Gut 2003;52:966-970 Delayed gastric emptying can be due to muscular, neural, or humoral abnormalities. In the absence of an identified cause, gastroparesis is labelled as idiopathic. We present the case of a patient with severe idiopathic gastroparesis. Pharmacological approaches failed, as well as reduction in gastric emptying resistance with pyloric injection of botulinum toxin and pyloroplasty. Therefore, subtotal gastrectomy was performed. Histological and immunohistochemical study of the resected specimen showed hypoganglionosis, neuronal dysplasia, and a marked reduction in both myenteric and intramuscular interstitial cells of Cajal. To our knowledge, this is the first time these rare histological findings have been described in a patient with idiopathic gastroparesis. U nderstanding of both normal and abnormal gastrointestinal function has gained momentum in recent decades. However, gastric motility and, in particular, the relative contribution of all of the factors involved in the coordination of food propulsion are still poorly understood. Gastric emptying reflects the integration of tonic contractions of the proximal stomach (fundic tone), phasic contractions of the antrum, and the inhibitory forces of pyloric and duodenal contractions. These complex phenomena require cooperation between smooth muscle, enteric and autonomic nerves, and interstitial cells of Cajal (ICC).

Achalasia is dominated by injury to inhibitory nerves. As intramuscular interstitial cells of Cajal (ICC-IM) are proposed to form functional units with nitrergic nerves, their fate in achalasia may be critically important. We studied the relationship between loss of nitrergic nerves and injury to ICC-IM in patients with achalasia and determined associations between ICC-IM and mast cells (MC), using quantitative immunohistochemistry and electron microscopy. Loss of neuronal nitric oxide synthase (nNOS) immunoreactivity was completed within 3 years of acquiring achalasia. Thereafter, progressive ultrastructural injury to remaining nerve structures was evident. Within the first 2 years, the number of ICC-IM did not decline although ultrastructural injury was already present. Thereafter, loss of ICC-IM occurred unrelated to duration of disease. Damage to ICC-IM appeared unrelated to nerve injury. A significant MC infiltration was observed in the musculature; the number of MC was positively related to the persistent number of ICC-IM. Mast cell formed close contacts with ICC-IM and piecemeal-degranulation occurred towards ICC-IM. In conclusion, injury to ICC-IM in achalasia is variable, but not related to duration of disease and injury to nitrergic nerves. MC are prominent and form close functional contact with ICC-IM which may be responsible for their relatively long survival.

The role ofHelicobacterpylori infection in the pathogenesis of functional dyspepsia is debated. It is known that a substantial fraction of dyspeptic patients manifest a low discomfort threshold to gastric distension. This study investigated the symptomatic pattern in 27 Hpylori positive and 23 H pylori negative patients with chronic functional dyspepsia, and potential relations between infection and gastric hyperalgesia. Specific symptoms (pain, nausea, vomiting, bloating/fullness, early satiety) were scored from 0 to 3 for severity and frequency (global symptom scores: 0-15). The mechanical and perceptive responses to gastric accommodation were evaluated with an electronic barostat that produced graded isobaric distensions from 0 to 20 mm Hg in 2 mm Hg steps up to 600 ml. Gastric compliance (volume/pressure relation) and perception (rating scale: 0-10) were quantified. Standard gastrointestinal manometry and recorded phasic pressure activity at eight separate sites during fasting and postprandially were also assessed. H pylon positive and H pylon negative patients manifested similar severity and frequency of specific symptoms and global symptom scores (mean (SEM)) (severity: 9'5 (2.0) v 9.0 (2.1); frequency: 10-8 (2.0) v 9*7 (2.2)). No differences were seen either in gastric compliance (53 (4)

Little information is available regarding acute upper gastrointestinal bleeding as a presenting sign of gastric carcinoma. Of 427 patients with gastric cancer, 36 (8.4%) underwent early endoscopy due to hematemesis. The hemorrhage was self-limited in 16 patients (44.4%), most of whom underwent elective surgery. Twenty patients (55.6%) had persistent or massive bleeding, and 13 of these underwent early surgery with a surgical mortality of 3 cases (23.1%); the remaining 7 patients were not operated on, and died secondary to the hemorrhage. The total mortality rose to 10 patients (27.7%). The mean age was higher in patients with persistent or massive bleeding, mainly in those who did not undergo surgery and died. We conclude that the immediate outcome is related to age and previous general condition, rather than to the definite diagnosis of gastric cancer. Moreover, emergency endoscopy may be useful in determining the exact source of hemorrhage and in identifying potential candidates for emergency surgery.