Gut 2001;48:283–284 283

addition to the numerous reports on antibiotic Reply sensitive gastric lymphomas,1 those of the ,2 salivary glands,34nasal mucosa,5 and EDITOR,—Hoption Cann et al again point out

LETTERS TO Gut: first published as 10.1136/gut.48.2.284 on 1 February 2001. Downloaded from colon67have recently been reported. the fact that is not the sole cause of mucosa associated lymphoid tissue THE EDITOR Although Helicobacter pylori is generally implicated as the inducing agent, this does not (MALT) lymphoma in some cases. They also always appear to be the case. A related bacte- suggest other, as yet undefined, bacterial/ infectious causes in MALT lymphomas in rium, H heilmannii, has also been found in extragastric sites in view of our case and the and bowel function association with gastric MALT lymphomas, including H pylori negative patients whose recent literature. While we believe this to be a EDITOR,—I read with great interest the article disease was still responsive to antibiotic treat- valid point and agree with the already estab- by Hearing et al (Gut 1999;45:889–894) on the ment.8 Furthermore, other non-H pylori lished notion of other contributing factors in eVect of cholecystectomy on bowel function. In bacterial9 and protozoal10 flora have been addition to H pylori, we nevertheless advise this elegant publication, however, the authors observed in gastric lymphomas specific to that our findings should be interpreted with mistakenly assume that published estimates of involved regions. In the report by Raderer et caution. In contrast with other cases reported the prevalence of postcholecystectomy diar- al, and in several of the others previously in the literature and cited by the authors, our rhoea derive from retrospective or uncon- mentioned,3–7 H pylori was not identified in the patient suVered from concurrent gastric and trolled data only. In this context I would like to extragastric lesions, leaving it open to specula- colonic MALT lymphoma and had evidence draw attention to earlier publications derived tion how H pylori may induce antigenic of H pylori infection. Thus one cannot rule out from the Rotterdam Gallstone Study.12 stimulation of these lymphomas. Moreover, in the fact that antigenic shedding of H pylori In the first paper the results are discussed the report by Inoue and Chiba,7 not only was from the throughout the gastro- of a prospective analysis of biliary and gastro- the rectal lesion H pylori negative but upper intestinal tract or the presence of specific T intestinal symptoms (including diarrhoea) gastrointestinal was normal. Their cells alone was able to provide the colonic prior to and up to two years after gall stone patient was seronegative for H pylori and had lesion with an antigenic drive needed for therapy.1 Therapy consisted of either conven- a negative rapid test, culture, and maintenance of the lymphoma. In this sce- tional cholecystectomy or extracorporeal histological examination. nario, one would expect eradication of H pylori shock wave (ESWL), allocated In light of this evidence, it seems that to lead to regression of the (still antigen and/or randomly. The second paper focused on sur- although H pylori may be the most common T cell dependent) lymphoma. The fact that gery and reported on symptoms before and cause of many gastrointestinal MALT lym- various (apparently not H pylori related) intes- after conventional and laparoscopic cholecys- phomas, it is not the only causative organism. tinal as well as extraintestinal lesions regressed tectomy.2 This study was based on the same This is an important point to consider when with antibiotic treatment is indeed highly sug- concept, and treatment depended on the confronted with patients diagnosed with H gestive of an underlying infectious process but availability of a laparoscopic set. Generally, pylori negative MALT lymphomas. does not necessarily constitute proof of this we found that the reported incidence of diar- assumption, as direct antiproliferative mecha- rhoea before and after surgery did not S A HOPTION CANN J P VAN NETTEN nisms of various antibiotics, including clari- change. In fact, there was no diVerence in the Special Development Laboratory, thromycin, have been reported in diVerent set- reported incidence of diarrhoea at any time Royal Jubilee Hospital, tings. Further investigations are needed before between cholecystectomy and gall bladder Victoria, BC, Canada and definite recommendations for (as yet empiri- preserving therapy (that is, ESWL). We also Department of Biology, University of Victoria, cal) antibiotic therapy in patients with extra- found that there were no diVerences in the Victoria, BC, Canada gastric MALT lymphomas can be given. reported incidence or severity of diarrhoea C VAN NETTEN between laparoscopic and conventional M RADERER Department of Health Care and Epidemiology, Department of Internal Medicine I,

cholecystectomy at any time. http://gut.bmj.com/ University of British Columbia, Vancouver, BC, Division of Oncology, University of Vienna, Although the study design of our two studies Canada V6T 1Z3 Waehringer Guertel 18-20, diVered largely from that of Hearing’s, the Correspondence to: Dr J P van Netten, Special A-1090 Vienna, Austria results and conclusions are in agreement, in that Development Laboratory, Royal Jubilee Hospital, ANDREAS CHOTT clinical diarrhoea seldom develops after chole- 1900 Fort Street, Victoria, BC, Canada V8R 1J8. [email protected] Department of Clinical , cystectomy. O’Donnell is correct that objective University of Vienna, assessment rarely demonstrates new onset diar- Waehringer Guertel 18-20, 3 rhoea after cholecystectomy. I agree with 1 Ng WW, Lam CP, Chau WK, et al. Regression A-1090 Vienna, Austria Hearing that postcholecystectomy diar- of high-grade gastric mucosa-associated lym- et al phoid tissue lymphoma with Helicobacter pylori Correspondence to: Professor M Raderer. rhoea is in fact an unproved entity. Given our after triple antibiotic therapy. Gastrointest En- [email protected] on September 26, 2021 by guest. Protected copyright. and Hearing’s results, I doubt if more prospec- dosc 2000;51:93–6. tive studies are needed to solve this problem. 2 Fischbach W, Tacke W, Greiner A, et al. Regression of immunoproliferative small intes- P W PLAISIER tinal disease after eradication of Helicobacter Guidelines for the management of iron Department of General Surgery, Medisch Spectrum Twente, pylori. Lancet 1997;349:31–2. deficiency anaemia 3 Alkan S, Karcher DS, Newman MA, . PO Box 50 000, et al Regression of salivary gland MALT lymphoma EDITOR,—It is somewhat self contradictory to NL-7500 KA Enschede, Netherlands after treatment for Helicobacter pylori. Lancet suggest that “a transferrin saturation of <30% [email protected] 1996;348:268–9. 4 Berrebi D, Lescoeur B, Faye A, et al. MALT may help the diagnosis” if there is still doubt lymphoma of labial minor salivary gland in a about validation of iron deficiency after receipt 1 Plaisier PW, van der Hul RL, Nijs HGT, et al. immunocompetent child with a gastric Helico- of the serum ferritin result, the authors having The course of biliary and gastrointestinal infection. 1998; :290–2. symptoms after treatment of uncomplicated bacter pylori J Pediatr 133 5 Gupte S, Nair R, Naresh KN, et al.MALT previously acknowledged that the latter is “the symptomatic gallstones: results of a rand- lymphoma of nasal mucosa treated with antibi- most powerful test for iron deficiency” (Gut omized study comparing extracorporeal shock otics. 1999; :195–7. wave lithotripsy with conventional cholecystec- Leuk Lymphoma 36 2000;46(suppl IV):iv1–5). Statistical consid- 6 Matsumoto T, Iida M, Shimizu M. Regression erations which dictate that serum ferritin will tomy. Am J Gastroenterol 1994;89:739–44. of mucosa-associated lymphoid-tissue 2 Plaisier PW, van der Hul RL, Nijs HGT, et al. lymphoma after eradication of Helicobacter always outrank transferrin saturation in pre- Quality of life and the course of biliary and . 1997; :115–16. gastrointestinal symptoms after laparoscopic pylori Lancet 350 dictive power have their basis in the compari- 7 Inoue F, Chiba T. Regression of MALT son between the receiver operating characteris- and conventional cholecystectomy. Dig Surg lymphoma of the after anti- 1995; :87–91. H. pylori 12 therapy in a patient negative for H. pylori. Gas- tic (ROC) curves for serum ferritin versus 3 O’Donnel LJD. Post-cholecystectomy diarrhoea: troenterology 1999;117:514–15. transferrin saturation, yielding values of 0.91 a running commentary. 1999; :796–7. Gut 45 8 Morgner A, Lehn N, Andersen LP, et al. Helico- versus 0.71 (p<0.001) for the area under the bacter heilmannii-associated primary gastric 1 low-grade MALT lymphoma: complete remis- curve. Statistical considerations also dictate MALT lymphomas and Helicobacter pylori? sion after curing the infection. Gastroenterology acknowledgement of mean corpuscular 2000;118:821–8. haemoglobin (MCH) as a predictive entity in EDITOR,—Raderer et al (Gut 2000;46:133–5) 9 Jonkers D, Gisbertz I, De Bruine A, et al. Helico- its own right following documentation than an bacter pylori and non-Helicobacter pylori bacte- present an interesting case report of a patient rial flora in gastric mucosa and tumour MCH of <27 pg was superior to a mean with a mucosa associated lymphoid tissue specimens of patients with primary gastric corpuscular volume (MCV) of <77 fl in (MALT) lymphoma of the stomach and de- lymphoma. Eur J Clin Invest 1997;27:885–92. predicting serum ferritin levels of <20 µg/l.2 All scending colon. Their report adds to the grow- 10 Otrakji CL, Albores-Saavedra J, Martinez AJ. low MCV values had low MCH values but Gastric malignant lymphoma with superim- ing literature of gastrointestinal MALT lym- posed amebiasis. Am J Gastroenterol 1990;85: nine hypoferritinaemic patients with low phomas that respond to antibiotic treatment. In 72–5. MCH had MCV within the normal range.2

www.gutjnl.com 284 Letters, Correction, Notes

In my own study, comprising 201 subjects Ireland). Further information: Maddalena with iron deficiency (characterised by serum Massaro, Project Leader, AISC-AIM Group, ferritin <18 µg/l), the MCH conferring Via A Ristori 38, 00187 Rome, Italy. Tel: +39

CORRECTION Gut: first published as 10.1136/gut.48.2.284 on 1 February 2001. Downloaded from optimum trade oV between sensitivity 06 809681; fax: +39 06 80968229; email: (65.2%) and specificity (65.9%) for iron defi- [email protected]. ciency was <24 pg, and this yielded a positive predictive value of 70%. By contrast, for Two abstracts in Gut 2000;47(suppl III) had MCV, optimum trade oV between sensitivity incomplete author lists. The authors of A136 3rd European Federation of Autonomic (61.7%) and specificity (59.1%) was obtained are L Sarli, R Costi, S Gobbi, D Iusco, Societies (EFAS) with a cut oV level of <77 fl, giving a positive D Sarli, and the authors of A138 are L Sarli, The third European Federation of Autonomic predictive value of 65%.3 There were 31 R Costi, S Gobbi, C Pavlidis, L Roncoroni. Societies (EFAS) meeting in conjunction with patients with an MCH <26 pg in the presence the annual meeting of the sections “Auto- of an MCV >80 fl compared with only four with an MCV <80 fl in the presence of an nomic nervous system” of the German Neuro- MCH >26 pg3 and, among these, four had an logical Society, “Diabetes and Nervous Sys- MCH <24 pg in the presence of an MCV >77 tem” of the German Neurological Society, and fl in contrast with only one with an MCV <77 NOTES “Autonomic Nervous System” at the Univer- fl in the presence of an MCH >24 pg. In my sity of Erlangen-Nuremberg, Germany, will be study, the most stringent cut oV diagnostic held in Erlangen, Germany on 26–28 April level for iron deficiency was a serum ferritin 2001. Further information: Professor Dr M J Hilz, Department of Neurology, University or level <10 µg/l found in a subgroup of 145 American College of Gastroenterology subjects. At this level, the MCV characterised Erlangen-Nuremberg, Schwabachanlage 6, 2001 International GI Training Grants by optimum trade oV between sensitivity D-91054 Erlangen, Germany. Tel: +49 0131 (65%) and specificity (66%) was <76 fl (iden- Programme 8534444; fax: +49 9131 8534328; website: tical with the cut oV level in the guidelines), The ACG International GI Training (IGT) www.neurologie.med.uni-erlangen.de/ and this yielded a positive predictive value of Grant Programme provides funding for clini- oeVentliche_Veranstaltungen.htm 55%. Correspondingly, the optimum MCH cal or clinical research training in gastroenter- was either <24 pg, characterised by sensitivi- ology and hepatology so that an individual can ties, specificities, and positive predictive acquire or develop new cognitive knowledge or Falk Workshop values of 74%, 59%, and 80%, respectively, or a technical skill. This newly acquired knowl- The workshop entitled Update in Inflamma- <23 pg, characterised by sensitivities, specifi- edge or skill would then be used to improve tory Bowel Diseases will be held in Ljubljana, cities, and positive predictive values of 58%, patient care in the applicant’s geographic area. Slovenia, on 5 May 2001. Further infor- 75%, and 62%, respectively. Physicians outside of the United States and mation: Prof Dr S Markovicˇ, University O JOLOBE Canada are eligible to apply. At least one Medical Center Ljubljana, Division of Inter- Department of Medicine for the Elderly, fellowship with a maximum of $10 000 per nal Medicine, Japljeva 2, 1525 Ljubljana, Tameside General Hospital, IGT fellowship will be awarded during 2001, Slovenia. Tel: +386 (1) 231 6925; fax: +386 Fountain Street, for a training period of not less than six (1) 433 4190; email: [email protected] Ashton under Lyne OL6 9RW,UK months. Awards will be made by a special [email protected] committee of the ACG and will be based upon 1 Guyatt GH, Patterson C, Ali M, et al. Diagnosis the applicant’s credentials, the merit of the Gastroenterology and Endotherapy: of iron-deficiency anemia in the elderly.AmJ proposed training by the selected host training XIXth European Workshop Med 1990;88:205–9. centre and the potential for enhancing the field 2 O’Broin SD, Kelleher BP, McCann SR, et al. This course, to introduce the experienced The value of erythrocyte indices as a screening of gastroenterology in the applicant’s home http://gut.bmj.com/ gastroenterologist to the growing field of procedure in predicting nutritional deficien- country. Application forms can be obtained cies. 1990; :247–55. therapeutic endoscopy, will be held on 18–20 Clin Lab Haematol 12 from the ACG administrative oYce: 4900B 3 Jolobe OMP. Prevalence of hypochromia (with- June 2001 in Brussels, Belgium. Further South 31st Street, Arlington, Virginia 22206- out microcytosis) vs microcytosis (without information: Mrs Nancy Beauprez, Gastro- hypochromia) in iron deficiency. Clin Lab Hae- 1656. Tel: +1 703 820 7400; fax: +1 703 931 enterology Department, Erasme Hospital, matol 2000;22:79–80. 4520; website: www.acg.gi.org. Deadline for Route de Lennik 808, B-1070 Brussels. Tel: submission of application is 1 April 2001. +32 02 555 49 00; fax: +32 02 555 49 01; Reply email: [email protected]

EDITOR,—Suggesting both that transferrin Cleveland Clinic Florida’s on September 26, 2021 by guest. Protected copyright. saturation may help in the diagnosis and that Gastroenterology Update 2001 Falk Symposium ferritin is the most powerful test for iron defi- Cleveland Clinic Florida will be sponsoring a ciency anaemia (IDA) is not contradictory. postgraduate course entitled “Gastroenterol- The symposium Inflammatory Bowel Disease: Being the most powerful test does not mean it ogy Update 2001” to be held on 10–11 Feb- A Clinical Case Approach to Pathophysiology, is always reliable. For example, in inflamma- ruary 2001 in Fort Lauderdale, Florida, Diagnosis, and Treatment will be held in tory conditions such as rheumatoid arthritis, USA. Further information: Sally Jagelman, Bologna, Italy on 22–23 June 2001. Further ferritin may be normal even if there is iron Manager of Continuing Medical Education, information: Prof Dr M Campieri/ Dr P Gion- deficiency. Cleveland Clinic Florida, 3000 West Cypress chetti, Policlinico S. Orsola - Malpighi, Dipar- We find the reference to the greater Creek Road, Fort Lauderdale, FL 33309, timento di Medicina Interna e Gastroenterolo- reliability of mean corpuscular haemoglobin USA. Tel: +1 954 978 5539; fax: +1 954 978 gia, Via Massarenti 9, I-40138 Bologna, Italy. (MCH) compared with mean corpuscular 5056; email: [email protected] Tel:+39 (051) 6364 116 or 6364 122; fax: +39 volume (MCV) in diagnosing IDA interest- (051) 392538; email: [email protected] ing. We agree that MCH can be useful in the or [email protected] diagnosis of iron deficiency. However, none GI malignancies can be prevented and of the papers quoted takes account of the red treated: from the bench to the bedside cell distribution width (RDW). We wonder if This international meeting will be held on Summer Abdominal Imaging Dr Jolobe would still be able to demonstrate 14–17 February 2001 in Jerusalem and the Conference the superiority of MCH compared with Dead Sea, Israel. Further information: Mari- A five day course designed for the practising MCV if anaemic patients with a normal lyne Katz, Secretariat, GI Malignancies, Tar- radiologist with a primary interest in abdomi- MCV but raised RDW were excluded. We get Tours, PO Box 29041, Tel Aviv 61290, nal imaging, emphasising the most recent explain in our guidelines that combined defi- Israel. Tel: +972 3 5175150; fax: +972 3 advances in helical CT, MRI, US, and ciency (that is, iron deficiency together with 5175155; email: [email protected] gastrointestinal imaging. It will be held on B12 and/or folate deficiency) may be associ- 23–27 July 2001 in BanV Springs, Canadian ated with a normal MCV and may be recog- Rockies. Twenty-five category 1 credit hours. nised by a raised RDW. Redefining Priorities in Gastroenterology Further information: Janice Ford Benner, B B SCOTT University of Pennsylvania Medical Center Department of Gastroenterology, This congress will be held on 11–14 April Lincoln County Hospital, 2001 in Monte Carlo, Italy. It will be chaired (Radiology), 3400 Spruce Street, 1 Silver- Lincoln LN2 5QY,UK by Professor Massimo Crespi (Rome, Italy) stein Building, Philadelphia, PA 19104, USA. [email protected] and Professor Eammon Quigley (Cork, Tel: +1 215 662 6904; fax: +1 215 349 5925.

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