 patient, two prostheses were lost between 3 and 6 months. Median GERD-HRQL scores improved from 23.0 at baseline (off PPI) to 9.0 at 4 wks (n=9) and 7.5 at 6 mos (n=8). The 24h pH-metry improved at 3 mos in 5 of 9 pts and at 6 mos in 6 of 7 pts. Medication use was diminished in 7 of 9 pts. Four were off medication and 3 reduced their PPI-dosage by at least 50%. CONCLUSION: With the Gatekeeper System(TM) it is possible to safely place prostheses in the submucosa of the esophagus with subsequent improvement in patient symptom scores and 24h pH-metry results. Medication use diminished in 78% of patients.

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Molecular evidence for complete reversal of Barrett's oeso-phagus with high-grade dysplasia following argon plasma coagulation alone or in combination with photodynamic therapy. M Hage, H van Dekken, CJ Vissers, W van de Vrie, J Haringsma, EJ Kuipers, PD Siersema. Depts of Gastroenterology & Hepatology and Pathology, Erasmus MC/University Medical Center, Rotterdam. In this study, the efficacy of Argon Plasma Coagulation (APC) and Photodynamic Therapy (PDT) in reversing Barrett?s oesophagus (BO) with high-grade dysplasia was assessed. Between April 2000 and January 2001, six patients (4 M, age 45-75) with high-grade dysplasia in BO, who refused (n=1) or were unfit for surgery (n=5), were treated with 2xAPC (Erbe Argon Beamer, 60 W) with a one-month interval, or with PDT (5-aminolevulenic acid-induced, 1x100 J/cm2 or 2x100 J/ cm2 with a 1-hour interval). One, 4, 8 and 12 months later, 4-quadrant biopsies were taken at 1-cm intervals from the ablated area. Residual BO was treated with APC (60W). Ploidy status and p53 protein overexpression were deter-mined in residual BO by means of in situ hybridisation with a (peri-)centromeric-1 probe and immunohistochemistry. After a mean follow-up of 10.7 months (range: 4-12), complete ablation without microscopical BO was observed in 5 of the 6 patients. Three patients were treated with APC-only. In 2 patients, BO was eradicated after respectively the 1st and 2nd treatment, in 1 patient residual nondysplastic BO remained. Three patients were treated with PDT+APC. High-grade dysplasia regressed to low-grade dysplasia in 1 patient after PDT (double light dose), in the other 2 patients (single light dose) after APC. In all 3 patients, BO was completely ablated after additional APC. Aneuploidy and p53 overexpression decreased along with the downstaging of dysplasia in all patients, but one. In that patient p53 overexpression even increased (from 23% to 57%), but no aneuploidy was found. One patient developed a stricture after APC, which could be treated by dilatation. Conclusions: (1) Both PDT plus APC and APC alone are effective in eradicating BO harbouring high-grade dysplasia. (2) Residual BO may still contain "genetic" abnormalities. Further studies with a longer follow-up are needed to study the risk of progression in residual BO underneath complete re-epithelialisation. Until then, the primary goal must be a complete reversal of BO, instead of downstaging dysplasia.

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Re-intervention after self-expanding metal stent placement for palliation of esophageal carcinoma. MYV Homs, M van Blankenstein, J Haringsma, EJ Kuipers, PD Siersema. Dept of Gastroenterology & Hepatology, Erasmus MC/ Erasmus Medical Center Rotterdam. To investigate the occurrence and causes of recurrent dysphagia after self-expanding metal stent placement for palliation of esophageal carcinoma, and to evaluate the outcome of re-intervention. Two-hundred sixteen patients underwent placement of a self-expanding metal stent (Ultraflex, n=75; Flamingo Wall, n=71; Gianturco-Z, n=70) for malignant dysphagia, and were followed prospectively. We evaluated the causes of recurrent dysphagia, including time interval after first stent placement, procedures used for treatment, and survival after re-intervention. Recurrent dysphagia occurred in 63 (29%) of the patients, due to tumor overgrowth (n=30; median of 129 days), migration of the stent (n=26; median of 92 days), food-bolus impaction (n=16; median of 80 days), and/or fracture of the stent (n=2). Tumor overgrowth was treated in 18 (69%) patients with placement of a second metal stent, various other treatments (n=7), or no further treatment (n=5). Re-intervention was successful in 23/25 (92%) (23/25) patients and dysphagia score (scale: 0 = normal to 4 = complete dysphagia) improved from a median of 4 to 1 (p=0.001). Stent migration was treated with placement of a second stent (n=14), repositioning of the migrated stent (n=7), brachytherapy (n=2), a feeding tube (n=1), or no further treatment (n=2). Here re-intervention was successful in 20/24 (83%) patients, and median dysphagia score improved from 3 to 2 (p=0.001). Food-bolus impaction was treated with endoscopic stent clearance in all patients. Median survival after re-intervention was 64 days for tumor overgrowth, 65 days for stent migration , and 81 days for food-bolus impaction. Conclusions: Recurrent dysphagia after stent placement for malignant dysphagia occurs in one third of the patients. Both tumor overgrowth and migration could generally be treated successfully by placement of a second stent, or by repositioning of the stent in case of migration. Re-intervention for recurrent dysphagia in patients is likely to improve their quality of life.

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Covered metal stents for the treatment of non-malignant perforations of the esophagus. MYV Homs, HW Tilanus, J Haringsma, EJ Kuipers, PD Siersema. Dept of Gastroenterology & Hepatology and Surgery, Erasmus MC/University Medical Center Rotterdam. Perforation of the esophagus caused by vomiting (Boerhaave's syndrome), a medical intervention, or trauma, and presenting >24 hours after its occurrence is a life-threatening condition generally mandating surgical intervention. However, placement of a metal stent may be an alternative in selected patients. Between March 1998 and November 2001, eight patients (5M/3F), with a mean age of 64 (range 38-91) years, presented with eso-phageal perforations caused by Boerhaave's syndrome (n=4), resection of an epiphrenic diverticulum (n=2), an endoscopic procedure for removal of a gastric balloon (n=1), and an unknown cause (n=1). The interval between perforation and stenting ranged from 24 hrs - 3 wks. Six patients had developed (bilateral) pleural effusion(s). In 6 patients a covered Flamingo Wallstent (length: 14 cm, prox./dist. diameter: 30/20 mm) and in 2 patients a covered Ultraflex stent (length: 12 cm, prox./dist. diameter: 28/23 mm) was placed. In addition, antibiotics were administered and pleural effusions were drained percutaneously. The outcome and compli-cations were evaluated. Total closure of the perforation was achieved in 7 of 8 patients. In one patient, an esophageal resection was needed 4 days after stent placement, because of incomplete drainage. The other 7 stented patients resumed a normal diet within 7 days. No complications were observed. Five metal stents were successfully retrieved endo-scopically after a median of 7 weeks (range 6.5 - 12 weeks), whereas 2 patients refused retrieval of the stent (in 1 patient the stent migrated to the stomach, the other patient died after 6 months from an unrelated cause). Conclusions: Patients with delayed perforations of the esophagus can be treated successfully with covered metal stents, on the condition that adequate drainage of the thoracic cavity can be established.

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Prior radiation and/or chemotherapy for esophageal carcinoma has no effect the outcome of self-expanding metal stent placement. MYV Homs, BE Hansen, J Haringsma, M van Blankenstein, EJ Kuipers, PD Siersema. Dept of Gastroenterology & Hepatology, Erasmus MC/University Medical Center Rotterdam. To evaluate the influence of prior radiation and/or chemotherapy (RTCT) on the outcome of self-expanding metal stent placement in patients with inoperable esophagogastric carcinoma. From October 1994 to December 2000, 200 consecutive patients underwent self-expanding metal stent placement for malignant dysphagia, and were followed prospectively. Forty-nine of these patients had received prior RTCT (chemotherapy n=34, radiation therapy n=8, or both n=7). At 4 weeks after stenting, the dysphagia score had improved similarly in patients with or without prior RTCT, from a median of 3 to 0 (p<0.001). The occurrence of major complications (bleeding, perforation, fistula formation, fever and severe pain) was not diffe-rent between patients with or without prior RTCT (29% versus 21%), as was the number of patients with recurrent dysphagia due to tumor overgrowth, stent migration, or food-bolus impaction (35% versus 27%). Median survival of both patient groups after stent placement was similar (110 versus 93 days). Only the occurrence of minor complications (mainly mild retrosternal pain) was more common in patients with prior RTCT compared to patients without RTCT (41% versus 15%, p<0.001). Conclusion: The outcome and the incidence of major complications after self-expanding metal stent placement for esophagogastric carcinoma are not effected by prior RTCT, however, retrosternal pain occurred more frequently in patients with prior RTCT.

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Newly developing hiatus hernia (HH) in patients undergoing upper gastrointestinal endoscopy. RJLF Loffeld, ABMM van der Putten. Dept of Internal Medicine, De Heel Zaans Medisch Centrum, Zaandam. The presence of a HH is a major risk factor for development of reflux. The prevalence of HH increases with rising age. Data on the number of HH’s developing on a yearly basis in the population are lacking. The only way to study the incidence of HH is study a group of healthy subjects longitudinally applying endoscopy at regular intervals. The present study probably is the second best approach. A cross-sectional study was done in consecutive patients under-going endoscopy in order to assess the yearly incidence of HH. Included were patients in whom no macroscopic abnormalities were seen and who underwent a second upper gastrointestinal endoscopy in the study period of 8 years. The reasons for doing the second endoscopy were recurrence of dyspeptic or reflux com-plaints or newly developed upper abdominal or reflux complaints. A total of 12122 endoscopies was done in 9580 patients. Of these 1277 men and 1213 women had a HH, while in 3477 men and 3613 women no HH. There were no significant differences in gender between these groups. Ninety patients (37 m, 53 w, mean age 59 years, SD 13.5, range 26-84 years) developed a HH. This was not the case in a control group of 353 patients (291 m, 62 w, mean age 49 years, SD 17, range 15-90). Patients who developed a HH were significantly older than those who did not develop the condition (p<0.001). The number of women developing HH was significantly higher (p<0.0001). The time between the two consecutive en-doscopies in both groups was not different; mean 31 months (SD 20, range 2-86) in patients developing a HH versus mean 30 months (SD 20, range 3-97) in patients who did not. Ninety patients out of these 443 patients developed a HH in this period of time. If this is extrapolated to a yearly occurrence than 35 (19.9%) out of 176 patients will develop a HH. It takes an average of 1.9 years for the HH to develop. It is concluded that HH actually develops later in life. This is an argument for the presence of a structural abnormality due to weak-ness and ageing of the diaphragm.

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Prospective Study On The Impact Of EUS-Guided FNA Of Sub- And Supracarinal Lymph Nodes In Patients With Distal Oesophageal Cancer MA Brink, JJGHM Bergman, M Bruno, WA Marsman, ME Smits, JJB van Lanschot, P Fockens. Dept of Gastroenterology and Surgery, Academical Medical Center Amsterdam. Introduction: A recent multi-centre study comparing transhiatal with transthoracic oesophageal resection for distal esophageal cancer have not shown survival benefit for the trans-thoracic approach. Therefore our standard remains the transhiatal procedure. However, a high percentage of metastatic lymph nodes were found in the subcarinal (20%) and paratracheal (8%) area. These LN's can only be resected transthoracically and EUS- guided FNA of these LN's could help in the selection of these patients. The aim of our study is to determine the clinical impact of EUS-guided FNA of sub- and supracarinal LN's in patients with distal esophageal cancer. Methods: In consecutive patients with distal esophageal cancer, EUS-FNA of subcarinal and supracarinal LN's was performed using a Cook-echotip needle. Results: Up till now 10 patients have been included and subcarinal LN's were seen in everyone, in two patients these nodes were classified as suspicious. Four patients had suspicious supracarinal LN's. EUS-FNA confirmed malignancy in 1 of the subcarinal, and 2 of the supracarinal LN's. The surgical approach was changed in two patients. Conclusion: This preliminary data suggest an important role for EUS-guided FNA of mediastinal LN's in the selection of the surgical approach in patients with distal esophageal cancer.

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Transanal endoscopic microsurgery instead of endoscopic resection of benign rectal tumours; is there an indication? R Bakx, ICE Wesdorp, G Brutel, WF van Tets. Depts of Surgery, Gastroenterology and Pathology, Sint Lucas / Andreas Hospital, Amsterdam. Transanal Endoscopic Microsurgery (TEM) is a minimal invasive technique for the resection of benign rectal tumours located 4 to 25 cm from the anal verge. Complete and full-thickness excision of large rectal tumours in one session is one of the main advantages of TEM compared with the piece-meal resection performed by endoscopy in multiple sessions. The in toto excision of the lesion also enables the pathologist to assess more accurately both the deep and lateral margins of the lesion. The TEM procedure is relatively expensive compared to endoscopic resection. The aim of this study was to evaluate whether there is an indication for the introduction of TEM technique for excision of rectal adenomas which are currently resected by endoscopy. All patients who underwent a rectosigmoidoscopy or coloscopy in 2000 with histological exami-nation of material gained during this procedure were retrospectively analysed whether they would have been eligible for the TEM procedure. A total of 315 patients were included; 115 patients had an adenoma, 46 had a carcinoma and 154 patients appeared to have a colitis or no abnormality was found. All patients with a carcinoma were operated and none with an adenoma. The charts and endoscopy reports of 115 patients with an adenoma were analysed. From the 115 patients, six underwent multiple endoscopies with piece-meal resection and only two patients were found suitable for TEM. These patients underwent respectively six and eight endoscopies with resection before the lesion was com-pletely removed. One of these two had a recurrent lesion which was also treated by piece-meal resection. Conclusion: Only two patients with adenomas located in the rectum and treated by piece-meal resection were suitable for TEM. There-fore we conclude that there is no reason for the introduction of TEM in our hospital for the treatment of rectal adenomas.

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CT virtual colonoscopy versus conventional colonoscopy for the detection of colorectal polyps. JM Jansen, MHJ Voormolen, GHA Dodemont, KH Schuur, WNHM Stuifbergen, AWM van Milligen de Wit. Depts of Internal Medicine and Gastroenterology and Radiology, St. Elisabeth Hospital, Tilburg. The aim of the study was a prospective evaluation of the diagnostic accuracy of CT virtual colonoscopy versus conventional colono-scopy as the gold standard for the detection of colorectal polyps. Fifty patients at high risk for colorectal neoplasia and polyps underwent virtual colonoscopy just prior to conventional colonoscopy. The endoscopists and radiologists were unaware of the results of each others examination. After administration of Buscopan® i.v. and pneumatic distension of the colon CT images were obtained in both supine and prone position. CT images were acquired using 5 mm collimation, 3 mm reconstruction interval, a table index of 7 mm at 120 kV and 175 mAs. The grade of patients discomfort was assessed by a questionnaire. Data were complete for evaluation in 42 patients. Conventional colonoscopy showed no abnormalities in 21 patients. In 21 patients with one or more colorectal polyps present on endoscopy, virtual colonoscopy identified polyps in 17 patients. Virtual colonoscopy resulted in 2 false positive findings. Sensitivity, specificity and positive predictive value of virtual colonoscopy for the detection of colorectal polyps were 71%, 91% and 88%, respectively. The sensitivity of virtual colonoscopy appears related to polyp-size (57% for polyps < 1 cm and 100% for polyps >1 cm). The discomfort data show a tendency for the virtual colonoscopy to be more uncom-fortable, however endoscopy was performed under i.v. midazolam sedation. Conclusion: CT virtual colonoscopy versus conventional colono-scopy in patients at high risk for colorectal neoplasia and polyps show similar diagnostic accuracy for polyps larger than 1 cm.

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Basic Endoscopy Training: Use of an Improved Endoscopic Computer Simulator. J Haringsma, SPC Brouwers, EJ Kuipers. Dept of Gastroenterology & Hepatology, Erasmus MC/University Medical Center Rotterdam; Cook Nederland, Son, NL. Gastrointestinal endoscopy is currently taught by hands-on training in a clinical setting. Changes in medical practice limit education time and patient availability, whereas the number of different diagnostic and therapeutic techniques to be mastered has increased. Mecha-nical and cadaveric models have proven inadequate for basic endoscopy training. New computer-based virtual reality simulators with tactile feed-back offer a realistic environment for training many aspects of flexible endoscopy. The simulator provides computer-animated virtual reality endoscopy, based on real-life video-endoscopy cases. During and after each procedure, trainee and trainer receive feedback on relevant items such as duration, scanned percentage of surface, missed lesions, inadequate handling, air insufflation, pain, and 3D-position of the endoscope within the body. A structured 2-day basic training course was developed with theoretical introduction, video demonstrations and 100 minutes of hands-on simulator training using the GI-mentor® (Simbionix, Israel). Ten first-year endoscopy trainees (4F, 6M, mean age 33 yrs) from different teaching hospitals in the Netherlands entered the program. The estimated number of endoscopies performed before the course was 82 (range 0-290). All trainees rated the training as excellent or good. Individual performance on eye-hand-coordination exercises, as scored by time to completion, improved 24.9% (10-33%) over the course of the training. Conclusions: Structured skills training using a computer-based virtual reality simulator is valuable in basic endoscopy training. The simulator offers rapid development of eye-hand coordination and intubation ability. The training program has a high acceptance by the trainees. Structured simulator training should become part of the general endoscopy training.

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HNF-1α, GATA-4 and Cdx2 functionally interact to stimulate sucrase-isomaltase gene expression. * ** EHHM Rings, F Boudreau, HM van Wering, GP Swain, SD Krasinski, ER Shu, RJ Grand, PG Traber. Division of Pediatric Gastroenterology, Dept of Pediatrics, University Hospital Groningen, The Netherlands, Division of Gastroenterology, Dept of Medicine, University of Pennsylvania, Philadelphia, USA, Division of Gastro-enterology, Children Hospital of Boston, Harvard Medical School, Boston, USA. Sucrase-isomaltase (SI) is a critical intestinal disaccharidase. This enterocyte-specific gene is induced during the developmentally regulated suckling-weaning transition. We have previously described that the evolutionarily conserved SI promoter contains DNA regulatory elements that interact with Cdx2, HNF-1α or GATA proteins. Our aim was to study the temporal distribution and functional interaction of Cdx2, HNF-1α and GATA-4 and to elucidate the mechanisms involved in the induction of SI transcription during the suckling-weaning transition. Western blot and immunohisto-chemistry were performed to evaluate the expression and distribution of Cdx2, GATA-4 and HNF-1α proteins during the suck-ling-weaning transition. Physical interaction among the transcription factors was studied by co-immunoprecipitation and GST-pulldown assays. Functional interaction of these factors was determined by transient transfections. The Cdx2 protein was detected in entero-cytes of both the crypt and villus compartments throughout post-natal development, while GATA-4 and HNF-1α proteins were mainly restricted to the villous epithelial cells where SI mRNA is expressed. GATA-4 was expressed in a decreasing gradient of expression along the horizontal axis of the intestine. A marked induction of HNF1α protein level was observed during the suckling-weaning transition. Furthermore, Cdx2, GATA4 and HNF-1α physically interacted in vitro and in vivo and synergistically activated the SI promoter. Conclusion: These observations suggest that Cdx2, GATA4 and HNF1Α may co-exist in a complex and synergistically regulate SI gene transcription. The temporally coordinated and physically re-stricted expression of these transcription factors in the intestinal epi-thelium suggests that they play a role for the induction of SI gene expression during the suckling-weaning transition. (**The first two authors have equally contributed to this work.)

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Similar mechanisms of damage control in small and large intestine? IB Renes, M Verburg, B de Koning, HA Büller, J Dekker, AWC Einerhand. Erasmus Medical Center and Sophia Children’s Hospital Rotterdam. Knowledge of damage control mechanisms in the intestine is limited. Therefore, intestinal epithelial responses were studied after methotrexate (MTX) treatment as a model for small intestinal damage, and during dextran sodium sulfate (DSS) treatment as a model for colonic damage. Thereto, rats were treated with MTX or with DSS. Epithelial proliferation (BrdU incorporation), apoptosis (hematoxylin eosin staining/caspase-3 staining), and morphology were studied. Enterocyte-specific functions i.e. sucrase-isomaltase (SI), glucose transporter 2 (Glut2) and intestinal fatty acid binding protein (i-FABP) expression in the MTX-model, and carbonic anhydrase (CA) I, CA IV and i-FABP expression in the DSS-model and goblet cell-specific functions i.e. mucin Muc2 and trefoil factor 3 (TFF3) expression were analyzed. Alkaline phosphatase activity (AP) was used as marker for enterocyte function in both models. Both MTX and DSS decreased the number of BrdU-positive cells and induced apoptosis in the epithelium. Thereafter, an increase in BrdU-positive epithelial cells was observed in both models. MTX and DSS treatment induced flattening of epithelial cells which coincided with down-regulation of the enterocyte markers SI, Glut2, and i-FABP in the MTX-model and of CA I, CA IV, and i-FABP in the DSS-model. However, in both models AP activity maintained. Goblet cells accumulated in the surface/villus epithelium and continued to express Muc2 and TFF3. Conclusions: MTX and DSS inhibited proliferation and induced apoptosis in the epithelium. The epithelium responded with hyperproliferation and flattening of cells. Con-comitant with epithelial flattening was the down-regulation of specific, but not all, enterocyte functions in both models. This suggests that enterocytes specifically down-regulate distinct functions to prepare themselves for epithelial restitution and defense. Accumulation of goblet cells and sustained expression of Muc2 and TFF3 in both models implies an important role for goblet cells in epithelial protection and repair. Given the similarities in epithelial responses in these dissimilar models it seems justified to assume a common mechanism for damage control in the intestine.

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Serine 60 residue phosphorylation within the Cdx2 activation domain mediates its trans activation capacity. * EHHM Rings, F Boudreau, JK Taylor, J Moffett, ER Shu, PG Traber. Division of Pediatric Gastroenterology, Dept of Pediatrics, Academic Hospital Groningen, The Netherlands, Division of Gastroenterology, Dept of Medicine, University of Pennsylvania, Philadelphia, USA. Cdx2 is a critical transcription factor in intestinal proliferation and differentiation and in intestine-specific gene expression. Modulation of Cdx2 function in response to cellular signaling is to be elucidated. We hypothesize that phosphorylation of the Cdx2 activation domain can modulate its function. The Cdx2 activation domain was delineated in transient transfections using different portions of Cdx2 fused to the Gal4-DNA binding domain. In vivo phosphorylation was studied by metabolic labeling with 32P-orthophosphate. To study a potential phosphorylation site, polyclonal antibodies were generated: CNL was raised against amino acids 54-66 of Cdx2 and P-Cdx2-S60 against the same epitope in which serine 60 was phosphorylated. A critical region for transactivation resides within amino acids 60-70. Substitution of serine 60 with alanine reduces incorporation of 32P-orthophosphate substantially. S60-phosphorylation decreases transactivation by Cdx2 of several intestine-specific genes. Phos-phorylation of serine 60 can be inhibited with the mitogen-activated protein kinase kinase inhibitors PD98059 or UO126. P-Cdx2-S60 recognizes phosphorylated serine 60 mainly in proliferative com-partment of the intestinal epithelial layer. In contrast, CNL recognizes Cdx2 predominantly in the differentiated compartment. Conclusions: The Cdx2 activation domain is phosphorylated at serine 60 via the MAPK pathway. S60-phosphorylated and S60-nonphosphorylated Cdx2 have different transcriptional activity as well as different spatial expression patterns in the intestinal epithelium. We therefore conclude that phosphorylation of the Cdx2 activation domain modulates its function.

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Transcriptional activation of the murine Muc5ac mucin gene by Sp1, Smad4 and GATA-4. * I van Seuningen, M Sutmuller, A Velghe, M-P Ducourouble, M-P Buisine, J-P Aubert, HA Büller, J Dekker, AWC Einerhand. Unité INSERM 377, Lille, France, Lab Pediatrics, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands. Mucin MUC5AC is the major structural component of gastric mucus. In the healthy GI-tract MUC5AC is only expressed by the gastric surface epithelium. Its expression appears in diseases such as Barrett's oesophagus and colon cancer. Little is known about regulation of MUC5AC expression in health and disease. The aims were to obtain gene-regulatory sequences for the murine Muc5ac mucin gene, and analyze its promoter activity. Therefore, the murine Muc5ac 5'-flanking region was isolated and characterized after screening a murine genomic library with a probe spanning 750 bp of the human MUC5AC N-terminus. To assay promoter activity, pGL3-Muc5ac deletion mutants were generated and transfected into the murine rectal cancer cell line CMT-93. By RT-PCR this cell line was shown to express Muc5ac, Muc2 and Muc5b. Sequence analysis of the 5.5 kb fragment revealed a translational start codon (position 3223) and 3 short exons encoding a total of 69 amino acids with 52% identity to human MUC5AC and 78% identity to rat Muc5ac. Analysis of 3.2 kb upstream of the translational start site revealed 4 TATA box-like sequences and putative binding sites for the transcription factors Sp1, Smad, and GATA involved in development and carcinogenesis. Deletion analysis revealed that the -1024/-379 region is essential for basal activity of the Muc5ac promoter. Functional analyses using expression vectors encoding Sp1, Smad4 and GATA-4 factors confirmed their transactivating effect on Muc5ac promoter (2-, 8- and 16-fold, respectively). Furthermore, TGFbeta2 was shown to increase the promoter activity by 2-fold. Conclusions: The N-terminus of mouse Muc5ac is very homologous to human and rat Muc5ac. Deletion analysis of the murine Muc5ac promoter revealed that sequences downstream of -379 are not sufficient for transcriptional activity, whereas a 1024 bp promoter fragment is transcriptionally active. TGFbeta2/Smad4, Sp1 and GATA-4 responsive-elements are present in the -1024/-379 region upstream of the translational start site. These results indicate that Muc5ac expression is under the influence of factors involved both in GI development and diseases.

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Identification of Helicobacter pylori virulence factors by ran-dom mutagenesis R de Jonge, D Bakker, SCL Langeveld, RGJ Pot, EJ Kuipers, AHM van Vliet, CMJE Vandenbroucke-Grauls, JG Kusters. Dijkzigt University Hospital, Rotterdam, Vrije Universiteit Amsterdam. Random insertional mutagenesis has been a versatile tool for the identification of bacterial virulence genes. However, for the human pathogen Helicobacter pylori most strategies for random mutagenesis require cloning in Escherichia coli for passage of plasmids or for phenotypic selection. This may result in biased selection due to toxicity or DNA restriction. Here, we describe a simple, direct mutagenesis technique to create random H. pylori mutant libraries, that are based on insertion of a kanamycin resistance (Kan) cassette followed by double homologous recombination, which do not require passaging through E. coli. Two independent insertional mutant libraries were created and 450 randomly selected mutants of each library were stored at -80°C. Insertion of the Kan cassette was demonstrated to be random by Southern hybridization. The libraries were screened for two pro-cesses important in H. pylori pathogenesis: urease activity and cyto-kine induction in monocytes. Two mutants did not express the active urease enzyme, due to absence of the UreB enzyme subunit. Screening the libraries for cytokine induction revealed one mutant that showed a >70% decrease compared to wild-type H. pylori. The insertional mutagenesis technique has been successfully used for the identification of virulence factors and immunogenic factors of H. pylori. These factors are believed to be essential for patho-genesis, colonization or survival.

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MUC5AC is the primary receptor for H. pylori in human stomach. JHB van de Bovenkamp, AM Korteland-Van Male, T Boren, HA Büller, AWC Einerhand, J Dekker. Laboratory Pediatrics and Sophia Children’s Hospital, Rotterdam, The Netherlands and Dept Odon-tology/Oral microbiology, Umea, Sweden. Helicobacter pylori (Hp) shows a characteristic tropism for the mucus-producing gastric epithelium. In infected patients, Hp co-localizes with the gastric mucin MUC5AC (GUT 2000,46,601-7). The carbohydrate blood group antigen Lewis B (LeB) was deemed responsible for the adherence of Hp to the gastric surface epithelium (Science 1993, 262,1892-5). We sought to determine if MUC5AC is the carrier of LeB, and thus if MUC5AC is the underlying gene product, functioning as main receptor for Hp in stomach. We studied 3 types of tissue producing MUC5AC: Barrett's esophagus (BE, n=4), normal (non-inflamed) gastric tissue (n=11), and gastric metaplasia of the duodenum (GMD, n=4). We studied adherence of 4 Hp strains: CCUG17875 (binds LeB), CCUG17875babA1A2 (carries mutated LeB adhesin, binds no LeB), P466 (binds LeB), 26695 (binds no LeB). Tissue sections were stained for MUC5AC or LeB immunohistochemically using fluorescent secondary antibodies (FITC-labeled), and then incubated with identical amounts of fluorescently labeled Hp (Texas red). We determined the co-localization of MUC5AC or LeB with Hp bound to the tissue. In general, the binding patterns for the LeB-binding strains, CCUG17875 and P466, to all tissues were similar, whereas the strains unable to bind to LeB did not bind to any of the tissues, indicating that the ability to bind LeB is very important for the binding properties of Hp. In normal gastric tissue the LeB-binding strains always bound (n=11) to MUC5AC-positive epithelial cells, and in 9 patients these cells also had LeB. In 2 patients some co-localization to MUC5AC-positive gastric epithelial cells was found, while LeB was absent, indicating that additional structures on MUC5AC may play a role in binding of Hp. In BE, the LeB-binding Hp strains co-localized very specifically to MUC5AC, also in LeB-negative tissues. MUC5AC-producing cells in GMD also contained LeB. Yet, LeB-binding Hp did not only co-localize to the MUC5AC or LeB present in GMD, but bound also to the LeB-positive brush border of normal duodenal epithelium. Conclusion: MUC5AC is the most important carrier of the LeB carbohydrate structure in normal gastric tissue (and in BE) and forms the major gastric receptor for Hp.

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Proliferative kinetics and histological damage of the intestinal epithelium after rotavirus infection in mice. JA Boshuizen, J Reimerink, AM Korteland-van Male, VJJ van Ham, M Koopmans, HA Büller, J Dekker, AWC Einerhand. Erasmus Medical Center, lab Pediatrics/Sophia Children’s Hospital, Rotterdam. National Institute of Public Health and the Environment, Bilthoven. Rotavirus (RV) is the most important cause of infantile gastroenteritis. RV infection can cause villus blunting resulting in a reduced small intestinal absorptive area which contributes to RV induced diarrhea. To gain insight in the intestinal proliferative kinetics and histological damage during RV infection, 7-day-old BALB/c mice were inoculated intra-gastrically with 2 X 104 ffu of murine RV. 5-bromo-2'-deoxyuridine (BrdU, 30 mg/kg) was ad-ministered at t=0. Small intestines were isolated 6 h, and 1, 2, 3, 4, 7, and 14 days post infection (p.i.). Proliferation kinetics were evaluated after immunohistochemical (IHC) staining of incorporated BrdU. RV (NSP4) gene expression was evaluated by IHC staining and RNA dot blotting. Crypt depth and villus length were measured and the position of RV and histological damage along the crypt-villus axis were assessed. Two peaks of RV replication were observed at days 1 and 4 p.i.. Histological changes were characterized by the accumulation of supra-nuclear vacuoles. RV infected cells were exclusively found in the upper two-thirds of the villi. However, vacuolated cells where additionally observed at the base of the villi where no RV was detected. At days 1 to 4 p.i., villus length and crypt depth where decreased and increased respectively. At day 7 p.i., while RV replication was absent, villus length and crypt depth in infected animals were comparable with controls. BrdU labeling showed that from day 1 p.i., labeled cells migrated significantly higher up the villi than in respective controls. In control animals, BrdU-labeled cells where observed until day 7 p.i.. However, in infected animals labeled cells where already lost from the villi at day 4 p.i.. Conclusions: RV infection caused villus atrophy and was localized at the tips of the villi. However, vacuolated enterocytes were also detected at the base of the villi, suggesting that there is a secreted factor that is responsible for the vacuolation. Since the BrdU-labeled cells were lost from the villus at day 4 p.i. in infected animals, the second peak of infection at day 4 p.i. is caused by infection of newly formed epithelial cells at the villus tips.

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MUC2 deficiency in IL10 knock out mice both before and after induction of colitis by commensal bacteria MK Makkink, NJ Schwerbrock, M van der Sluis, HA Büller, RB Sartor, AWC Einerhand, J Dekker. Lab Pediatrics, Erasmus University and Sophia Children’s Hospital, Rotterdam, The Netherlands, Division Digestive Diseases, University North Carolina, Chapel Hill NC, USA. Germ free (GF) IL10 knockout mice (IL10 KO) do not show symptoms of intestinal inflammation, whereas IL10 KO mice with normal enteric bacteria under pathogen free conditions develop chronic colitis. The mucin Muc2 is the major structural component of the mucus layer in the colon. In active ulcerative colitis we showed a decrease in Muc2 synthesis and sulfation. We assessed the effects of deregulation of the immune system in IL10 KO mice on synthesis of colonic Muc2, prior to and after the induction of colitis by normal enteric bacteria (NEB). GF IL10 KO and control mice were colonized with specified pathogen free NEB. Colitis was quantified by histological score and IL12 secretion. Total amounts of Muc2, Muc2 sulfation and Muc2 precursor synthesis were measured by quantitative assays. GF IL10 KO mice showed more than 10-fold reduced levels of Muc2 precursor synthesis compared to GF controls. NEB induced severe colitis in IL10 KO mice, but controls remained healthy. Muc2 precursor synthesis was unchanged in controls. In contrast, IL10 KO mice showed a peak increase in Muc2 precursor synthesis shortly after introduction of NEB, returning to GF levels after 2 weeks. In GF controls, total Muc2 levels were 5-fold higher than in GF IL10 KO mice. After introduction of NEB, the levels of total Muc2 decreased 2-fold, both in control and IL10 KO mice. Muc2 sulfation levels were 2-fold lower in GF IL10 KO mice compared to GF control mice. Upon introduction of NEB, Muc2 sulfation increased 2-fold in control mice, whereas in IL10 KO mice Muc2 sulfation levels decreased about 10-fold, compared to GF IL10 KO levels. Conclusions: The absence of IL10 in GF non-inflamed IL10 KO mice resulted in reduced Muc2 synthesis, total Muc2, and Muc2 sulfation, indicating a primary defect in mucosal protection by Muc2. NEB induced colitis in IL10 KO mice, followed by a secondary reduction in total Muc2 and Muc2 sulfation, compared to control mice. Both the primary and secondary reduction in Muc2 levels and Muc2 sulfation in IL10 KO mice likely contribute to the development as well as perpetuation of colitis.

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LPS Binding Protein (LBP) mediates LPS detoxification by Chylomicrons; a potential defense mechanism of the intestine against bacterial toxins. A Vreugdenhil, C Rousseau, T Hartung, C van ‘t Veer, J-W Greve, W Buurman. Dept of Surgery, Maastricht University, The Netherlands, Dept of Biochemical Pharmacology, University of Konstanz, Germany. Enteric bacteria and their toxins are involved in the pathogenesis of systemic and local intestinal inflammation. Chylomicrons have been shown to improve survival when given in a murine endotoxemia model. The acute phase protein LBP is involved in detoxification of LPS by lipoproteins. We recently reported evidence for the synthesis of LBP by enterocytes. This triggered us to investigate whether LBP participates in the interaction of LPS with enteric lipoproteins, i.e. chylomicrons. The binding of LBP and LPS to chylomicrons was studied in a solid phase ligand-binding assay. The kinetics of LBP induced LPS transfer to chylomicrons was studied using fluorescence dequenching experiments. The effect of LBP and chylomicrons on the ability of LPS to induce cytokine release by peripheral blood mononuclear cells (PBMC) was assessed. LBP was demonstrated to associate with chylomicrons. LBP enhanced and accelerated the amount of LPS binding to chylomicrons in a dose dependent fashion. This LBP induced binding of LPS to chylomicrons prevented endotoxin toxicity within 30 minutes as demonstrated by a reduced cytokine secretion by PBMC. When postprandial circulating concentrations of chylo-microns were compared with circulating levels of LDL, VLDL, and HDL, chylomicrons exceeded the other lipoproteins in LPS in-activating capacity. Furthermore, in presence of LBP chylomicrons inhibited also the ability of LTA, a fragment of gram-positive bacteria, to stimulate cytokine secretion by PBMC. Our results indicate that LBP binds to chylomicrons and enables chylomicrons to rapidly bind high amounts of LPS, thereby preventing cell activation. This function is not limited to gram-negative bacterial toxins since also fragments of gram-positive bacteria are neutralized by chylomicrons in the presence of LBP. Although we consider inactivation of bacterial toxins by LBP-chylomicron complexes of significance in the circulation, we hypothesize that this is also part of a local defense mechanism of the intestine against translocated bacterial toxins, since LBP and chylomicrons are both synthesized by enterocytes.

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Prevention Of Duodenal Bacterial Overgrowth Decreases The Rate Of Secondary Pancreatic Infection In Rats ID van Felius, LMA Akkermans, A Verheem, W Harmsen, MR Visser, HG Gooszen. Universitair Medisch Centrum Utrecht, afdeling Heelkunde en Microbiologie. It has been demonstrated that reducing Gram-negative intestinal colonisation by selective decontamination decreases the risk for secondary pancreatic infection. The colon has been considered to be the main source of bacterial spread to pancreatic necrosis. But the role of the upper gut is unknown. Aim of this study was to investigate whether the effect of selective decontamination on small intestinal bacterial flora correlates with bacterial translocation during acute necrotising pancreatitis (ANP). Forty-four rats were divided into 4 groups: 1. 8 Controls (saline iv and intraductally); 2. 10 Controls with enteral antibiotics; 3. 14 ANP (cerulein iv, bile infusion intraductally); 4. 12 ANP with enteral antibiotics. Enteral antibiotics (colistin 1mg/ml, tobramycin 0.5 mg/ml and metronidazole 1mg/ml in their drinking water) were administered during 7 days. Within these 7 days ANP was induced and three days after induction of ANP, blood, peritoneal fluid, spleen, liver, pancreas, mesenteric lymph nodes, duodenum and terminal ileum were harvested for bacteriology. There was significantly (P<0.05) more Gram-negative flora in the duodenum in group 3 (log 6.9 CFU/g) compared to group 1(< log 3 CFU/g). Gram-negative flora in the duodenum was significantly (P<0.05) reduced in group 4 (<log 3 CFU/g) compared to group 3 (log 6.9 CFU/g), whereas the terminal ileum showed no significant difference between group 3 (log 7.3 CFU/g) and 4 (log 6.6 CFU/g). Counts of Gram-positive bacteria were comparable in all groups. A significant reduction (P<0.05) between pancreatic infection of group 3 (10/14) and 4 (3/12) was observed. There was a significant correlation (r=0.64) (P<0.01) between bacterial infection of the pancreas and growth of Gram-negative duodenal flora. Conclusion: We conclude that prevention of bacterial overgrowth of the duodenum reduces the rate of secondary pancreatic infection.

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In the absence of intestinal mucin MUC2 mice are more susceptible to dextran sodium sulfate-induced colitis. M van der Sluis, MK Makkink, M Sutmuller, HA Buller, J Dekker, LH Augenlicht, A Velcich, AWC Einerhand. Laboratory of Pediatrics, Erasmus MC / Sophia Children’s Hospital, Rotterdam, The Netherlands, Dept Oncology, Albert Einstein College, New York, USA. We previously demonstrated that MUC2 is the major mucin of the mucus layer covering the human and rodent colonic epithelium. The mucus layer is thinner in ulcerative colitis. The aim was to study the role of Muc2 in epithelial protection against noxious agents present in the intestinal lumen. Therefore, mice, in which the Muc2 gene was disrupted, were developed and characterized (Velcich et al., submitted). Muc2 deficient (Muc2 -/-) and wild type mice (age 12 weeks) were treated for 5 days with 2.5% dextran sulfate sodium (DSS) in their drinking water. DSS is a cytotoxic agent which is known to induce colitis in mice. The intestinal mucosa of the Muc2-/- mice was characterized by an absence of Muc2 expression and goblet cells were unrecognizable in hematoxilin and eosin stainings. However, intestinal trefoil factor was detectable in the small and large intestine, indicating that goblet cells were still present. Muc2-/- mice maintained under specified pathogen free conditions showed abnormalities in colonic crypt architecture and cell maturation in the absence of gross inflammation in the intestine of mice. Proliferation was increased as measured by BrdU-labeling and the colonic mucosa was thickened. DSS-treatment led to earlier appearance of bloody diarrhea (day 1) compared to similarly treated wild type animals (day 4). Furthermore, the DSS-induced 3-fold inhibition of proliferation and histological signs of severe inflammation, (i.e. crypt loss, infiltration of inflammatory cells, ulceration) occurred much faster in Muc2-/- (day 2) than wild type mice (day 5). Conclusions: Due to the absence of Muc2, the intestinal goblet cells loose their characteristic goblet-like appearance in histology, indicating that Muc2 is the major phenotypic determinant of goblet cells. Muc2-/- mice are more susceptible to DSS-treatment, indicating that Muc2 plays an essential role in epithelial protection. Thus, deficiency of Muc2 might be an etiological factor in the development or perpetuation of inflammatory bowel disease.

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Improved survival from severe DSS-induced colitis of trans-genic Cu/Zn-SOD overexpressing mice. L Kruidenier, ME van Meeteren, I Kuiper, CBHW Lamers, HW Verspaget. Dept of Gastroenterology-Hepatology, Leiden University Medical Center, Dept. of Pharmacology, Erasmus University Rotterdam. Mucosal tissue damage in inflammatory bowel disease (IBD) is partly caused by exposure to excessive amounts of reactive oxygen metabolites (ROM). Although most intestinal cell types constitutively express the highly specific, key ROM-neutralizing cytosolic enzyme Cu/Zn-superoxide dismutase (SOD) to counteract any adverse effects of ROM, its protein and activity levels have consistently been reported as being decreased under inflammatory conditions. To elucidate a direct in vivo functional relationship between intracellular Cu/Zn-SOD expression and intestinal inflammation, we investigated the effects of transgenic human Cu/Zn-SOD overexpression in severe acute and chronic murine dextran sodium sulfate (DSS)-induced colitis. The Cu/Zn-SOD overexpressing transgenic mice showed a remarkably lower mortality from severe DSS colitis than their non-transgenic littermates (3/29 vs 10/31, p<0.03), particularly during or shortly after the acute inflammatory phase. Similar to a previous study in mild colitis, we observed a male gender bias for DSS susceptibility now reflected by an increased male colitis mortality (11/31 vs females 2/29, p<0.02). Paradoxically, however, overexpression of Cu/Zn-SOD did not obviously improve the colitis-related (oxidative) injury or symptoms at this or any other stage of the experiment. In addition, the colonic activities of other (anti)oxidant enzymes like Mn-SOD, catalase, glutathione peroxidase, and neutrophilic myeloperoxidase were similarly upregulated during acute colitis in both groups. Yet, when the animals were subsequently allowed to recover, myeloperoxidase levels were significantly lower in the transgenic animals as compared to the non-transgenes (p<0.01), suggesting Cu/Zn-SOD’s involvement in neutrophil migration and clearance. During the chronic inflammatory phase, not characterized by massive neutrophil infiltration, no major effects of Cu/Zn-SOD overexpression were noted. Our findings provide in vivo evidence for a protective, neutrophil-related role for Cu/Zn-SOD in intestinal inflammation. As such, they support the concept of SOD-based antioxidant treatment strategies in inducing or prolonging remission in IBD patients.

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Decision analysis in the surgical treatment of colorectal cancer due to a mismatch repair gene defect WH de Vos, E Buskens, P van Duijvendijk, JH Kleibeuker, FH Menko, G Griffioen, FM Nagengast, BG Taal, F. Slors, HF Vasen. Leiden University Medical Center, Dept of Clinical Epidemiology, Utrecht, Amsterdam Med Center, Groningen Universitay Hospital, VU Medical Center, Amsterdam, Nijmegen University Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands Foun-dation for the Detection of Hereditary Tumors, Leiden. Mutation carriers in hereditary non-polyposis colorectal cancer (HNPCC) have a 60-85% life-time risk to develop colorectal cancer (CRC). In HNPCC patients, identified with CRC, total colectomy (TC) rather than partial colectomy (PC) is recommended because of the risk of developing a new primary CRC. However, TC implies a substantial decrease in quality of life (QOL). Colonoscopic surveil-lance has been shown to reduce CRC occurence and leads to the identification of mainly local tumours. Aim of this study was to compare the potential health effects in terms of life expectancy (LE) for patients undergoing TC or PC for CRC followed by surveillance. A decision analysis model (Markov model) was created. Information on the 10 year risk of CRC after TC(4.4%)and PC (12.5%)followed by surveillance and stages of CRC were derived from two cohort studies from Finland and the Netherlands. Two distributions of tumor stages detected within surveillance programs were accounted for, i.e. tumors detected within a 2-year interval (33% Dukes A, 53% Dukes B and 14% Dukes C) and tumours detected within a 5-year interval (26% Dukes A, 55% Dukes B and 19% Dukes C). Five-year survival rates for different Dukes stages used were 98% for Dukes A, 80% for Dukes B and 50% for Dukes C. Remaining life expec-tancies were calculated for hypothetical cohorts of patients with an age at first CRC detection of 27, 47 and 67 years respectively. If only tumors detected within a 2-year interval were included, the difference in overall life expectancy for a mutation carrier after total colectomy compared to partial colectomy for CRC at age 27, 47 and 67 was 0.9, 0.3 and 0.1 years respectively. In case all tumors detected within a 5-year interval were included the difference in life expectancy after TC compared to PC for CRC was 1.1, 0.4 and 0 years respectively. The choice between PC and TC is a difficult de-cision in that the personal preferences of a patient weigh heavily. There is a difference in life expectancy between the two options in favor of TC at young age. However, if PC leads to a substantial better QOL, it might well be an option for HNPCC especially in patients at older age.

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'Planned relaparotomy' or 'relaparotomy on demand' in secon-dary peritonitis: a meta-analysis of observational studies. B Lamme, MA Boermeester, JWO van Till, JB Reitsma, H Obertop, DJ Gouma, Dept of Surgery and Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam. Relaparotomies after the initial operation in patients with secondary peritonitis can be performed by either the 'planned' (PR) or the 'on demand' (ROD) strategy. A systematic review and meta-analysis of studies was performed to evaluate the effectiveness of both strategies. Eight databases were systematically searched using the keywords 'abdominal sepsis', 'secondary peritonitis', 'relaparotomy' and 'plan-ned relaparotomy' identifying English studies comparing the PR and ROD strategy in adult patients with secondary peritonitis with in-hospital mortality as an outcome. The search included a cross-reference search of eligible articles and data on methodology, level of evidence, population and intervention were extracted. The search yielded 181 articles. Excluded were 159 articles for not meeting the inclusion criteria and 13 articles for providing insufficient data. Eight observational studies (total 1266 patients; 286 PR, 980 ROD) were entered in the meta-analysis. No randomized studies comparing the PR and ROD strategy were found. The combined odds-ratio (OR) calculated by using two different models yielded a nearly identical odds-ratio. The 'fixed effects' model resulted in a pooled OR of 0.69 (0.49-0.96 95% CI; c2=40.7, P<0.03) in favor of the ROD strategy. The 'random effects' model resulted in a pooled OR of 0.70 (0.27-1.80 95% CI, P=ns). Overall mortality in the PR and ROD group was 35.3% and 18.6% respectively, resulting in an absolute risk reduction of 16.7% in the ROD group. Six patients need to be treated by the ROD strategy to save 1 additional life (NNT= 6). Conclusion: The combined results of observational studies in secondary peritonitis show a reduction of mortality when the 'relaparotomy on demand' strategy is utilized as compared with planned relaparotomy. However, the heterogeneity of the included patients and studies, which are non-randomized, prohibit definite conclusions. A multicenter randomized trial comparing both treat-ment strategies is therefore initiated.

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Small and multiple gallstones are major risk factors for acute biliary pancreatitis. NG Venneman, MGH Besselink, PMNYH Go, K Bosscha, HG Gooszen, GP van Berge Henegouwen, KJ van Erpecum. Gastro-intestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center Utrecht, Dept of Surgery, St. Antonius Hospital Nieuwegein. Although acute gallstone pancreatitis is associated with con-siderable morbitity and mortality, potential risk factors have not yet been clearly defined. Therefore, we compared sizes and numbers (by ultrasound) of gallbladder and –if present- bile duct stones (by ERCP) in 98 pts with acute pancreatitis, 57 pts with obstructive jaundice but without pancreatitis, 77 pts with acute cholecystitis, and 142 pts with uncomplicated symptomatic gallbladder stones. Gallstone sizes by ultrasound were highly correlated to sizes at subsequent surgery (n=16: r = 0.92). Patients with complicated gallstone disease were older (58 vs 47 yrs, P < 0.001) and more often males (44% vs 22%, P < 0.001) than pts without complications. Both pts with acute pancreatitis and pts with obstructive jaundice had more and smaller stones or sludge in their gallbladders than pts with acute cholecystitis or uncomplicated disease (smallest stone diameters: 3±1, 3±1, 8±1, 9±1 mm resp., P < 0.001). In contrast, bile duct stones (by ERCP) were smaller (smallest stone diameters: 3±1 vs 9±1 mm, P < 0.001) and sludge occurred more frequently (33% vs 17%, P = 0.03) in case of pancreatitis than obstructive jaundice. Multivariate analysis identified stone size and age as independent risk factors for pancreatitis. Conclusions: Small and multiple gallbladder stones are major risk factors for acute pancreatitis or obstructive jaundice. After migration to the bile ducts, small stones and sludge are more likely to induce pancreatitis, whereas larger stones may induce obstructive jaundice. Threshold for cholecystectomy should be low, particularly in case of small gallbladder stones.

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PRSS1 mutations in chronic pancreatitis: is the A16V mutation important? M. Verlaan R Te Morsche, JBMJ Jansen, JPH Drenth. Dept of Gastroenterology and Hepatology UMC St. Radboud, Nijmegen. Cationic trypsinogen (PRSS1) gene mutations are associated with hereditary pancreatitis (HP). Some PRSS1 mutations have been described in pure association with HP and also in chronic pancreatitis (CP). One particular PRSS1 mutation, A16V, appears to be a true disease-causing mutation causing HP. This mutation, which probably disrupts the intracellular transport of trypsinogen, has also been described in certain cases of CP. Genomic DNA from the blood of 94 adult chronic pancreatitis patients with alcoholic (n=45), hereditary (n=11), idiopathic (n=29), and miscellaneous (n=9) origin, was isolated according to a standard protocol. Detection of the A16V mutation was carried out by polymerase chain reaction followed by digestion using the restriction enzyme Fnu4H I. The accuracy of the test was confirmed by 2 positive control samples. The A16V mutation was not present in any of the 94 CP samples. This contrasts to earlier studies which demonstrated a 0.9-9.0% frequency of the A16V allele. These studies however used highly selected cases with HP or idiopathic CP. Our data suggest that the contribution of the A16V allele in adult CP is not as important as previously suggested.

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Pancreaticoduodenectomy for palliative treatment of pancreatic cancer. KFD Kuhlmann, SMM de Castro, ORC Busch, TM van Gulik, H Obertop, DJ Gouma. Academic Medical Center Amsterdam, Dept of Surgery. Since perioperative mortality and morbidity are decreasing rapidly, the complex question arises whether pancreaticoduodenectomy has a role in the palliative treatment of pancreatic adenocarcinoma. We studied the role of palliative tumour resection by analysing survival and comparing the occurrence of procedure-related mor-bidity and mortality in patients who underwent non-radical (palliative) resection versus patients who underwent bypass surgery. Between January 1992 and December 2000, 298 patients under-went surgical treatment for pancreatic carcinoma, of which 72 patients palliative resection and 153 patients bypass surgery. Survival of bypass patients was calculated using a subgroup of patients treated for non-metastatic disease (n=76). In this subgroup 39.5% of patients received palliative chemo/radiotherapy versus 11.1% in the palliative resection group. Data were analysed using chi-square test and one-way ANOVA. Survival analysis was performed using the Kaplan-Meier method, a P-value <0.05is significant. The two groups were similar with respect to age, presenting symptoms and tumour size. The overall in hospital mortality was not different, 0% and 1.3% after palliative resection and bypass respectively. The length of postoperative stay after resection was 21.4 days and was significantly longer than after bypass surgery (14.1 days). Anastomotic leakage, intra-abdominal haemorrhage and relaparotomy were significantly more frequent after resection (5.7% versus 0.7%, 9.7% versus 1.3% and 9.6% versus 3.3% respectively), other complications were equally distributed between groups. Survival was significantly longer (p<0.0001) in patients who underwent palliative resection (median survival 16.9 versus 9.5 months, 1-year and 2-year survival 61.7% versus 34.5% and 30.0% versus 0%). Overall survival was significantly longer for patients who underwent palliative resection compared to patients who underwent bypass surgery, but the procedure was associated with a higher incidence of postoperative complications. Although patient selection is a major factor in explaining the difference in survival, these data suggest that a selected group of patients could benefit from palliative resection.

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Survival after surgical treatment of 402 patients with pathology proven pancreatic adenocarcinoma and analysis of prognostic factors for survival. KFD Kuhlmann, SMM de Castro, ORC Busch, TM van Gulik, H Obertop, DJ Gouma. Academic Medical Center Amsterdam. Between October 1983 and December 2000, 777 patients underwent surgical treatment for periampullary carcinoma, of which 448 for pancreatic carcinoma. The aim of this study was to evaluate survival and to analyse prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma. In 402 of 448 patients pathological conformation of the diagnosis pancreatic adenocarcinoma could be obtained. Survival analysis was performed using the Kaplan-Meier method and evaluated with log-rank tests. After univariate analysis was performed, significant prognostic factors (p<0.05) were entered into a Cox regression model to determine independent predictors of survival. The mean age was 62 years and male to female ratio was 1 to 1. 205 patients underwent resection with a curative attempt (34% classic pancreaticoduodenectomy, 58% pylorus preserving pancrea-ticoduodenectomy, and 8% total pancreatectomy) and 197 patients underwent palliative bypass surgery (91% biliary and gastric bypass, 9% biliary or gastric bypass). Overall in hospital mortality after resection and palliative bypass was respectively 2.4% and 1.5% (n.s.). Median survival was 16.1 and 7.0 months and 5-year survival was 12.9% and 0.6% respectively. In univariate analysis age (p=0.02), abdominal pain (p=0.03), hospital stay (p<0.01), urinary infection (p=0.05), non-radical surgery (p<0.01), metastatic disease (p<0.01), tumour size more than 2 cm (p<0.01) and poor tumour differentiation (p<0.01) significantly predicted lower survival. In multivariate analysis age (p=0.01), non-radical surgery (p=<0.01), metastatic disease (p<0.01), tumour size (p<0.01) and poor tumour differentiation (p<0.01) were prognostic for survival. For patients treated with bypass surgery palliative chemo/radiotherapy significantly increased survival (p<0.01). Age, non-radical surgery, metastatic disease, tumour size and poor tumour differentiation are independent prognostic factors for patients who underwent surgical treatment for pancreatic adenocarcinoma. In the subgroup of patients treated with bypass surgery chemo/radiotherapy increased survival.

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Sporadic and syndromic fundic gland polyps: differences in proliferation, apoptosis and expression of ß-catenin. M Jalving, JJ Koornstra, W Boersma-van Ek, S de Jong, A Karrenbeld, H Hollema, EGE de Vries, JH Kleibeuker. Depts of Gastroenterology, medical Oncology and Pathology, University Hospital Groningen. Fundic gland polyps (FGPs) are the most common gastric polyps, occurring in both sporadic and syndromic forms. The prevalence of FGPs in patients with familial adenomatous polyposis (FAP) is 40-60% and 1.9% in sporadic cases. Sporadic FGPs are regarded as benign while FGPs in FAP patients have occasionally been reported to become malignant. Activation of the Wnt-APC-ß-catenin pathway, resulting in nuclear ß-catenin accumulation, is thought to be involved in the pathogenesis of FGPs: in FAP due to a germline APC mutation and subsequent somatic APC mutation in the second allele; in sporadic cases due to ß-catenin mutations. Whether there is a true difference in malignant potential between syndromic and sporadic FGPs is unknown. In this study, parameters of malignant potential were investigated of syndromic versus sporadic FGPs. We studied 9 FGPs from 6 FAP patients and 19 FGPs from 18 non-FAP patients. Surface/foveolar epithelial dysplasia was graded on histological examination of hematoxylin-eosin stained tissue sections. Proliferative activity (MIB-antibody), degree of apoptosis (M30 antibody) and expression of ß-catenin were examined by immunohistochemistry. One FAP-associated FGP was dysplastic; four were indefinite for dysplasia (3 syndromic FGPs and 1 sporadic FGP); the remaining FGPs were negative for dysplasia. There was no significant difference in proliferative activity between syndromic and sporadic FGPs: 5.9 % ± 1.8 vs 5.2 % ± 1.4 (mean ± SEM). No difference was found in degree of apoptosis: 4.9 ± 0.9 vs 5.2 ± 1.2 (mean ± SEM). However, indices of proliferation and apoptosis were significantly higher in the 5 dysplastic or indefinite for dysplasia FGPs compared to FGPs negative for dysplasia. Nuclear accumulation of ß-catenin was observed in the one FAP-related FGP that showed dysplasia. In conclusion, the different activation routes of the Wnt-APC-ß-catenin pathway in syndromic and sporadic FGPs are not reflected by differences in degree of proliferative activity or apoptosis. However, the development of dysplasia seems to be associated with higher cell turnover rates and translocation of ß-catenin from the cell membrane to the nucleus.

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ECF-chemotherapy (epi-adriamycin, cisplatin and continuously 5-FU) in advanced cancer of the stomach and gastro-eso-phageal junction (GEJ). SH Tonino, BG Taal, A Cats, R Dubbelman, HM Zuetenhorst, P Kuijer, H Boot. Dept of Gastroenterology, Netherlands Cancer Institute / Antoni van Leeuwenhoek Hospital, Amsterdam. Chemotherapy plays an increasing role in metastatic and locally advanced adenocarcinoma of the stomach and gastro-oesophageal junction (GEJ). We tested local feasibility of the ECF-regimen in a confirmatory phase II study in a Dutch cohort. The regimen consisted of epi-adriamycin 50 mg/m2 and cisplatin 60 mg/m2 every 3 weeks and 5-FU 200 mg/m2 continuously administered via an implanted venous access system. Response rate (RR) was assessed according WHO-criteria and toxicity according Common Toxicity Criteria. RRs were evaluated after every 2 cycles. The first 77 patients (61 males), age 31-75 years (median 59 years), were evaluated. Tumour localisation was GEJ (n=37) and stomach (n=40). Twenty-two patients had locally advanced and 55 metastatic disease. Thirty patients underwent prior surgery: resection (n=13), diagnostic laparotomy (n=13) and gastroenterostomy (n=4). Major symptoms at presentation were dysphagia, loss of appetite, local pain and weight loss. A total number of 322 cycli were administered. Technical problems with the pump device occurred in 2, thrombosis in 6, dislocation in 4, infection in 2, pneumothorax in 1 and 5-FU extravasation in 2 patients. Severe side effects (grade 3 or 4) were infrequent: nausea and vomiting (n=8), diarrhoea (n=4), stomatitis (n=2), hand-foot syndrome (n=7), leucopenia (n=9) and thrombocytopenia (n=1). In gastric cancer the ECF-regimen resulted in 3 complete remissions (CR) and 16 partial remissions (PR), leading to an overall RR of 48%. In GEJ cancer overall RR was 49% (1 CR, 17 PR). In locally advanced disease overall RR was 55% (2 CR, 10 PR). Eight of these 22 patients (36%) underwent additional resection. In metastatic disease the RR was 45% (2 CR, 23 PR). All responses, but 2, occurred after 2 cycles. Conclusion: The ECF-regimen is equally effective in advanced gastric and GEJ cancer with an overall RR of nearly 50%. Responses were achieved early during treatment. Toxicity is generally manageable. Therefore, the ECF-regimen is feasible as induction chemotherapy before surgery and should be further explored.

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Outcome of patients with esophageal carcinoma and suspicious truncal nodes as determined by endoscopic ultra-sonography. WA Marsman, M van Wissen, JJGHM Bergman, GNJ Tytgat, P Fockens. Dept of Gastroenterology, Academic Medical Center Amsterdam. For patients with esophageal cancer, the TNM-classification defines tumor positive celiac lymph nodes (CLN) as distant metastases (M1-disease). Endoscopic ultrasonography (EUS) is an accurate mo-dality to identify patients with CLN. The management of patients with EUS positive CLN is controversial. Our aim was to evaluate management and survival of patients with EUS positive CLN. Survival of patients treated with esophageal resection was compared to that of conservatively treated patients. In addition potential prognostic features of EUS were analyzed. The EUS database of the AMC was retrospectively screened for patients who had an esophageal carcinoma with EUS positive CLN. An EUS positive CLN was defined as a hypoechoic node of at least 1 cm with a sharp border, located within 2 cms of the celiac axis. Patients with distant metastasis elsewhere or EUS-T4 tumors were excluded. Follow-up comprised review of medical charts and contact with general practitioners. Between 1992 through 2000, 95 patients, who underwent EUS for staging of esophageal cancer, were found to have positive CLN. Twenty-three patients were lost to follow-up and were excluded from analysis. The median survival of patients with CAN size < 2 cms was 404 days vs. 220 days for patients with CLN size > 2 cms in size (p=0.03). From the 72 included patients, 12 patients underwent esophagectomy and 60 patients received palliative therapy. The median age in the surgical group was 57 years, and 70 years in the palliative group (p=0.11). It appeared that only patients with a CLN size < 2 cms, underwent esophagectomy. The median survival for the surgical group was 328 days versus 404 days for the palliative group with a CLN size < 2 cms (p=0.98). The median survival is 264 days for conservative treated patients, irrespective of CLN size. In this retrospective study a CLN size > 2 cms was associated with poorer survival. The operated patients all had CLN size < 2cms and did not have an improved survival compared to conservative treated patients with CLN size < 2cms. These results show that the management of patients with positive CLN, is not conclusive.

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The prognostic significance of elevated Cyclooxygenase-2 expression in patients with adenocarcinoma of the esophagus. CJ Buskens, BP van Rees, GJA Offerhaus, PJ Bosma, A Ristimäki, JJB van Lanschot. Depts of Surgery, Pathology and Experimental Hepatology, Academic Medical Center/University of Amsterdam, The Netherlands, Dept of Pathology, Helsinki University Central Hospital and Molecular and Cancer Biology Research Program, Finland. The use of NSAIDs is associated with a reduced risk of gastrointestinal cancer. Cyclooxygenase (COX) is the best-known target of NSAIDs, and expression of the inducible COX-2 isoform is elevated in adenocarinomas of the esophagus but its clinical significance remains unclear. We examined COX-2 expression in esophageal adenocarcinomas and its relation to prognosis. Tumor sections of 145 consecutive patients undergoing potentially curative surgery for an adenocarcinoma arising from a Barrett’s esophagus were immunohistochemically stained using a COX-2 specific anti-human monoclonal antibody. The specimens were scored based on the intensity and extent of COX-2 immunopositivity. We studied survival in relation to COX-2 expression and other prognostic factors. COX-2 immunoreactivity was negative to weak in 21% (COX-2 Low) and moderate to strong in 79% (COX-2 High) of the tumors. Survival was significantly worse among patients with high COX-2 expression compared to COX-low patients (p=0.002, log rank test) with a 5-year survival rate of 35% and 70% respectively. Patients with high COX-2 expression were more likely to develop distant metastases (p=0.02) and local recurrences (p=0.05). The effect of COX-2 expression on survival was still present after adjustment of other prognostic factors in a multivariate analysis. Conclusion: Elevated expression of COX-2 protein is associated with reduced survival of patients with esophageal adenocarcinoma. These findings support the effort to initiate clinical studies to the use of COX-2 inhibitors as a novel (adjuvant) chemotherapeutic modality for the treatment of esophageal adenocarcinoma.

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Oesophageal cancer does not affect survival of patients with Barrett's oesophagus. M Hage, H van Dekken, PD Siersema, EW Steyerberg, EJ Kuipers, J Dees. Depts of Gastroenterology & Hepatology, Pathology and Public Health, Erasmus MC / University Medical Center Rotterdam. We previously reported on the incidence of oesophageal cancer in a cohort of 166 patients with Barrett?s oesophagus (BO), diagnosed endoscopically between 1973 and 1986 (Gut 1996;39:5-8). The purpose of the present study was to identify the cancer risk without endoscopic surveillance in BO patients diagnosed according to the current guidelines, requiring the histological presence of intestinal metaplasia for a diagnosis of BO. From the database containing all patients referred for upper GI endoscopy to our unit between 1973 -1986, those with endoscopical signs of >3cm BO were identified. >From this group, the oesophageal biopsies were reviewed and those with confirmed intestinal metaplasia were included in this study. Follow-up data were collected by telephone and postal inquiry, and from patient and authority records. A total of 109 patients [60/49 M/F, mean age 63 yrs (16-96)] met the criteria, and follow-up data could be obtained for all cases. During a total amount of 1263 yrs (mean 11.6 yrs) of non-surveillance follow-up, six patients developed oesophageal cancer at 4, 6, 11, 11, 14, and 16 yrs after the diagnosis BO, whereas two patients developed high-grade dysplasia (HGD) after 1 and 12 yrs. Thus, the incidence of cancer in BO is 1:210 patient-years, the incidence of cancer + HGD in BO is 1:158 patient-years. Out of 109 patients, 75 patients had died at a mean age of 78 yrs (34-99); six of them had cancer in BO (8%), but only three of them died from this cancer in BO (4%). The mean age at death of the six patients with cancer in BO was 80 yrs (70-96). One of the two patients with HGD died at the age of 67 from an unrelated cause 2.3 yrs after oesophageal resection; the other patient is alive 19.5 yrs after resection. Conclusions: 1. Few patients with BO die from cancer in BO (4%). 2. The age at death of patients with cancer in BO was not different from the age at death of patients without cancer in BO. 3. The tumor incidence (HGD included) of 1:158 patient-years in the sub-cohort of 109 patients was not markedly different from the incidence of 1:180 patient-years in the original cohort of 166 patients.

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Staging procedures and treatment strategies for patients with esophageal carcinoma: a survey in the Netherlands. MYV Homs, EW Steyerberg, HW Tilanus, A van der Gaast, J Haringsma, EJ Kuipers, PD Siersema. Depts of Gastroenterology & Hepatology, Public Health, Surgery and Internal Oncology, Erasmus MC / University Medical Center, Rotterdam. Since guidelines are not widely available at present, we surveyed currently employed staging procedures and treatment strategies for esophageal carcinoma in the Netherlands. A questionnaire was sent to all physicians working in the field of gastroenterology in the Netherlands. This questionnaire focused on their clinical preferences regarding staging procedures and treatment strategies, both curative and palliative, for esophageal cancer. Furthermore, patient vignettes were presented with varia-tions in age (55 or 80 years), general health (good or poor), pre-sence of metastases, or local regional tumor ingrowth in order to investigate the impact of presenting factors on treatment choice, particularly surgical treatment. Response rate was 64% (426/667) and included 336 questionnaires from clinicians presently involved in the care of patients with esophageal cancer. Almost 90% of the clinicians treated fewer than 20 patients annually, mostly in their own hospital. Computer tomography (CT) was the most frequently used staging procedure (70% in >50% of patients), whereas endoscopic ultrasound (EUS) was less frequently used (42% in <50% of patients). The treatment choice for specific patients varied widely among clinicians. Stent placement was the most frequently used treatment modality for palliation of malignant dysphagia: 60% of the clinicians used stenting for >50% of patients. Factors influencing the choice to operate or not were metastases, local regional tumor ingrowth, poor general health, and advanced age, with only 8%, 22%, 20%, and 53% respectively of the clinicians considering surgery in the presence of one of these factors, in contrast to 99% in patients without any of these factors. Surgeons more often preferred surgical treatment compared to internists and gastroenterologists. Conclusions: A wide variation exists in staging procedures and treatment strategies for patients with esophageal carcinoma in the Netherlands. There is a need for more scientifically based guide-lines, taking into account specific patient and tumor characteristics.

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Fas Ligand expression in sporadic and hereditary non-polyposis colorectal adenomas and carcinomas and correlation with apoptosis. JJ Koornstra, FEM Rijcken, W Boersma- van Ek, H Hollema, EGE de Vries, S de Jong, JH Kleibeuker. Depts of Gastroenterology, Pathology and Medical Oncology, University Hospital Groningen. In hereditary nonpolyposis colorectal cancer (HNPCC), colorectal carcinogenesis is believed to be accelerated compared to sporadic cases, possibly through differences in the regulation of apoptosis. Fas Ligand (FasL) is a mediator of apoptosis via the Fas receptor. Many sporadic colorectal carcinomas and adenomas express FasL which may contribute to tumor immune escape via the so-called Fas counterattack against antitumor cells. To date, FasL expression has not been correlated with the degree of apoptosis in colorectal tumors nor has it been examined in HNPCC. We studied FasL expression and apoptosis in colorectal neoplasms from HNPCC and sporadic cases. In addition, correlations between FasL expression and histopathological characteristics were explored. FasL expression was determined by immunohistochemistry in sporadic adenomas (n=75), HNPCC adenomas (n=53), sporadic carcinomas (n=26) and HNPCC carcinomas (n=24). Patients with HNPCC had known mutations in hMLH1 or hMSH2 genes and/or fulfilled the Amsterdam criteria. Apoptotic cell death was determined by M30 immunostaining. FasL expression was positively correlated to the degree of apoptosis (p<0.01), both in hereditary and sporadic adenomas and carcinomas. FasL expression was seen in 51/53 HNPCC and 70/75 sporadic adenomas (n.s.). Expression in >50% of adenoma cells was seen in 27/53 HNPCC and 28/75 sporadic adenomas (n.s.). No correlation was found between FasL expression and size, growth pattern or the degree of dysplasia. In carcinomas, FasL expression was observed in all HNPCC and sporadic cases. Expression in >50% of tumor cells was observed in 25/26 sporadic and 18/24 HNPCC carcinomas (n.s.). The degree of apoptosis did not differ between HNPCC and sporadic cases. In conclusion, FasL expression is positively correlated with the degree of apoptosis and not different between sporadic and hereditary tumors. Our results indicate that FasL expression is an early event in both HNPCC and in sporadic colorectal carcinogenesis, and that differences in carcinogenesis in HNPCC compared to sporadic cases cannot be attributed to differences in FasL expression or degree of apoptosis.

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Germline mismatch repair gene mutations in patients with multiple HNPCC-related tumors. MJW Brends, Y Wu, H Hollema, RH Sijmons, EGE de Vries, CHCM Buys, AGJ van der Zee, RMW Hofstra, JH Kleibeuker. Depts of Gastroenterology, Medical Genetics, Pathology, Medical Oncology and Gynecology, University Hospital, Groningen. Hereditary nonpolyposis colorectal cancer (HNPCC) mostly results from germline mutations in the mismatch (MMR) genes MLH1, MSH2 or MSH6. HNPCC is suspected, if patients have multiple HNPCC-related cancers, i.e. colorectal, endometrial, ovarian, gastric, small bowel, biliary, pancreatic and urothelial cancer. We studied the prevalence of mutations in 82 such patients and related the results to age of diagnosis, first degree family history, tumor microsatellite instability (MSI) and tumor immunohistochemistry (IHC) for the MMR-gene protein products. Only patients with at least one GI-tract tumor were included, 78 of them had at least one colorectal cancer (CRC). In 15 pts (18%) a truncating mutation was found in MLH1 (n=3), MSH2 (n=6) or MSH6 (n=6). All 15 had at least one CRC. All were < 60 yrs at diagnosis of the first tumor, 4 were > 50, one had a mutation in MSH2, 3 in MSH6.12/15 pts had a first degree relative with a HNPCC-related cancer, only 7 fulfilled the Amsterdam II criteria. Tumors of 12/15 pts were MSI-high, MSI-low tumors occurred in 3 MSH6 mutation carriers. Tumors of 12 pts could be studied for IHC, all showed loss of staining of the mutated gene protein. Conclusion: The prevalence of germline MMR gene mutations in pts with multiple HNPCC-related cancers is high. Mutations seldomly occur in pts with a negative family history. Both tumor microsatellite instability and immunohistochemistry are good predictors of a mutation, but tumors in MSH6 mutation carriers are not seldomly MSI-low.

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SKY, chromosome CGH and array CGH analysis of two types of epithelial tumors: squamous cell carcinoma versus adenocarci-noma. M Hermsen, A Snijders, MA Guervos, S Tanzer, J Baak, D Pinkel, D Albertson, G Meijer, E Schrock. Dept Pathology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands, UCSF Compre-hensive Cancer Center, San Francisco, CA, USA; Institut fur Medi-zinische Genetik, Humboldt University, Berlin, Germany. Chromosomal instability is the most important type of genetic instability in solid tumors. Until now, little is known about chromosomal translocations in these tumors. The question remains whether structural chromosomal changes directly contribute to carcinogenesis, or rather their resulting gains and losses of chromosomal material. Ten colon adenocarcinoma cell lines (CAC) and nine oral squamous cell carcinoma cell lines (OSCC) were analyzed with SKY, chromosome CGH and array CGH for mapping of structural and numerical chromosome aberrations, respectively. Neither CAC nor OSCC showed recurrent translocations. In the CAC, chromosome bands 1p36, 4q31, 8q24, 9p21, 9q34, 12q21, Xp22 were frequently involved in rearrangements. In the OSCC, rearrangements occurred in much higher frequency and different chromosomal regions were recurrent: 1p31, 1p32, 3p21, 3q25, 4q28, 11q13, 15q15, 17p12, 18q23, 20q13.3, 22q11.2, 22q12. The majority of these abnormalities resulted in loss or gain of chromosomal regions, which were visible with chromosome CGH and the breaking points could be localized up to 1 Mbp accuracy using the array CGH data. Moreover, CAC and OSCC differed strongly with regard to the involvement of centromeres in rearrangements, often presenting as whole arm translocations. OSCC had more centromeric translocations than CAC (43% versus 21%), whereas CAC showed more 'band-band' translocations than OSCC (62% versus 35%). In conclusion, colon adenocarcinoma and oral squamous cell carcinoma differed both in chromosomes involved and in type of rearrangements, which indicate that structural chromosomal changes do not occur randomly and must therefore play a direct role in carcinogenesis.

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Restriction of amplicon boundaries at 20q13 by microarray based comparative genomic hybridization in human gastric cancer MM Weiss, AM Snijders, EJ Kuipers, B Ylstra, D Pinkel, SGM Meuwissen, D Albertson. GA Meijer. Depts of Gastroenterology, Pathology and Microarray Core Facility, VU University Medical Center, Amsterdam, The Neterlands, University of California San Francisco, California, USA, Dept of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands. Gain of chromosome 20 is frequently found in gastric carcinomas, as detected by comparative genomic hybridization (CGH) (Van Grieken, J Pathol, 2000). In order to investigate this chromosomal aberration with a higher resolution and sensitivity, we performed microarray based CGH, both with a scanning and a high-resolution array of chromosome 20, in a series of 27 gastric cancers. Array CGH hybridizations were carried out as described previously (Pinkel 1998, Albertson 2001). The scanning array contained 27 BAC clones covering chromosome 20q, each BAC clone has been cytogenetically mapped and contains at least one STS for linkage to the sequence of the human genome. The high-resolution array contained a contig of 27 BAC clones at 20q13.2. The high-resolution array was used to narrow down the amplicon at 20q13.2 in tumors showing amplification of this chromosomal region with the scanning array. The integrated tumor to reference fluorescence ratio was calculated per spot. Thresholds of 0.8 and 1.2 were used for losses and gains, respectively. To confirm the microarray CGH data, FISH for 20q13 has been performed on tissue sections of selected cases. Gains on chromosome 20q were detected in 12 of 27 cases (44%). These changes included a gain of the whole arm of chromosome 20q in 8 of 27 (30%) cases, a gain restricted to 20q12.1 in 1 case, and a gain restricted to 20q13 in an additional 3 cases. The tumors showing a gain restricted to 20q13 were further analysed using the high-resolution array. In one tumor the whole length of the contig was amplified at a constant level. One of the other two tumors had a clear proximal breakpoint, while the other tumor had a clear distal breakpoint within the 20q13.2 region. The proximal and the distal breakpoint are approximately 800 kb apart. Conclusions: In the present study we narrowed down the amplicon at 20q13.2 to 800 kb. This region harbours one or more putative oncogenes relevant to gastric cancer. Quantitative analysis of the expression levels of a number of candidate oncogenes within this amplicon is currently performed.

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Phenotypical differences in T-lymphocytes of non-coeliacs, coeliacs and refractory coeliacs; association with Enteropathy Associated T-cell Lymphoma MS Goerres, CJJ Mulder, JAM Kerckhaert, H van Dijk. Dept of Gastroenterology and Immunology, Rijnstate Hospital Arnhem, Dept of Immunology, Eemland Hospital Amersfoort. Coeliac disease (CD) is a chronic small bowel disorder cha-racterised by malabsorption due to a T-lymphocyte (T-cell) mediated gluten sensitivity. Although the presence of an intra-epithelial lymphocytosis, with predominantly T-cells, in the small intestinal mucosa is well described, the exact architecture and function of these T-cells is poorly understood. Recently, a changing T-cell marker profile was described, characterised by a lack of markers (surface CD3), maybe related to an Enteropathy Associated T-cell Lymphoma (EATL). In a subgroup of our refractory coeliacs (type II) we recognised this abnormal T-cell profile. The aim of our study was to investigate the small intestinal T-cell phenotypes of patients diagnosed with CD, refractory CD (RCD), type I and II, and controls using flowcytometry . >From January 1999 until October 2001 we performed T-cell immunophenotyping using a Fluorescence Activated Cell Scanner on the small intestinal biopsies (SIB) of 32 controls, 38 coeliacs and 32 refractory coeliacs (16 RCD type I and 16 RCD type II). Overall, we saw a higher percentage of intra epithelial T-cells in the SIB of patients diagnosed with CD and RCD type I as compared to healthy controls (mean 91 vs. 76%). In contrast, in RCD type II there was a significant decrease in the percentage of normal T-cells in favour of a population of immature T-cells (mean 65%). These immature T-cells were characterised by the presence of intracytoplasmic CD3; surface CD2; CD7; CD103 (mucosal marker) and CD95 (TNF-receptor) and in the majority of cases the absence of surface CD3, CD4 and CD8. In 11 of 16 (69%) RCD type II patients an EATL was diagnosed, 9 of 11 (81%) died. Conclusions: In contrast to an increased percentage of normal intra epithelial T cells in patients with CD and RCD type I, the presence of an immature T-cell population was recognised in RCD type II. In our study-group, this aberrant T-cell population was highly related to the development of an EATL (69%), followed by death in the majority of cases. These results call out for prospective and therapeutical trials in RCD, particularly in type II.

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Clinical and pathological features of pancreatic carcinomas in carriers of a specific 19 deletion of p16 (P16-LEIDEN). WH de Vos, GJA Offerhaus, M van Puijenbroek, E Caspers, N Gruis, F de Snoo, G Griffioen, W Bergman, HFA Vasen, H. Morreau. Leiden University Medical Center, Dept of Gastroenterology, Pathology, Dermatology and Dept of Clinical Genetics, Academic Medical Center Amsterdam, Dept of Pathology, Netherlands Foundation for the Detection of Hereditary Tumours, Leiden. Carriers of a specific p16-Leiden mutation (a 19 bp deletion in exon 2) are not only at risk of developing melanoma (The Familial Atypical Multiple Mole Melanoma Syndrome) but do also have an estimated lifetime risk of developing pancreatic cancer (PC)of 17%. Aim of the present study was to demonstrate the clinical and pathological features of PC in p16-Leiden mutation carriers. Clinical data and paraffin embedded tissue of 12 subjects, that belonged to p16-Leiden positive FAMMM families, and died of PC was obtained. Genomic tumour DNA was isolated from formalin fixed paraffin embedded material. Due to the 19 bp deletion we could specifically analyze the fate of the wild type allele in terms of loss of heterozygosity (LOH). If both normal and tumour tissue of the PC was present, LOH was scored. K-ras mutations were determined by sequencing and dot blot analysis. Immunohistochemical testing for p16, p53, Smad4 and Cox-2 was performed. A somatic p53 mutation was scored when >75% of the nuclei stained positive. The average age of subjects that developed PC (8 males) was 57 years (range: 43-74 years). Tumours were detected at TNM stages I (n=1) II (n=1) III (n=2) IV (n=7) and unknown (n=1). Histology was scored as conventional ductal adenocarcinoma (11/12) and neuroendocrine PC (1/12). Location of the carcinoma was in the head (10/12), corpus (1/12) and tail (1/12) of the pancreas. The average survival was 7 months (range 0-13 months). The specific p16-Leiden mutation was confirmed in all patients. LOH on the wild type allele was present in 3/7. K-ras codon 12 mutation were present in 9/10 including GAT (5/9), GTT (3/9) and CGT (1/9). Immunostaining for p16 was negative in 10/10, p53 mutations were scored in 5/12. Smad4 was negative in 5/12, Cox 2 was positive in 11/12. Pancreatic cancer in p16-Leiden mutation carriers is a conventional ductal adenocarcinoma. The p16 protein expression was lost in all tumours. Cox-2 expression was positive in almost all subjects These are important findings for p16-Leiden mutation carriers participating a surveillance program.

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Effect of caffeine and nicotine on rectal tone and sensitivity. CEJ Sloots, RL West, RJF Felt-Bersma, EJ Kuipers. Dept of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, Rotterdam. Physiologic stimuli such as a meal can influence rectal tone. In addition, coffee use and cigarette smoking are believed to induce bowel movements. Aim of this study was to investigate the effect of coffee and nicotine on rectal tone, compliance and sensitivity in healthy subjects. Sixteen healthy volunteers were recruited and participated in two experiments, eight in each. A flaccid polyethylene bag was mounted on a double lumen catheter and connected to a barostat apparatus. The bag was inserted in the rectum. After continuous volume distension and pressure distension, an isobaric procedure was performed. After 30min of adaptation, 280ml strong coffee or warm water was given in experiment one (randomly on separate days) and 2mg nicotine or placebo in experiment two followed by 60 min of volume registration. Continuous pressure distension was repeated. In experiment one, rectal volume decreased significantly starting at 30min from 126±24 (mean±sem) to 80±28ml (45%) after coffee (P=0,031) and from 142±22 to 110±30ml (30%) after water (P=0,032). The response after coffee or water was not significantly different. Compliance and visceral sensitivity were not different after coffee compared to water, however, compared to basal measure-ment sensitivity was impaired with either of them (P=0,033). In experiment two, rectal volume did not decrease significantly after administration of nicotine (from 151±16ml to 137±19ml; 7%) or placebo (from 158±25ml to147±35ml; 10%). Rectal visceral sensiti-vity was significantly lower after nicotine (P=0,012) and after placebo (P=0,034) compared to basal, however compliance was not significantly changed. Conclusion: Rectal tone increased after coffee (45%) and warm water (30%) intake suggesting that this alteration is an effect from the gastric volume load, and in a minor extent due to the caffeine-compound of coffee. Neither nicotine nor placebo influenced rectal tone. After coffee, warm water, nicotine, and placebo, rectal sen-sitivity was decreased suggesting that other factors were of in-fluence such as the two hours of bed-rest.

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Fluoxetine (Prozac) for the treatment of Irritable Bowel Syndrome: a randomized, controlled clinical trial SD Kuiken, P Burgers, GNJ Tytgat, G Boeckxstaens. Dept of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam. The use of low dose antidepressants may be effective for the treatment of Irritable Bowel Syndrome (IBS). However, placebo controlled trials are lacking. Therefore, we studied the effect of fluoxetine on quality of life, symptoms and rectal sensitivity in IBS patients, in a double blind, randomized, placebo controlled manner. 40 patients received placebo (PLAC: n=21, 10 F) or 20 mg fluoxetine (FLU: n=19, 12 F) once daily for 6 weeks. At day 1 and after 6 weeks, subjects underwent a barostat study to determine the sensitivity to rectal distention. In addition, global symptom relieve, quality of life (MOS 24) and symptoms (Gastrointestinal Symptom Rating Scale) were assessed. At inclusion, patients had to fulfill the Rome I criteria for IBS and depression was excluded using the Zung depression scale. Statistical analysis was performed using a Student's t-test. Thresholds for discomfort were not significantly altered in both groups (PLAC: from 28 (3) to 29 (3) mmHg, p=0.5; FLU from 30 (3) to 28 (3), p=0.3). Global relieve of symptoms at 6 weeks was similar for both groups (PLAC: 43% vs. FLU 53%, p=0.4, x2 test), and was not related to gender, hypersensitivity to rectal distention or dominant bowel habit. In both groups, individual symptoms of diarrhea, constipation, bloating, flatulence, urgency and incomplete evacuation did not significantly improve during treatment. Pain scores (MOS 24) significantly decreased during FLU treatment (from 4.1 (0.1) to 3.6 (0.1), p<0.05) but not during PLAC (from 3.8 (0.3) to 3.6 (0.3), p=0.1). At 6 weeks, FLU significantly reduced pain scores in female (FLU: 3.6 (0.2) vs. PLAC: 4.3 (0.2), p<0.05), but not in male patients (FLU: 3.4 (0.2) vs. PLAC: 3.0 (0.4), p=0.4), compared to placebo. Other items derived from the MOS 24 questionnaire, such as vitality, physical- and mental functioning, were not significant different between groups and during treatment. Conclusions: FLU reduces pain scores in IBS, especially in female patients. This beneficial effect does not result from reduced rectal sensitivity. Global relieve of symptoms, quality of life and gastro-intestinal symptoms were not altered by FLU, compared to PLAC.

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Studying Gastrointestinal Motility, Allexythimia, Psychological Profile And Quality Of Life (QoL) In Patients With Irritable Bowel Syndrome (IBS) P Portincasa, A Moschetta, V Causarano, DF Altomare, G Palasciano. Chair of Semeiotica Medica and Section of Internal Medicine, Section of Internal Medicine, Dept Internal and Public Medicine (DIMIMP), Section of Surgery, Dept Emergency Organ Transplant (DETO), University Medical School, Bari, Italy. Since gastrointestinal misperception and dysmotility can be variably associated with abnormal psychological profile in IBS, potential interactions between such conditions were studied by careful assessment of dyspepsia, allexythimia, QOL and psychological profile in IBS patients. Methods: 30 patients (M:F=7:23; age 45±3 yrs, mean±SE) with recently diagnosed IBS (ROME II criteria) were compared with 30 healthy control subjects (M:F= 10:20, 47±2 yrs). Specific questionnaire assessed dyspepsia (Buckley, 1997), colonic transit (daily diary + Bristol Scale Stool Form), allexythimia (TAS-20), QOL (SF-36, eight domains), psycho-affective profile (MHQ). Gallbladder and gastric emptying were assessed ultrasono-graphically (Nutridrink® 200 mL liquid test meal, 13g fat, Nutricia, NL). Orocecal transit time (OCTT) was measured by H2-lactulose-breath test. Results: compared with control, IBS patients had increased dyspepsia (score 12.3±1.5 vs 5.2±0.2, P<0.0001), weekly bowel movements (13.1±1.1 vs 5.2±1, P<0.00001; no difference in stool shape), and increased allexythimia (score 48.7±2.7 vs 41.6±1.7, P=0.04). QOL was significantly poorer in all domains and there was increased prevalence of anxiety, phobia and somatization. Also, IBS patients had delayed gastric emptying (T50: 32.81±1.8 vs 24.1±0.7 min, P=0.0001), delayed OCTT (158.2±9.6 vs 97.9±2.5 min, P=0.0001) but normal gallbladder kinetics. The score of dyspepsia was negatively correlated with QOL domains (physical pain: r=-0.59, P=0.012; health: r=-0.57, P=0.02) and positively correlated with somatization (r=0.73, P=0.002). Conclusions: Newly diagnosed ROME II IBS patients have multiple and simultaneous gastrointestinal motility defects associated with severe dyspepsia and a background of psychological disturbances. Such abnor-malities result in a significantly impaired QOL and underscore the importance of fullly approaching IBS patients (i.e. studies of motility defects and psychological profiles, or viceversa).

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Effect of neurotensin on colo-rectal motor and sensory function. EDCM Schots, PPJ van der Veek, AAM Masclee. Dept of Gastroenterology-Hepatology, Leiden University Medical Center, Leiden, The Netherlands. Background: Animal studies have shown that neurotensin stimulates colonic motility but little is known on the effect of neurotensin on colonic function in humans. Aim of the study was to investigate the effect of neurotensin on rectal and colonic motor and sensory function and colonic reflexes in humans. Methods: Motor and sensory function of the descending colon and rectum were studied in 8 healthy volunteers (3 males, 5 females, age: 27±4 yr) using a dual computerized barostat assembly. Measurements were performed during placebo and neurotensin infusion (5 pmol/kg/min) in random order. Barostat catheters with bags were positioned in the descending colon and rectum under endoscopic guidance and after bowel cleaning. First, compliance of both rectum and colon was assessed during stepwise pressure distensions from 6 to 30 mmHg. Thereafter rectocolonic and colorectal reflexes were studied: while the rectal bag was distended at 15, 20, 25 and 30 mmHg for 5 min, changes in colon bag volume were registered (colon barostat at MDP + 2 mmHg) and vica versa. Symptom perception (urge and pain) was scored using Visual Analogue Scales (0-10 cm). Results: Neurotensin significantly (p<0.05) increased rectal compliance (from 9.0±1.1 to 10.1±1.1 ml/mmHg) but not colonic compliance during isobaric distensions. During distensions urge was not affected by neurotensin, but pain during neurotensin infusion was significantly increased over control (3.3±0.9 vs 0.6±0.2; p<0.05). As for colonic reflexes: during rectal distension the colonic bag volume increased significantly (p<0.05) while during colonic distension the rectal bag volume decreased significantly (p < 0.05). Neurotensin delayed the occurrence of these reflexes: they were present at 25 instead of 15 mmHg (p<0.05). Conclusions: We have demonstrated the presence of both a recto-colonic inhibitory and a colorectal stimulatory reflex in healthy volunteers. Neurotensin influences compliance and sensitivity of the rectum, but not of the descending colon. Colorectal and rectocolonic reflexes are delayed during infusion of neurotensin.

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In search of objective manometric criteria for colonic high-amplitude propagated contractions AMP de Schryver, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of Gastroenterology and Surgery, University Medical Center Utrecht. Although colonic high-amplitude propagated contractions (HAPCs) are said to be clearly identifiable manometrically, different inves-tigators use different criteria to detect them. The aim of our study was to explore all possible characteristics of HAPCs that would allow separating them from non-HAPC colonic pressure waves. 24-hour colonic manometry recordings (6-channel, solid state), obtained from 24 healthy volunteers (11 male) were used. Automated analysis using locally developed software was performed to detect colonic pressure waves and to determine their amplitude, duration and area under the curve (AUC). Propagated pressure waves were defined as waves propagating over at least three channels, with a velocity of > 0.22 cm/s and < 10 cm/s. For each of the variables mentioned distribution plots were made. Furthermore, HAPCs were detected automatically and the results were compared to those of visual analysis by three experienced investigators. A total of 141093 colonic pressure waves was detected and analyzed. The distribution plots for amplitude, duration and AUC did not show a bimodal pattern, neither was this the case for distribution plots of propagated contractions (n= 8758). These negative findings precluded objective determination of thresholds for amplitude, duration or AUC. With increasingly high amplitude thresholds for HAPC detection a gradual decrease in the automatically detected number of HAPCs was observed, again precluding determination of a threshold. Finally, HAPCs detected by a panel of 3 human observers were taken as reference. With this as gold standard automated analysis using an amplitude threshold of 100 mmHg in two channels and 80 mmHg in one channel yielded a sensitivity of 91.9% and a specificity of 99.1%. 8.9% of all automatically detected HAPCs was detected by none of the three observers. Conclusions: Objective criteria to distinguish HAPCs from other propagated colonic pressure waves on the basis of their amplitude, duration or AUC do not exist. Use of empirically derived criteria leads to an acceptable degree of correspondence with visually detected HAPCs.

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Fully automated analysis of prolonged ambulatory colonic manometry recordings AMP de Schryver, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of Gastroenterology and Surgery, University Medical Center Utrecht. The purpose of our study was to develop a computer program for the analysis of all colonic motor patterns in prolonged colonic motility recordings. 24-hour colonic manometry recordings (6-channel, solid state), obtained from 24 healthy volunteers (11 male) were used. Algorithms were developed for the calculation of five types of pressure waves (>10 mmHg): antegrade and retrograde (propa-gating over at least two channels, with a velocity of > 0.2 cm/s and < 10.0 cm/s), simultaneous (in at least two channels, with a velocity of > 10.0 cm/s), high-amplitude propagating contractions (HAPCs, propagating over at least 3 channels, with an amplitude > 100 mmHg in two and > 80 mmHg in one channel) and isolated pressure waves (remaining waves). Furthermore, the percentage time of colonic and rectal motor complexes was calculated (at least 3 pressure waves per minute for at least 3 min in the colon and rectosigmoid area respectively). Validation was performed by comparison with visual analysis by one experienced observer. Statistical differences for the 7 patterns recorded on the 1st half day (6:00 AM to 14:00 PM) were compared with those recorded on the 2nd half day (14:00 PM to 22:00 PM) and during the night (22:00 PM to 06:00 AM) using the multiple-factor ANOVA with Bonferroni correction. The results of automated analysis correlated very well with those of visual peak detection (99%). Most colonic motor patterns showed a clear-cut diurnal variation. As compared to the 1st half day there was a clear nocturnal decrease of incidence of antegrade (46.6 ± 4.6 vs. 22.4 ± 3.3; P<0.05), high-amplitude (0.43 ± 0.0 vs. 0.12 ± 0.0; P<0.05), simultaneous (2.4 ± 0.3 vs. 1.5 ± 0.7; P<0.05) and isolated pressure waves (140.3 ± 3.8 vs. 86.7 ± 1.7; P<0.05). The percentage time of rectal motor complexes was also decreased during the night (2.43 vs. 1.79% ;P<0.05). Conclusions: Automated analysis of all hitherto described colonic motility patterns is feasible. Most colonic motor patterns show a diurnal variation.

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Functional Non-Retentive Fecal Soiling (FNRFS) in children: 10 years of follow up. * WP Voskuijl, F de Lorijn, R van Ginkel, MP van Wijk, JA Taminiau, MA Benninga. Dept of Pediatric Gastroenterology and Nutrition, Academic Medical Center, Amsterdam. FNRFS, encopresis in the absence of signs of fecal retention, is a frustrating phenomenon in children and difficult to treat. It is assumed that FNRFS will resolve spontaneously, however no data on long term outcome are available. Aim of the study was to investigate the long term outcome of children with FNRFS after intensive medical and behavioral treat-ment. Between 1990 and 1999, 114 patients (90 boys) with FNRFS were enrolled in a prospective, randomized trial in which the additional benefit of biofeedback training to conventional laxative therapy was evaluated. All patients had to be 5 years to understand the biofeedback procedure. Follow up was performed at 6 months, 1 year and thereafter annually after the end of the intervention until November 2001. A standardized questionnaire was used, either during clinical visit or by telephone, to evaluate symptoms. Success was defined as having less than 1 encopresis episode in 2 weeks while not using medication for more than 1 month. At enrolment, the median age was 9.1 (5.4-17.7) years and the median duration of symptoms was 4.6 (0.6-12.2) years. The median total period of treatment before intake was 6 (2-93) months. After 2, 5 and 8 years of intensive medical and behavioral therapy, 33 out of 113 (29.2%), 57 out of 90 (63,3%) and 39 out of 48 (81,3%) patients were successfully treated, respectively. At the age of 12, 56.6% (43/76) of the patients still complained of encopresis. Whereas, at the age of 18, even 20.5% (8/39) experienced symptoms of FNRFS. A 90 % follow-up was achieved at all stages of the study. Conclusions: Despite a gradual increase in success, 20% of FNRFS patients have encopresis after 8 years of follow-up. FNRFS in childhood does not always resolve in adulthood since 20.5% of patients in this study still experience encopresis after the age of 18.

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The value of diagnostic tests in Hirschsprung's disease. F de Lorijn, WP Voskuijl, DC Aronson, FJ ten Kate, JB Reitsma, AM Smets, JA Taminiau, MA Benninga. Depts of Pediatric Gastroenterology and Nutriton, Pediatric Surgery, Pathology, Clinical Epidemiology and Biostatistics, Radiology, Emma Children’s Hospital/Academic Medical Center, Amsterdam. Hirschsprung's disease (HD) is characterized by the absence of ganglion cells from the distal rectum to a variable length up to the duodenum. The diagnosis of HD is not always easy to establish. The accepted diagnostic approach in HD consists of a contrast enema (CE) (localizing transitional zone), anorectal manometry (ARM) (absence of recto-anal inhibition reflex) or rectal suction biopsy (RSB) (aganglionosis and elevated acetyl cholinesterase activity). The diagnostic value of each investigation was never evaluated in a prospective study. The aim of this study was to evaluate the distinctive diagnostic value of contrast enema, anorectal manometry and rectal suction biopsy in infants suspected of HD. Infants suspected of HD were enrolled in the study and underwent CE, ARM and a RSB in a random order. All investigators did not know the outcome of the other tests. If, after all three investigations diagnosis was uncertain, a full thickness biopsy was performed under general anesthesia. Between 2000 and 2001, 40 consecutive patients (22 boys, mean age: 9.4 months; 1 week – 43 months) suspected of HD were investigated. HD was found in 13 out of 40 patients. Sensitivity and specificity of the CE were 46% and 89%, respectively (N=40). ARM showed a sensitivity and specificity of 80% and 91%, respectively (N=33). In 7 infants ARM could not be analyzed due to agitation during the procedure. Three out of 7 of these infants had HD. The RSB showed a sensitivity and specificity of 90% and 100% respectively (N=37). In 3 patients the RSB was not conclusive. Since these patients continued to have severe complaints of constipation a full thickness biopsy (FSB) was performed which showed HD in all 3 children. Conclusion: 1) In infants the accuracy of ARM is high, but histology/enzym histochemistry remains the gold standard in the diagnosis of HD. 2) A CE does not add to the diagnostic work-up of HD and should be reserved as a preoperative imaging in proven HD patients.

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Maturation of the rectoanal inhibitory reflex in very premature. F de Lorijn, TI Omari, JAJM Taminiau, MA Benninga. Dept of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Center, Amsterdam, The Netherlands, Gastroenterology Unit, Women’s and Children’s Hospital, North Adelaide, Australia. Defecation problems in neonates are common. Around 60% of infants less than 2500 g, and less than 37 weeks gestation, fail to pass meconium by 24 hours after birth. Occasionally, particularly in the term and preterm neonate, Hirschsprung’s disease needs to be excluded. Anorectal manometry using a micromanometric sleeve assembly offers a noninvasive diagnostic test for identifying anorectal motor dysfunction in the neonate. We have previously shown that older preterm and term infants exhibit a normal anal sphincter function. The aim of this study was to characterize anal sphincter function in very premature infants ≤ 30 weeks postmenstrual age (PMA) and to evaluate the time of maturation of the anorectal inhibitory reflex using a sleeve catheter. Anorectal manometry was performed in 15 healthy neonates (8 female) with a mean PMA of 29 weeks (range: 27 to 30 weeks) with a micromanometric assembly (od 2.0 mm). The assembly incor-porated a 2-cm-long sleeve sensor for measurement of resting anal sphincter pressures and relaxation, and 4 sideholes recorded anal and rectal pressures. Rectal distension was performed with direct air insufflation to elicit the rectoanal inhibitory reflex (RAIR). The first production of meconium varied between directly after birth within 72 hours after birth. The mean basal anal sphincter pressure, rectal pressure, and rhythmic wave frequency were 24.8 mmHg (range: 5 to 46 mmHg), 6.7 mmHg (range: 1 to 19 mmHg), and 11/min (range: 9 to 15/min), respectively. A normal RAIR could be elicited in 12 (80%) infants studied. In two infants the RAIR could not be elicited due to a low anal sphincter pressure of only 5 mmHg. In the other child, no RAIR was seen despite the repeated insufflation of at least 5 ml of air. Conclusion: An anorectal micromanometric sleeve catheter is suitable for use in evaluating anorectal pressures in very premature neonates. 80% of premature infants older than 26 weeks PMA have normal anorectal pressures and a normal RAIR, this compares with 95% of older preterm infants and 100% of term infants.

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The effect of acute tryptophan depletion on gastric emptying and gastric myoelectrical activity. MA van Nieuwenhoven, SDM Valks, WJ Riedel, R-JM Brummer. Depts of Gastroenterology and Psychiatry & Neuropsychology, University Hospital Maastricht. Serotonin (5-HT) is involved in the brain-gut axis. The precursor of 5-HT is the essential amino acid tryptophan. It is possible to lower the 5-HT level in the body by means of a nutritional intervention; the acute tryptophan depletion method (ATD). The aim was to investigate the effect of ATD on both gastric emptying and gastric myoelectrical activity (GMA). Ten healthy females (age 19 -25 y) received both ATD and placebo in a randomised double-blind design. Gastric emptying of a tryptophan-free test meal was measured using the 13C-octanoic acid breath test. GMA was measured by electrogastrography (EGG) in the fasting state (30 min baseline) and after the test meal (30 min postprandial). The following EGG-parameters were determined: dominant frequency (DF), dominant power (DP), instability coefficient (IC), power ratio (PR) and percentages dysrhythmias (bradygastria (BG) < 2 CPM and tachygastria > 4 CPM). Data were compared using Wilcoxon's Signed Rank test and presented as median (range). ATD did not lead to significant differences in DF, DP, IC, and BG respectively, compared to placebo, both in the fasted and post-prandial state. No significant differences in PR or tachygastrias were observed. In contrast, 8 out of 10 subjects showed a delayed gastric emptying in the ATD experiment. Both the T1/2 and the Tlag were significantly prolonged in the ATD experiment (T1/2 ATD: 137.2 min (range: 76.2-634.8), T1/2 placebo: 98.5 min (range 63.7-168.8), P = 0.028. Tlag ATD: 83.7 min (range: 45.1-356.2), Tlag placebo: 56.9 min (range: 23.2- 101.2), P = 0.007). Conclusions: Lowering the 5-HT level in the body by ATD leads to a significantly delayed gastric emptying, with a significantly prolonged lag phase. ATD does not lead to significant differences in gastric myoelectrical activity. There appeared to be no relationship between GMA and gastric emptying. Nutritional manipulation of the serotonergic system may lead to alterations in GI motility.

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3-Dimensional ultrasonographic measurements of gastric volume in healthy volunteers; Gastric distribution in relation to sensations. MW Mundt, M Samsom, AJPM Smout. Gastrointestinal Research Unit, Dept of Gastroenterology and Surgery, University Medical Center, Utrecht. 3D ultrasound is a non-invasive technique to measure gastric volume. Aim of this study was to investigate the relation between total and partial gastric volume changes and sensations. The study was performed in 10 healthy volunteers (4 male, age range 20-39). First 2D ultrasonographic images were acquired using the sweep technique. During each sweep 400 images were recorded within 20 sec and stored in a personal computer. A pulse-magnetic field generator and a probe sensor enabled 3D orientation. Gastric wall (lamina propria) was outlined manually using 3D analysis software (InVivo, MedCom GmbH, Germany) and 3D gastric volume was calculated (3DV). Furthermore antral area (AA) was measured and sensations (epigastric pain, fullness, nausea, and hunger) were scored using a VAS list. The subjects received a 500-ml liquid meal (200 ml Nutridrink+300 ml water, 300 kcal.) within 2.5 min. Data were acquired while fasting and at 5,15,30,45,60 min postprandially. To investigate intragastric distribution we created a distribution ratio (DR=100x(∆AA/∆3DV)). Mean fasting gastric volume was 34.1(3.4) ml. Maximum 3DVs were seen 5 min after the meal (494(8.8) ml). 3DVs decreased linearly with time (repeated measures ANOVA, p<0.001). Between 5 and 60 min postprandially a 32% decrease in gastric volume (5 min: 494(8.8) ml, 60 min: 337(3.5) ml, p<0.001) could be demonstrated. The distribution ratio 5 min after the meal ingestion was comparable to the distribution ratio at 15 min (DR: 3.0(0.28), 2.9(0.29), resp., p=0.71). ∆AAs were correlated to the ∆fullness (r=0.74, p<0.001) and ∆hunger (r=-0.32, p=0.024) sensations. Moreover, ∆fullness was strongly correlated to distribution ratios (r=0.75, p<0.001). No relationships could be found with the sensations pain and nausea (r=0.03 resp. r=-0.11). Conclusions: Volume changes of total stomach and antrum in response to a meal remain constant in the early postprandial period indicating that the accommodation response is fast and completed after meal ingestion. Antral size relative to total gastric volume is strongly associated with the sensation fullness.

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The effect of different drinks on the occurrence of gastrointes-tinal complaints during running: A randomized controlled field study. MA van Nieuwenhoven, F Brouns, EMR Kovacs. Depts of Gastroen-terology and Human Biology, Maastricht University. GI complaints may occur during running. Commercially available sports drinks to prevent dehydration and hypoglycemia during exercise are generally used. In addition, some sports drinks also contain caffeine to enhance performance. The aim was to inves-tigate the effect of 3 different drinks on GI complaints and per-formance during competitive running in a controlled field study. Ninety-eight well-trained (3-15 h running/week) healthy subjects (90 M, 8 F, age 41 ± 8 y) performed a competitive 18 km run three times within 8 days. The study was a controlled, standardized field experi-ment following a randomised, crossover design. Three different drinks were compared: water (WAT), a sports drink (CES) and a sports drink with added 150 mg/l caffeine (CAF). Prevalence and intensity of gastrointestinal complaints during the run were scored using a 10 points scale questionnaire. The intervention consisted of drinking 4 times 150 ml of the test drink at the start, after 4.5 km, 9 km and 13.5 km of the run. There were no significant differences in performance between the 3 drinks. Runtime (18 km, mean ± SD): WAT 1:18:03 ± 08:30, CES 1:18:23 ± 08:47, CAF 1:18:03 ± 08:42. The use of carbohydrate-containing sports drinks led to higher incidences of all types of GI complaints compared to water. Significant differences (P < 0.05) were reached for flatulence (lower GI complaint): incidence: WAT 17.9 %, CES 28.6%, CAF 30.6%, and reflux (upper GI complaint). incidence): WAT 55.7%, CES 78.6%, CAF 72.5%. There were no significant differences in intensity of the GI complaints. Conclusions: Results obtained in laboratory experiments, usually in a limited number of subjects, cannot always be extrapolated to field conditions with a higher number of subjects. The use of sports drinks during an 18 km run led to a higher incidence of both upper and lower gastrointestinal complaints than water. Sports drinks used during an 18 km run do not support the performance better than plain water. Addition of caffeine to the sports drink has no effect on either performance or GI complaints.

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Octreotide affects gastric motor and sensory function after chemical but not after mechanical stimulation. P Verbeek, PPJ van der Veek, C Penning, AAM Masclee. Dept of Gastroenterology-Hepatology, Leiden University Medical Center. Visceral hypersensitivity is an important feature of patients with functional dyspepsia (FD). Symptoms in FD patients are provoked by meal ingestion and consist of both chemical (nutrients) and mechanical (distension) stimulation of the gut. Several substances are under evaluation for their antinociceptive effects in FD. The somatostatin analog octreotide has been shown to reduce upper gastrointestinal symptoms in FD patients but the mechanisms of action are poorly understood. We have therefore explored the effect of octreotide on proximal gastric motor and sensory function in healthy volunteers after mechanical, chemical and combined mechanical+chemical stimulation. Two experiments were performed in random order in 8 healthy volunteers (3F, 5M; age 21+/-1 yr) during iv infusion of octreotide 25ìg/h or saline (placebo). Proximal gastric motility was measured using a barostat and perception was scored on visual analog scales (0-100mm). Minimal distension pressure (MDP) was determined. Mechanical stimulation by pressure distension (0-14mmHg), chemical stimulation by intralipid (2 kCal/min intraduodenally) and combined chemical mechaniccal stimulation was performed. Results: MDP was not sign. different between octreotide and placebo: 7.0+/-0.3 vs 7.6+/-0.2mmHg. Octreotide did not influence gastric compliance during pressure distension: 36+/-8mL/mmHg vs 37+/-7mL/mmHg. Fullness increased during distension without any difference between octreotide and placebo. Intraduodenal fat increased gastric volume during placebo from 190+/-18mL to 419+/-18mL (p<0.05) but not during octreotide: 118+/-34mL to 161+/-8mL (ns). Nausea and fullness induced by fat infusion were significant reduced during octreotide vs control. During combined mechanical + chemical stimulation gastric volume remained sign. (p<0.05) reduced during octreotide vs placebo (553+/-14 vs 790+/-10mL) but no differences in perception were found (nausea 43+/-11 vs 48+/-18mm). Conclusion: Dyspeptic symptoms are provoked by both mechanical and chemical stimulation of the gut. Octreotide sign. affects proximal gastric motor and sensory characteristics after chemical but not after mechanical stimulation.

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Motor function of the proximal stomach in intestinal metaplasia of the esophagogastric junction and in Barrett's esophagus YIP Ackermark, JMM Roelofs, R Timmer, C Wolf, CA Seldenrijk, R Breumelhof, AJPM Smout. Dept of Gastroenterology, Pathology, St. Antonius Hospital, Nieuwegein. Dept of Gastroenterology, Diakonessenhuis, Utrecht. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center Utrecht. Abnormal gastric function may contribute to the increased prevalence of reflux during transient lower esophageal sphincter relaxations (TLESRs) registered postprandially in patients with intestinal metaplasia (IM) limited to the esophagogastric junction (EGJ). In patients with GERD an enhanced postprandial fundic relaxation has been shown. This study aimed to evaluate gastric tone as well as lower esophageal sphincter (LES) tone in patients with IM limited to a normal appearing EGJ and in patients with Barrett's esophagus (BE). LES pressure was monitored with a sleeve device and proximal gastric accommodation was simultaneously assessed with a bag placed in the proximal stomach and connected to a barostat. Proximal gastric volumes were measured in fasting condition and two hours after ingestion of a 400ml/500kcal liquid meal. An isobaric distension was performed. Included were 7 patients with BE (columnar segments 2-4cm), 7 patients with IM at an endoscopically normal EGJ (IMEGJ) and a control group consisting of 7 patients without IM (IMneg). Hiatal hernia, if present, was <5cm. Each group consisted of 5 men and 2 women. Mean age and mean body mass index were similar in the three groups. A fall in LES basal tone was seen in all groups after the meal and reached significance in BE (p=0.04). There was a clear increase in incidence of TLESRs postprandially in IMneg (p=0.06) but no significant change was noted in the IMEGJ or BE groups (p=0.5, p=0.4). Neither minimal distending pressure nor gastric compliance were different between groups. The postprandial course of proximal gastric tone was not different between the groups (p=0.27) and the maximal gastric relaxation induced by the meal was similar in all three groups (p=0.3). Conclusions: In patients with IM limited to the EGJ and in patients with BE the postprandial gastric relaxation is neither more pronounced nor prolonged compared to patients without IM. These results do not support the hypothesis that a delayed recovery of proximal gastric tone after a meal would contribute to the increased prevalence of TLESRs accompanied by acid reflux in these patients.

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Neuro-immune interaction in manipulated intestine triggers an adrenergic inhibitory pathway maintaining prolonged post-operative ileus. WJ de Jonge, RM van den Wijngaard, RJ Bennink, SJ van Deventer, GE Boeckxstaens. Dept of Gastroenterology and Hepatology & Dept of Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands. Background. Post-operative ileus directly following abdominal surgery results from activation of inhibitory neural pathways due to intestinal handling. The prolonged period of hypomotility however, may be mediated by a manipulation-induced inflammatory response in the intestine. We hypothesized that these intestinal inflammatory cells are able to activate neural pathways, thus inhibiting motility of the entire GI-tract. Methods. The effect of laparotomy (L), or L combined with manipulation of the small intestine (L+IM), on gastric emptying was determined in a murine model of post-operative ileus. After 6 and 24 h, gastric emptying was determined by scintigraphic imaging after oral gavage of a 99Tc labeled semi-liquid meal (1.5 % methylcellulose). After the gastric emptying studies, gastric and ileal tissue was isolated and assayed myeloperoxidase (MPO) activity. In addition, the neuromuscular function of gastric muscle strips was studied in organ baths. Results: L+IM, but not L alone, elicited an increase in MPO activity from 5.3 ± 0.9 (6h after surgery), to 13.1 ± 2.9 U/g (24 h after surgery). No increased MPO activity was found in the stomach. The intestinal inflammation was paralleled by a delay in gastric emptying; gastric half-emptying time was significantly increased (p<0.05) from 8.9 ± 2.5% (L) to 63.8 ± 10.6% (L+IM) at 6h, and remained elevated after 24 hr 17.6 ± 4.4% (L) and 35.6 ± 5.3% (L+IM)). Treatment with the ganglion blocker hexamethonium (1mg/kg), or guanethidine (50mg/kg) prevented gastroparesis at 6 and 24h. Pre-operative inhibition of leukocyte recruitment by treatment with ICAM-1 and LFA-1 blocking antibodies was without effect 6h after surgery, but prevented gastroparesis at 24h. After L+IM, in vitro contractility of gastric muscle strips upon carbachol (10-10 to 3*10-6M) or nerve stimulation (0.5-16 Hz, 1 ms, 9V, pulse trains of 10 s) was not affected. Conclusions: Our results show that intestinal handling gives rise to local muscularic infiltrates that are able to activate inhibitory adrenergic pathways to inhibit gastric emptying. Prevention of the infiltrate prevented gastroparesis, indicating that activation of this neural pathway is maintained by a neuro-immune interaction.

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Influence of motilin on the proximal stomach in patients with functional dyspepsia. IMC Kamerling, AD van Haarst, I Biemond, H Heinzerling, R Jones, HC Schoenmaker, AF Cohen, AAM Masclee. Centre for Human Drug Research, Leiden, Dept of Gastroenterology, Leiden University Medical Center, The Netherlands, R.W. Johnson Pharmaceutical Research Institute, High Wycombe, United Kingdom. Background: Motilin is involved in the regulation of upper gastro-intestinal (GI) motility and has been implicated in the pathogenesis of several GI disorders such as functional dyspepsia (FD). The present study was performed to obtain more insight into the effects of exogenous motilin on the proximal stomach of healthy volunteers and patients with FD. Methods: Eight healthy volunteers and 12 patients with FD (Rome II criteria, early satiety type) were infused with synthetic motilin (4 pmol/kg/min) or placebo over 90 min, in a double-blind, randomized, cross-over design. Proximal gastric motor and sensory function was measured with a barostat at a predefined pressure (barostat procedure) and during isobaric distensions (distension procedure). Abdominal symptoms such as fullness, nausea and pain were scored by Visual Analog Scales (VAS). Blood samples were drawn for plasma motilin (RIA). Results (mean ± SD): The plasma-concentration time curves for motilin were comparable between controls and patients. Baseline gastric volumes were similar for controls and patients: 269 ± 147mL and 265 ± 97mL, resp. Motilin reduced proximal gastric volume with 112 mL(95% CI: 29-195 mL) in dyspeptic patients (p=0.01) and with 96 mL (95% CI: 0-199 mL) in healthy volunteers (p=0.06), when compared to placebo. Gastric volume wave frequency (contractions) was comparable: 10.9 ± 3 and 9.4 ± 2.8 per 10 min in controls and patients resp. before motilin infusion. Motilin increased volume wave frequency compared to placebo with 1.5 and 2.6 per 10 min in controls (p=0.19) and patients (p<0.01) resp. In dyspeptic patients, compliance decreased significantly (p=0.03) from 156 ± 108 mL/mmHg during placebo to 80 ± 43 mL/mmHg during motilin infusion and was comparable to that observed in controls (p=0.02). Dyspeptic patients were significantly more nauseous (p=0.04) during motilin compared to placebo. The healthy controls did not experience nausea. Conclusion: Motilin significantly reduces proximal gastric compliance and volume both in dyspeptic patients and healthy volunteers. During motilin infusion nausea is present only in dyspeptic patients.

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Motor events underlying incomplete oesophageal bolus trans-port in healthy volunteers BLAM Weusten, LMA Akkermans, AJPM Smout. Depts of Gastro-enterology and Surgery, University Medical Center Utrecht. In order to evaluate motor events underlying incomplete oeso-phageal bolus transport, we performed combined oesophageal manometry and videofluoroscopy in 11 healthy subjects (age 38.2 [22.3–57.0]). In each, 5 10-ml barium suspension swallows (liquid bolus) were given and 5 swallows of a newly developed stan-dardized solid bolus consisting of a 1-cm cubic block of barium-gelatin. This was done in supine and in upright posture. Contraction amplitudes were measured at 3, 6, 9, 12, 15, 18, 21 and 24 cm above the LES. Manometric tracings were analysed for failed peristalsis. Bolus transport was classified as incomplete when a considerable proportion of the liquid bolus was retained in the oesophagus after the initial swallow, or in case of stagnation of the gelatin cube. Using multivariate analysis amplitudes of contractions (proximal to the level of stagnation) of swallows resulting in incomplete bolus transport were compared with those of swallows resulting in complete bolus transport. Incomplete liquid bolus transport occurred in 10/54 (19%) in the supine, and in 14/52 (27%) in the upright posture. Failed peristalsis was the underlying mechanism in 3/10 (supine) and 3/14 (upright) liquid swallows. Solid bolus stagnation occurred in 41/52 (79%) in the supine, and in 39/55 (71%) in the upright position. Failed peristalsis was responsible for the stagnation in 9/41 (supine) and 17/39 (upright) swallows. After exclusion of swallows fulfilling the criteria of failed peristalsis, amplitudes of contractions resulting in incomplete liquid bolus transport were significantly lower than those resulting in complete bolus propulsion (supine: P<0.001; upright: P<0.001). In contrast, no significant difference could be found between peristaltic con-tractions associated with solid bolus stagnation as compared to those associated with complete propulsion. Conclusions: Whereas liquid boluses usually pass the oesophagus within one peristaltic contraction, stagnation of a solid bolus is rule rather than exception. Low amplitude peristalsis is an important factor in incomplete bolus transport for liquids, whereas in oesophageal stagnation of solid boluses other determinants are likely to play a role.

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The pressure inversion point revisited. AJ Bredenoord, A Baron, JMM Roelofs, BLAM Weusten, AJPM Smout. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht, The Netherlands. The pressure inversion point (PIP) is defined as the point at which, during stationary pull-through manometry of the esophagogastric junction (EGJ), the polarity of the respiratory-associated pressure variations (RPV) changes. Traditionally, the PIP is ascribed to transition of the pressure sensor from the abdominal to the thoracic cavity. We used high-resolution manometry to investigate the validity of this concept. Using an 18-channel catheter with sideholes at 1-cm intervals straddling the EGJ prolonged esophageal manometry was carried out in 6 healthy volunteers and 6 GERD patients with a sliding hiatus hernia of 3cm. In the analysis, the position of the PIP was identified. When there was a second, more distal PIP, its position was also noted. The amplitude of the RPVs, defined as the difference between expiratory and inspiratory pressure, was measured in all signals. Double PIPs were found both in healthy controls (23% of total time) and in patients (38% of total time). Mean RPV amplitude in the body of the esophagus was 0.54±0.03 kPa and in the stomach 0.31±0.01 kPa. Mean RPV amplitude was 3.36±0.2 kPa at the proximal border and 2.29±0.2 kPa at the distal border of the PIP. During TLESRs RPV amplitude decreased to 0.61±0.02 kPa and 0.29±0.01 kPa, approximating RPV amplitudes in esophagus and stomach. When only one PIP was identified the highest end-expiratory pressure in the EGJ was adjacent to the PIP in 83% of the time and the largest RPV in 84% of the time. When also a second PIP was present, the highest pressure was adjacent to the distal PIP in 78% of the time and the largest RPV in 74% of the time. The observed relationships between the highest end-expiratory pressure, the RPV amplitude and the PIP supports the hypothesis that the PIP is a result of sliding of the high-pressure zone along pressure sensors. This explains why the RPVs are much larger in the LES than in the esophagus and the stomach and why these large RPVs are greatly reduced during a TLESR. The remaining RPVs are the compartment pressures of thorax and abdomen. Conclusion: The PIP is caused by sliding of the high-pressure zone along pressure sensors rather than by the transition from the thoracic to the abdominal compartment.

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Simultaneous gastroesophageal high-resolution manometry, pH metry and gastric volume assessment by 3D ultrasound in healthy subjects. RCH Scheffer, M Samsom, GS Hebbard, AJPM Smout, HG Gooszen. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center Utrecht, The Netherlands, Dept of Medicine, Repatriation General Hospital, Daw Park, Australia. Our understanding of the control mechanisms underlying transient lower esophageal sphincter relaxation (TLESR) is based on studies performed using the invasive barostat technique. In this study the relation between meal-induced gastric volume changes and TLESRs was investigated using non-invasive 3D ultrasound. Fifteen healthy volunteers (6 males, mean age 31(2.5) yrs) were studied. Mano-metry was done with a perfused assembly that incorporated side holes in the pharynx, the esophagus, and 11 side holes (1 cm apart) straddling the distal esophagus, the esophagogastric junction and the proximal stomach. Manometry and esophageal pH recordings were made with subjects sitting upright for a period of 1 hour followed by a 2nd hour after meal ingestion (500 ml/ 300kcal). 2D ultrasonographic images were acquired by the sweep technique (400 images within 20 sec). A pulse magnetic field generator and a sensor attached to the ultrasound probe enabled 3D orientation. Regions of interest were manually detected using the muscularis propria as outer profile and gastric volume (3DV) was calculated using 3D analysis software. Furthermore we measured antral area (AA). Ultrasonographic data were acquired while fasting and at 5, 15, 30, 45, and 60 min after meal ingestion. Manometry recordings were scored for TLESRs and gastroesophageal reflux. Gastric volumes and AA’s for the pre- and postprandial hour were averaged. All subjects showed a linear 3DV reduction with time in response to the liquid meal (r=0.99). No relationship between 3DV increase and ∆TLESRs was observed. However, a significant inverse correlation between meal induced AA changes and TLESR increase (∆TLESRs) was found (r=-0.73; p<0.05). Conclusions: 1) Simultaneous gastroesophageal manometry and 3D ultrasound is well feasible and provides a minimal invasive method to study the relationship between gastric volume and esophago-gastric junction physiology 2) Meal-induced gastric volume distri-bution plays an important role in TLESR elicitation. 3) Not only TLESR frequency but also the %TLESRs associated with reflux is increased after a meal.

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A Helicobacter pylori stress-induced locus shows genetic variation among clinical strains N de Vries, EJ Kuipers, EM van Ark, CMJE Vandenbroucke-Grauls, JG Kusters. Dept. of Gastroenterology and Hepatology, Dijkzigt University Hospital Rotterdam, Dept of Medical Microbiology, Faculty of Medicine, Vrije Universiteit Amsterdam. Adaptation of a microbial pathogen to its environment is essential for establishing a successful, persistent infection. Adaptive strategies employed by bacteria are genetic variation and regulation of gene expression in response to stress conditions. We studied these strategies in the human gastric pathogen Helicobacter pylori by the analysis of a stress-induced locus (hsp12) in clinical strains. The identities of genes present at the hsp12 locus of 30 clinical H. pylori strains were determined by PCR and sequence analysis. hsp12 transcription levels after growth under stress conditions were determined by northern hybridization. The hsp12 gene, a gene of unknown function, was previously identified as a heat-induced gene and appeared to be also induced by iron restriction and low pH. The hsp12 locus of 16 clinical strains contained a gene of variable length with partial homology to hsp12. In 14 strains non-related genes were present, showing that the hsp12 locus was highly variable. Of the 16 hsp12 genes, 12 were stress-induced, whereas 4 were not, indicating that also the stress response was subject to variation. The putative hsp12 promoter regions were highly similar (94% to 96% match in the 100 bp preceeding the open reading frame). Strains lacking a stress-response contained a T to C basepair substitution at 30 basepairs upstream of the hsp12 translational start site, suggesting a role for this position in hsp12 regulation. We are currently investigating the relationship between stress-response and allele-type of hsp12 genes and disease-outcome in H. pylori strains from patients with different clinical disorders. H. pylori uses two strategies for adaptation to environmental change at the hsp12 locus: genetic variation for long term adaptation and variable stress-responsive regulation for a rapid, short term adaptation.

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Selective gene transfer into human gastric tumors using adeno-viral vectors with ablated native tropism targeted towards EpCAM DAM Heideman, VW Beusechem, GJA Offerhaus, TJ Wickham, PW Roelvink, ME Craanen, HM Pinedo, CJLM Meijer, WR Gerritsen. Dept of Medical Oncology, Division of Gene Therapy, Gastro-enterology, Pathology, VU Medical Center, Amsterdam The Nether-lands; Dept of Pathology, Academic Medical Center, Amsterdam, The Netherlands; GenVec Inc., Gaithersburg, MD, USA Gene therapy based on recombinant adenoviral vectors (AdV) represents a rational approach for treatment of gastric cancer (GC). AdV can efficiently infect tumor cells from the digestive tract compared to alternative gene transfer vehicles, and AdV migrate to regional lymph nodes of the stomach after intra-tumoral injection into the primary tumor in a dog model. A current limitation of application of AdV for GC-gene therapy is the lack of specificity. Due to abundant expression of AdV-receptor CAR on normal gastric epithelial cells and relatively low expression on GC cells, the transduction of the normal epithelium is favored. Therefore, the aim of this study is to explore modified AdV with high level of specificity for GC cells. First, we applied an AdV lacking native binding capacities (AdLPB*F*). Secondly, we retargeted this vector towards human Epithelial Cell Adhesion Molecule (EpCAM) using a bispecific antibody. EpCAM is highly expressed on GC cells, whereas EpCAM is absent on normal gastric epithelium. On gastric cancer cell lines we demonstrated on average 1.5-log reduced gene transfer when using AdLPB*F* as compared to native AdV, and specific binding to EpCAM provided an efficient entry route for AdLPB*F*. Furthermore, we explored AdLPB*F* and EpCAM-targeting in a more clinical relevant setting using tumor and normal specimens from patients. Transduction of normal gastric epithelium and normal liver tissue was reduced approximately 1-log using EpCAM-targeted AdLPB*F* as compared to native AdV. Targeting AdLPB*F* towards EpCAM resulted in efficient transduction of primary human EpCAM-positive GC specimens. They transduced these cells with almost similar efficiency, as did native AdV. Thus, EpCAM-targeted AdLPB*F* were selective for human GC versus the surrounding normal gastric epithelium tissue and normal liver tissue. This study thus indicates that EpCAM-targeted adenoviral vectors lacking native binding capacities are promising tools for GC-gene therapy.

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Sphingomyelin Offers Protection Against Apoptosis And Hyperproliferation Induced By The Hydrophobic Bile Salt Deo-xycholate: Potential Implications For Colon Cancer A Moschetta, P Portincasa, KJ van Erpecum, L Debellis, GP van Berge Henegouwen, G Palasciano. Section of Internal Medicine, Dept of Internal and Public Medicine, University Hospital Bari, Italy, Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht The Netherlands; Dept of General and Ambiental Physiology, University of Bari, Italy. High fecal levels of hydrophobic bile salt deoxycholate (DCA) are associated with increased risk of colonic adenomas and cancer. Since phospholipids protect against detergent effects and cyto-toxicity of bile salt micelles, and ~30% of dietary sphingomyelin reaches the colon, we examined whether sphingomyelin (SM) influences apoptosis and hyperproliferation induced by deoxycholate in vitro. Methods: In CaCo-2 cells, apoptosis (ELISA detection of cytoplasmic DNA fragments) with concomitant caspase-3 activity was quantitated after 2, 4 and 16 hrs incubation with 50-500 mM deoxycholate, without or with sphingomyelin (DCA/(SM+DCA) ratios of 0, 0.05, 0.1, 0.15, 0.2, 0.3). Hyperproliferation (by bromodeoxyuridine assay) and phosphorylation of cellular proteins were evaluated. Apical membrane potential (Va) was measured using intracellular microelectrodes. In erythrocytes, phospha-tidylserine exposure upon incubation with DCA -without or with SM- was determined by quantitating its binding to annexin V. Results: at 2 and 4 hrs incubation, DCA caused dose-dependent apoptosis, with concomitant caspase-3 activation. At 16 hrs, apoptosis had decreased markedly, but there was dose-dependent hyper-proliferation (with changed phosphorylation status of cellular proteins) at this time-point. DCA also induced in the erythrocyte model (without intracellular signalling and nucleus) phospha-tidylserine exposure on the membrane outer leaflet. SM dose-dependently diminished DCA-induced hyperproliferation and apoptosis in CaCo-2 cells and phosphatidylserine exposure in erythrocytes at all time points. Finally, DCA-induced drop of Va was prevented by SM. Conclusions: sphingomyelin reduces DCA-induced hyperproliferation and apoptosis supposedly by decreasing amounts of free bile salt in the medium available for intracellular diffusion. These findings may have implications for colonic cancer protection by dietary modification.

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Gene therapy for esophageal carcinoma: the use of an explant model to test adenoviral vectors ex vivo. WA Marsman, CJ Buskens, GJA Offerhaus, JG Wesseling, JJGHM Bergman, GNJ Tytgat, JJB van Lanschot, PJ Bosma. Dept. of Experi-mental Hepatology, Gastroenterology, Pathology and Surgery, Academic Medical Center, Amsterdam. Adenoviral gene therapy might be a promising tool as a therapeutic strategy for esophageal carcinoma. For the development of a gene therapy vector established cell lines are commonly used both in vitro and in vivo. These cell lines, however, are transformed due to multiple passages and they do not represent the histology and anatomy as it occurs in vivo. To study gene therapy for esophageal carcinoma, we used an esophageal explant system to test the transduction of an adenoviral vector. Endoscopic biopsies were obtained from patients who underwent endoscopic ultrasonography for esophageal cancer, or underwent regular endoscopy for surveillance of a Barrett esophagus. The biopsies were taken from normal esophagus, esophageal tumor or metaplastic columnar epithelium. Soon after procurement, the biopsies were placed on a stainless steal grid to which culture medium was added. The grid was placed in a sealed jar which was continuously gassed with 95% oxygen. One hour after culture, one million pfu of an E1 deleted adenovirus encoding GFP, was added on the biopsy. After 24 hours of culture, the biopsies were fixated and histologically categorized in poor, moderate and good viability. Adenoviral transduction was analyzed by staining for GFP. 119 esophageal biopsies were cultured. >From the adenocarcinoma biopsies, only 21% had a good viability, compared to 36% and 52%, for normal esophagus and metaplastic columnar epithelium respectively. Transduction effi-ciency was good in normal squamous epithelium, mainly in the basal layer and not at all in the luminal layer. The transduction in the metaplastic columnar epithelium and adenocarcinoma was limited to stromal cells. No epithelial cell or cancerous cell was transduced. We used the esophageal explant system to test the transduction of an adenoviral vector. It appeared that the viability of cultured adenocarcinoma was very poor, and therefore less suitable to test a vector. Viability of metaplastic columnar epithelium and normal squamous epithelium was good and suitable for transduction experiments. It appeared that transduction was limited to the basal layer in normal esophagus or stromal cells in Barrett esophagus.

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Radioimmunotherapy for Peritoneal Carcinomatosis of Colo-rectal Origin; the Characterisation of an Experimental Model MJ Koppe, A Soede, WJG Oyen, RP Bleichrodt, OC Boerman. Depts of Surgery and Nuclear Medicine, University Medical Centre Nijmegen. Radioimmunotherapy using radiolabelled monoclonal antibodies directed against tumour-associated antigens may be an effective treatment modality for small volume disease. The aim of this study was to develop and characterise an experimental model and to investigate the potential of radioimmunotherapy for peritoneal carcinomatosis of colorectal origin. Peritoneal carcinomatosis was induced in nude mice by injecting 10*6 tumour cells of the human colon carcinoma cell line LS174T intraperitoneally. The high-affinity anti-CEA monoclonal antibody MN14 was radioiodinated. Biodistribution of the MN14 antibody after intravenous administration was compared to that after intra-peritoneal administration. A protein dose-escalation study was carried out to determine the optimal protein dose of MN14 to be used in radioimmunotherapy. Finally the therapeutic effect of an intraperitoneal injection of 500 µCi I-131-labelled MN14 was assessed in this model. Uptake of the radiolabelled antibody in the intraperitoneal tumour deposits was relatively high (50 ± 25% ID/g, 2-3 days p.i.). Only during the first 4 hours intraperitoneal administration revealed a higher tumour uptake than intravenous administration. Regardless of the route of administration uptake in normal tissues was very low (1.0 - 8% ID/g). Optimal tumour uptake was observed at protein doses up to 25 µg of MN14; higher doses led to reduced tumour uptake, probably due to saturation of the tumour antigens. While median survival of the control groups was 36 (unlabelled MN14) and 42 days (PBS), median survival of the mice that received 500 µCi I-131-labelled MN14 exceeded 124 days. In conclusion, the MN14 monoclonal antibody preferentially accu-mulated in intraperitoneally growing LS174T tumour xenografts, both after intraperitoneal as well as intravenous administration. Intra-peritoneal radioimmunotherapy using I-131-labelled MN14 had a pronounced anti-tumour effect in nude mice with peritoneal carcinomatosis of colorectal origin.

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High inducible nitric oxide synthase (iNOS) induction and increased FAS expression in colonic enterocytes in the CD45RBhigh transfer model of colitis in mono-associated SCID mice. NA Bos, G Dijkstra, JCAM Bun, GJ Geersing, H van Goor, HQ Jiang, N Kushnir, MC Thurnheer, JJ Cebra. Dept of Cell Biology, Histology and Immunology Section, University of Groningen, The Netherlands, Dept of Gastroenterology and Pathology, Academic University Hospital Groningen and Dept of Biology, University of Pennsylvania, Philadelphia. Background: The development of colitis in SCID mice injected with CD45RBhigh , CD4+ T cells is dependent on their gut flora.The mechanisms of this T cell and bacteria dependent induction of colitis is unclear. Since iNOS is expressed in epithelial cells of the inflamed mucosa of patients with Inflammatory Bowel Disease (IBD), nitric oxide could be involved in this model of colitis. Because CD45RBhigh , CD4+ T cells highly express FAS-L, FAS expression on epithelial cells could be a target for the injected T cells. Aim: To study the induction of iNOS and FAS expression in conventional reared and monoassociated SCID mice in the CDRB45high transfer model of colitis. Methods: CB-17 SCID mice were reared conventionally and mono-associated with H.muridarum, the mutant strain of L. monocytogenes, Segmented Filamentous Bacteria (SFB), and O. anthropi under specific pathogen free conditions. Purified CD4+ CD45RBhigh T cells were injected intraperitioneally and the mice were sacrificed after 3,5 months. FAS and iNOS expression was detected immunohistochemically. Results: Normal SCID mice and germfree SCID mice injected with CD45RBhigh, CD4+ T cells did not show any iNOS expression. Both in conventionally reared SCID mice and in SCID mice monoassociated with H.muridarum we observed high expression of iNOS in the affected colonic epithelial cells. SCID mice mono-associated with the mutant strain of L. monocytogenes showed some scattered staining and SCID mice mono-associated with SFB or O. anthropi were negative for iNOS expression.FAS expression was observed at the basolateral side in colonic epithelium cells in H. muridarum mono-associated mice and not in SFB mono-associated SCID mice. Conclusion: Conventional flora and H.muridarum can induce iNOS and increase the FAS expression in colonic epithelial cells in the CD45RBhigh transfer model of colitis. The produced NO could increase gut permeability whereas the increased FAS expression could render the epithelial cells to become a target for the injected T cells.

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Immunostimulated colonic explant cultures as a model for Inflammatory Bowel Disease. MJW Meijer, MAC Mieremet-Ooms, W van Duijn, JM van der Zon, CBHW Lamers, HW Verspaget. Dept of Gastroenterology-Hepatology, Leiden University Medical Centre. Inflammatory bowel disease (IBD) is characterized by severe inflammation of the gastrointestinal mucosa. Activated cytokine-secreting cells may alter the expression of matrix degrading proteolytic enzymes leading to abnormal tissue turnover. In IBD patients TNF-α and several members of the Matrix Metallo-Proteinase (MMP) family were shown to be upregulated and treatment with anti-TNF-α antibody results in remarkable im-provement of mucosal morphology. We set up an in vitro model for IBD to study the relation between TNF-α, MMPs and tissue morphology under inflammatory conditions. Normal human colon was obtained from surgical resections, mucosa/submucosa were cut into 0.1 cm² explants and cultured per 10 in 3.5 ml modified CMRL-1066 medium with or without Pokeweed Mitogen (PWM) immunostimulation in a 95% O2/5% CO2 atmosphere. Tissue mor-phology was evaluated by hematoxylin-eosin staining. Tissue homogenates and/or culture media were analysed for TNF-α, MMP-2, MMP-9 mRNA and protein levels by RT-PCR, ELISA and zymography. After 72 hours, PWM-stimulated explants showed degenerated ulceration-like morphology, while control explants showed good preservation of morphology. Stimulation with PWM resulted in an impressive gradual increase of TNF-α mRNA and protein, (80- and 19-fold compared to controls, respectively), while controls showed only minor increased levels compared to starting material. PWM-stimulated explants showed a marked gradual increase of MMP-2 and -9 mRNA (25- and 60-fold compared to starting material, 3- and 4-fold compared to controls, respectively). Surprisingly, although PWM-stimulated explants secreted large amounts of (active) MMP-2 and -9 protein (4 and 0.6 ng/mg tissue weight, respectively), these levels were 2-fold lower (MMP-2) and similar (MMP-9) compared to controls. In conclusion, the PWM-stimulated explants strongly resemble inflamed tissue in IBD patients with respect to tissue morphology, TNF-α/MMP protein and mRNA levels. Although part of the MMP production may reflect response to physical stress, it seems that MMP-2 and -9 protein expression in immunostimulated (IBD-like) colonic mucosa is differentially regulated and partially TNF-α independent.

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A possible mechanism for the difference in efficacy of inflixi-mab and etanercept in the treatment of Crohn's disease. JMH van den Brande, H Braat, GR van den Brink, I Hoedemaeker, MP Peppelenbosch, SJH van Deventer. Academical Medical Center AMC, Amsterdam. Steroid refractory Crohn's Disease (CD) is treated effectively (70%) with a chimeric anti-TNFα antibody, infliximab. Etanercept, a recombinant TNF receptor fusion protein, is highly effective in rheumatoid arthritis but not in CD. Both are TNFα-neutralizing drugs. The question arises what is causing the difference between both. We first used a sensitive assay of TNFα signaling to study the neutralizing effect of infliximab and etanercept. Hela cells were transfected with a green fluorescent protein (GFP) NFκB reporter construct and stimulated with recombinant human TNFα (rhuTNFα) in the presence or absence of both drugs. GFP expression was measured by FACS analysis. Next we examined the capability of both drugs to bind to the transmembrane form of TNFα (tm-TNFα). CD3/CD28 activated peripheral blood lymphocytes (PBL) from healthy volunteers were ex vivo incubated with both drugs and a FITC labelled anti-human secondary antibody for FACS analysis. Hereafter we studied the capability to induce apoptosis of each drug in activated lymphocytes. Activated PBL were treated with both drugs in human serum enriched medium to exclude complement-mediated cellysis. In a mixed lymphocyte reaction, activated PBL were treated with both drugs and an isotype control antibody. Lymphocyte apoptosis was determined by annexine V and 7AAD double staining for FACS analysis and cleaved caspase 3 immunoblotting. Both infliximab and etanercept neutralized rhuTNFα effectively at concentrations of 1x10-4 g/ml and 2.5x10-3 µg/ml respectively. Infliximab but not etanercept was capable of binding to tm-TNFα. Infliximab induced a significant increased rate of lympho-cyte apoptosis compared to etanercept and the control antibody (max. at 12 hrs. 35% vs.18%, n=6, all different donors, p<0.01). Infliximab induced lymphocyte apoptosis was not complement mediated. Infliximab activated caspase 3 in a time dependent manner whereas etanercept did not. Conclusions. Our data suggest that the membrane binding and apoptosis inducing capacity of infliximab may provide a biological basis for the different efficacy of the two TNFα neutralizing drugs in the treatment of Crohn's disease.

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The response of TNF-α producing cells to infliximab exposure. Q Gao, JM van der Zon, RA van Hogezand, MJW Meijer, CBHW Lamers, HW Verspaget. Dept of Gastroenterology and Hepatology, Leiden University Medical Center. Studies on the immunological mechanisms of response/failure to treatment of Crohn’s disease (CD) patients with the chimeric anti-TNF-α antibody infliximab, indicate downregulated secretion of TNF-α through antibody-induced death of TNF-α producing cells. We used a whole blood assay to determine the effect of infliximab on TNF-α production. Blood of 7 Crohn’s disease patients, pre- and 2 h post-infliximab infusion, and 5 healthy controls was cultured w-w/o lipopolysaccharide (LPS) for 5.5-24 h. TNF-α plasma levels and mRNA were assessed by ELISA (R&D Systems) and RT-PCR, respectively.Pre-infusion median 24 h LPS-stimulated TNF-α secretion of the CD patients’ blood was 381 pg/mL (range 205-5056). Stimulated post-infliximab infusion (5 mg/kg) blood showed hardly any detectable TNF-α. Addition of infliximab to blood, and post-culture plasma, of controls also completely inhibited TNF-α levels, compared to 4856 pg/mL (521-10135) without infliximab, although the TNF-α mRNA levels were 2- and 11-fold increased, respectively. We also assessed whether infliximab had lysed the TNF-α producing cells. Replacement of the post-infliximab infusion plasma by pre-infusion plasma, increased the post-infusion blood 24 h LPS-stimulated TNF-α production from <28 pg/mL to 245 pg/mL (174-280) in patients, which was identical to that of unexposed cells 287 pg/mL (136-432). In controls, after 4 h infliximab pre-exposure, wash and then LPS stimulation, this level was even higher, 5254 pg/mL (2460-8668) versus 3372 pg/mL (521-10135) after control pre-exposure. Also at the mRNA level a 3-fold higher induction was observed. Pre-exposure to both infliximab and LPS, however, renders the TNF-α production very low, i.e., 103 pg/mL (62-245). In conclusion, infliximab interferes in this ELISA determination of TNF-á, rendering it undetectable and unfit as read-out system, although the cells do show an increased mRNA level. Cells after exposure to infliximab, in vivo and in vitro, are not lysed and still capable of a normal or even enhanced TNF-α production and secretion, unless simultaneously exposed to an inflammatory stimulus. These obser-vations give a better insight into response/failure to infliximab treatment in Crohn’s disease.

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Concurrent Pseudomonas aeruginosa pneumonia aggravates acute cerulein-induced pancreatitis in mice DJ van Westerloo, M Schultz, S Knapp, SJH van Deventer, MJ Bruno, S Florquin, T van der Poll Intensive Care Geneeskunde, Experimentele Interne Geneeskunde, Maag-, Darm en Leverziekten; Academisch Medisch Centrum, Pathologie, Academisch Medisch Centrum, Amsterdam. Background: The outcome of serious acute pancreatitis is determined by the presence or absence of local and distant organ complications. The most serious complications are infectious in nature. One of the most prominent bacteria causing acute pan-creatitis related pneumonia is Pseudomonas aeruginosa. Objective: To determine the effect of concurrent pneumonia on the severity of local pancreatic damage. Methods: C57Bl/6 mice were used in all experiments. Pancreatitis was induced by 12 hourly intraperitoneal injections of the CCK analogue cerulein; immediately thereafter mice were intranasally inoculated with 5.5x106 CFU P. aeruginosa or saline (controls) and sacrificed 24 hrs later. Pancreatitis severity was determined by amylase and lipase levels, pancreatic weight, Trypsinogen Activation Peptide levels, histopathology and MPO levels. Data were compared by 2 tailed unpaired student t-tests except for histology scores (Mann Whitney U). Results: Mice with concurrent pneumonia had more severe pancreatitis than control mice without pneumonia, as reflected by higher severity scores for general histology, edema, inflammatory cell infiltrate and necrosis (all P £ 0.05), more neutrophil infiltration into the pancreas (MPO; P<0.05) and a higher relative pancreas weight (P<0.05). Furthermore, plasma amylase and lipase levels were higher in mice with concurrent pneumonia (P<0.05). Conclusion: In this murine model of severe acute pancreatitis, concurrent P. aeruginosa pneumonia dramatically augments the severity of the local damage in the pancreas. These data suggest that the worse outcome of acute pancreatitis in patients who develop extra pancreatic com-plications may in part be due to an exacerbation of the local damage in the pancreas itself.

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Expression of amidase- and urease-mediated ammonia pro-duction in Helicobacter pylori is modulated by Fur AHM van Vliet, J Stoof, SW Poppelaars, EJ Kuipers, JG Kusters. Dept of Gastroenterology and Hepatology, L-481, Academic Hos-pital Dijkzigt, Rotterdam. Ammonia production is of vital importance to Helicobacter pylori, since ammonia is involved in acid resistance, nitrogen metabolism, chemotactic motility and tissue damage. In H. pylori, ammonia is enzymatically produced by hydrolysis of urea or amides through urease and amidase, respectively. Previous studies have indicated that activity of amidase is increased in a H. pylori urease mutant, and conversely urease activity is increased in a amidase mutant. However, key regulatory components in this balance of ammonia production have not yet been identified. We have previously shown that urease expression in H. pylori is modulated by Fur, the main iron-regulatory protein of H. pylori. In this study we have characterized the role of H. pylori Fur and iron in regulation of amidase and urease expression. The AmiE amidase (HP0294) was identified on two-dimensional protein gels by MALDI-TOF mass spectometry. AmiE protein was only detected in iron-restricted conditions, but was absent in iron-supplemented media. Amidase enzyme activity and levels of amiE mRNA were regulated likewise. Regulation was absent in an isogenic H. pylori fur mutant, demonstrating that Fur mediates AmiE regulation. Regulation of amidase is inversely correlated with urease activity; high amidase activity is associated with decreased urease activity, while low amidase activity was linked to increased urease activity. Conversely, nickel-supplementation of growth media, known to induce urease activity, resulted in decreased amidase activity. The regulation of amidase by iron and Fur in H. pylori contrasts with findings in other amidase-positive bacteria, where amidase expres-sion is regulated in response to substrate availability. The Fur regulatory protein apparently is involved in regulation of at least two major ammonia-producing enzymes of H. pylori, and amidase and urease activity are inversely linked. This suggests that Fur may be the master regulator of ammonia production by H. pylori, and indirectly modulates nitrogen metabolism and acid resistance of this bacterium. This novel type of amidase- and urease-regulation may be an adaptation to the variable and harsh conditions existing in the gastric mucosa.

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Mucosal expression of motilin receptor mRNA and protein in humans WP ter Beek, ESM Muller, M van den Berg, I Biemond, CBHW Lamers. Dept of Gastroenterology-Hepatology, Leiden University Medical Center. Motilin it a biological active peptide involved in the regulation of the upper gastrointestinal tract motility. A receptor for motilin was identified by Feighner et al., they have shown mRNA expression in enteric neurons of human ileum and colon. So far no other studies have examined the distribution of this motilin receptor (MTLR). The aim of the present study was to further explore the localization and quantity of MTLR in the normal human colon and ileum, to get more information about the function of this receptor in the intestine. Full thickness intestinal tissue samples were collected and analyzed for their MTLR expression. Receptor protein was detected with quantitative autoradiography and immunohistochemistry using a polyclonal antibody directed against the previous described receptor. MTLR mRNA expression was analyzed using RT-PCR. In the intestinal muscle MTLR was detected both in colon and ileum, with ileal expression being significantly higher (respectively 4 vs. 9 fmol/g tissue; p=0.04). However, compared to MTLR expression found in antral smooth muscle (110 fmol/g tissue) colonic and ileal expression were low. Immunohistochemistry showed that in the intestinal muscle layer both muscle and myenteric plexus contained positive cells. Mucosal MTLR expression detected with auto-radiography was 20 and 28 fmol/g tissue for colon and ileum respectively, which is significantly higher than in intestinal muscle layer. Immunohistochemistry showed that the mucosal binding was due to location of the receptor in the epithelial cells. In ileum only the bottom of the crypts were positive for the MTLR, while in colonic mucosa all epithelial cells stained positive. RT-PCR showed that mRNA of the MTLR was also present in colonic and ileal mucosal tissue samples. These findings support a possible role for motilin in the secretion process. Concluding, our results showed for the first time that beside expression in the smooth muscle compartment, the MTLR is also expressed in epithelial cells of the colonic and ileal mucosa. This may indicate a role of motilin in epithelial secretion or other epithelial functions, besides its function in regulation of colonic and ileal motility.

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Incorporation of cholesterol in sphingomyelin-egg yolk phos-pha-tidylcholine vesicles has profound effects on detergent-induced phase transitions: a time-course study by cryo-trans-mission electron microscopy. A Moschetta, PM Frederik, P Portincasa, GP van Berge Hene-gouwen, KJ van Erpecum. Gastrointestinal Research Unit, Depts of Gastroenterology and Surgery, University Medical Center, Utrecht, Section of Internal Medicine, Dept of Internal Public Medicine, University Hospital Bari, Italy; Dept of Electron Microscopy, Maastricht University, The Netherlands. Vesicle <-> micelle transitions are important phenomena during bile formation and intestinal lipid processing. The hepatocyte canalicular membrane outer leaflet contains appreciable amounts of phos-phatidylcholine (PC) and sphingomyelin (SM), and both phospholipids are found in the human diet. We therefore studied detergent-induced phase transitions in SM-PC vesicles. Methods: Phase transitions were evaluated by spectrophotometry and cryo-transmission electron microscopy (cryo-TEM, 37°C, 100% humidity in fully automated vitrification robot) after addition of detergent taurocholate (3-7 mM) to SM-PC vesicles (4 mM phospholipid, SM/PC 40%/60%, without or with 1.6 mM cholesterol). Results: After addition of excess (5-7 mM) taurocholate, SM-PC vesicles were more sensitive to micellization than PC vesicles. As shown by sequential cryo-TEM, addition of equimolar (4 mM) taurocholate to SM-PC vesicles induced formation of open vesicles, then (at the absorbance peak) multilamellar and fused vesicular structures coinciding with thread-like micelles, and finally transformation into an uniform picture with long thread-like micelles. Incorporation of cholesterol in the SM/PC bilayer changed initial vesicular shape from spherical into ellipsoid and profoundly increased detergent resistance. Disk-like micelles and multilamellar vesicles, and then extremely large vesicular structures were observed by sequential cryo-TEM under these circumstances, with persistently increased absorbance values by spectrophotometry. Conclusions: Incorporation of cholesterol in SM-PC vesicles has profound effects on detergent-induced phase trasitions. These fin-dings may have implications for canalicular bile formation and intes-tinal lipid processing.

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Acute cerulein-induced pancreatitis develops independently of Toll Like Receptor 4 (TLR4) in mice. DJ van Westerloo, S Florquin, JW van Till, SJH van Deventer, MJ Bruno, T van der Poll. Depts of Pathology, Surgery, Gastroentero-logy and Experimental Internal Medicine, Academic Medical Center, Amsterdam. Background and Aim: acute pancreatitis is characterized by a rapid immunological response and release of pro-inflammatory cytokines. The inciting stimulus that leads to organ inflammation and cytokine release is still unidentified. Translocation of Gram-negative bacteria and endotoxin (the toxic moiety of the Gram-negative bacterial cell wall) from the gut has been implicated in the morbidity and mortality in patients with acute pancreatitis. Since TLR4 is the signaling receptor for endotoxin, we investigated the possible role of TLR4 in the development and the severity of experimental murine acute pancreatitis. Methods: acute pancreatitis was induced by 12 hourly intraperi-toneal injections of the cholecystokinin analogue cerulein in wild type (C3H/HeN) and TLR4 mutant (C3H/HeJ) mice. Severity of acute pancreatitis was assessed by measuring serum amylase and lipase, pancreatic histology, Myeloperoxidase, cytokines and tryp-sinogen activation peptide (TAP). To assess pancreatitis associated lung injury, lung injury was quantified by histology, cytokine levels, MPO and extravastion of Evans blue dye. Results: pancreatitis developed in all animals. TLR4 mutant mice developed acute pancreatitis that was in all parameters comparable regarding the severity and extent of acute pancreatitis in wild type mice. In concordance with this finding, pancreatitis associated lung injury was indistinguishable in TLR4 mutant and wild type mice. Conclusion: TLR4 does not play a role in the pathogenesis of acute cerulein-induced pancreatitis in mice. This finding argues against a significant role of translocation of endotoxin from the gut in this model.

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The Helicobacter pylori regulatory protein NikR is a nickel-responsive activator SW Poppelaars, J Stoof, EJ Kuipers, JG Kusters, AHM van Vliet. Dept of Gastroenterology and Hepatology, Academic Hospital Dijkzigt, Rotterdam. The genome sequence of the important human pathogen Helicobacter pylori encodes for relatively few regulatory proteins. This suggests that the regulatory systems in H. pylori are complexed with more functions than their counterparts in other bacteria. Recently we have demonstrated that a H. pylori homolog of the Escherichia coli NikR repressor functions as a nickel-responsive activator of the essential virulence factor urease, via a 19- bp palindromic sequence in the urease promoter region. In this study we have combined computer-assisted identification of putative NikR-targets with experimental validation of their regulation by NikR. A search of the H. pylori genome sequence allowed the identification of several promoters which contained a palindromic sequence homologous to the putative NikR-binding site. These included the amiE and gltS genes, encoding an amidase enzyme and a glutamate transporter, respectively. Both genes are thought to be involved in nitrogen metabolism of H. pylori. NikR-regulation was experimentally confirmed for the amiE gene by enzyme assays and Northern hybridization. Both AmiE activity and amiE transcription were induced by nickel-supplementation in wildtype H. pylori, while in a H. pylori nikR mutant this induction was absent. NikR belongs to a class of regulatory proteins, which in other systems functions as a repressor. In H. pylori however, NikR functions as an activator, mediating nickel-responsive induction of the expression of at least two components of nitrogen metabolism. These novel aspects of NikR-mediated regulation may be required for survival in the variable conditions thought to occur in the gastric niche of H. pylori.

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Implications for decreased ion and water uptake and increased epithelial protection and repair in experimental colitis. * IB Renes, M Verburg, DJPM van Nispen, HA Büller, J Dekker, AWC Einerhand. Erasmus Medical Center and Sophia Children’s Hospital Rotterdam. In ulcerative colitis epithelial functions are severely impaired. In the present study the ion and water uptake -, protective -, and repair capacities of the colonic epithelium were investigated during dextran sodium sulfate (DSS)-induced colitis. Thereto, rats were treated with DSS for 7 days followed by a 7-day recovery period. Colonic seg-ments were isolated on days 2, 7 and 14 for immunohistological and biochemical analysis. Enterocyte-specific carbonic anhydrase (CA) I, CA IV, sodium hydrogen exchanger (NHE) 2, and NHE3 expression were used do determine the ion and water uptake capacity. Goblet cell-specific mucin Muc2 and trefoil factor 3 (TFF3) expression and secretion were used to assess the protective - and repair capacity, respectively. DSS-induced crypt loss, ulcerations, and concomitant goblet cell loss were most pronounced in the distal colon. In situ detection and quantitative analysis revealed a down-regulation of CA I -, NHE2 -, and NHE3 mRNA and protein levels and of CA IV protein levels in the proximal and distal colon during DSS treatment. After DSS treatment CA I protein levels, and NHE2 and -3 mRNA and protein levels were still below control levels in both colonic segments. In contrast, Muc2 and TFF3 mRNA and protein levels were maintained or even increased in both colonic segments during DSS treatment. After DSS treatment Muc2 mRNA levels were decreased in both colonic segments, whereas the protein levels were maintained or even increased. TFF3 mRNA and protein levels were maintained in the proximal colon after DSS treatment and strongly increased in the distal colon. Importantly, during and after DSS treatment the percentage of Muc2 secretion was maintained in both colonic segments and the percentage of TFF3 secretion was strongly increased. Conclusions: Down-regulation of CA I, CA IV, NHE2, and NHE3 expression levels during DSS- colitis implies a decreased epithelial ion and water uptake capacity. Maintenance or up-regulation of Muc2 and TFF3 expression and secretion levels despite the ensuing goblet cell loss suggests that the epithelial pro-tective -and repair capacities are at least maintained during DSS-colitis. * De met asterisk gemerkte abstracts in dit programmaboekje zijn ingezonden voor de Sectie Kindergastroenterologie.

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Alfabetische lijst van standhouders voorjaarscongres 2002 Abbott BV K16 Asacol B8 AstraZeneca B23 Aventis Pharma B20 BostonScientific B7 BykNederland B21 CobraMedical B14 Cook Nederland B22 Crohn & Colitis Ulcerosa Ver. Ned. B10 Dako Diagnostics B13 Danica Nederland B4 Datex Ohmeda B12 Endomed K15 Endotechniek K2 Euro Steriel Medical B14a Ferring B2 Fresenius Kabi K5 Fujinon MedicalSystems B5 Ipsen Farma K22 Janssen Cilag K11 Maag Lever Darm Stichting B18 Medical Measurements K6 Medicor Nederland B6 Merck Sharp & Dohme B1 Nationaal Hepatitis Centrum K21 Norgine K18 NOVO Nordisk K10 Nutricia Nederland K17 Paes Nederland 1 B17 Paes Nederland 2 B16 Pentax Medical K3 Rita Medical Systems K25 Roche Nederland K24 RR-Medical K3 Schering Plough B15 Simac Diagnostica K9 Solvay Pharma K19 St. Specifieke Scholing Verpleegkundigen B11 Stichting Opsporing Erfelijke Tumoren K2a Surgical Technologies K8 Tefa Portanje K14 Tramedico BV K12 Tyco Healthcare Nederland K7 UCB Pharma K20 Utech Products K13 VMDLV + HAN B9 Wassenburg & Co K1 Will Pharma K23 Yakult B19 Zambon Nederland B3 K = Kempenhal B = Beneluxhal Bij de ingang van de expositiehal vindt u een plattegrond met de indeling van de stands.

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AANMELDINGSFORMULIER VOOR HET LIDMAATSCHAP VAN DE NEDERLANDSE VERENIGING VOOR GASTROENTEROLOGIE Naam : M/V* Voorletters : Geboortedatum : Titel : Specialisme : Assistent in opleiding voor : Werkadres instituut : afdeling : straat : postcode en plaats : telefoon : e-mail : Huisadres straat : postcode en plaats : telefoon : Doctoraalexamen : ja/neen*; zo ja, welke studierichting: Datum artsexamen : d.d. . . . . . ./n.v.t.* Inschrijving Specialistenregister : ja/neen*, zo ja, welk: Speciale interesses op GE-gebied : geeft zich hierbij graag op als : lid/buitengewoon lid* van de NVGE Tevens wil ondergetekende zich aansluiten bij: o Sectie Gastrointestinale Endoscopie o Sectie Endoscopie Assistenten (verpleegkundige/doktersassistente/.........................)* o Sectie voor Voeding en Metabolisme o Sectie Maagdarm-motoriek o Sectie Experimentele Gastroenterologie o Nederlandse Vereniging voor Gastrointestinale Chirurgie (contributie EUR 23,-- per jaar) o Sectie Kindergastroenterologie Toezending verenigingspost aan huis-/werkadres*. Datum: Handtekening: ────────────────────── Sturen aan de secretaris van de NVGE: Postbus 657 2003 RR Haarlem * doorhalen wat niet van toepassing is. U kunt zich tevens aanmelden via de website van de NVGE: www.nvge.nl

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AANMELDINGSFORMULIER VOOR HET LIDMAATSCHAP VAN DE NEDERLANDSE VERENIGING VOOR HEPATOLOGIE

Naam : M/V* Voorletters : Geboortedatum : Titel : Specialisme : Assistent in opleiding voor : Werkadres instituut : afdeling : straat : postcode en plaats : telefoon : e-mail : Huisadres straat : postcode en plaats : telefoon : Doctoraalexamen : ja/neen*; zo ja, welke studierichting: Datum artsexamen : d.d. . . . . . ./n.v.t.* Inschrijving Specialistenregister : ja/neen*, zo ja, welk: Speciale interesses op hepatologisch gebied : geeft zich hierbij graag op als : lid/buitengewoon lid* contributie: € 16,00 per jaar Toezending verenigingspost aan huis-/werkadres*. Datum: Handtekening: ────────────────────── Sturen aan de secretaris van de NVH: Postbus 657 2003 RR Haarlem * doorhalen wat niet van toepassing is

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