1088
ENDOSCOPIC DIAGNOSESACCORDINGTO H PYLORISEROLOGY
the vestibulum on colposcopy, and increased lymphocytes in a punch biopsy sample from the vestibulum. 12 of these 17 women accepted treatment by modified vestibulectomy (table). Two parallel incisions-one just inside the hymen and the other at the mucocutaneous border towards the perineum-were joined laterally (at 3 and 9 o’clock) and the posterior vestibulum was removed to a depth of 5-7 mm. The wound was sutured with isolated monofilic non-resorbable sutures
DU--duodenal ulcer,
(’Prolene’) which were removed 10-14 days postoperatively. 3 weeks after the operation, the women were requested to start postoperative training by inserting blunt glass-rods with a diameter of 2-4 cm through the introitus into the vagina. Sexual activity could be resumed when such training caused little or no pain. After 5-19 months follow-up, 10 women reported no or only slight pain during sexual intercourse and 1 woman moderate pain, but not so much as to cause her to abstain from intercourse (table). Of the 12 women operated on, 8 had been treated with local laser therapy, freezing, and/or podophyllotoxin for introital "condylomas" before consulting at the clinic (table). All 12 specimens removed at operation showed chronic vestibulitis, but only 4 had koilocytosis on histopathological examination. No improvement was reported by the 5 women not operated on. 3 had been treated by laser and/or podophyllotoxin before consulting us.
+ ve = positive
of IgG or IgA. 4 patients gave false-positive IgA results: in 2 coeliac disease was found, suggesting a MALT (mucosal-associated lymphoid tissue) immune response. 2 gave false-positive IgG results, associated with duodenitis in 1. In our experience (this report and ref 1), the presence of increased concentrations of IgG and IgA in the same patient is fully predictive of H pylori infection. If the screening policy had been followed, 7 children with both IgG and IgA seropositivity would have been diagnosed as having H pylori infection without the need for endoscopy; 9 seronegative children would not have undergone endoscopy, and duodenitis in 1 and oesophagitis in 3 would have been missed. These findings show that patients with oesophagitis need appropriate management and probably a symptom-based screening strategy. This study confirms the importance of a screening policy of dyspeptic children based on age and H pylori serology. Many endoscopies could be avoided with effective screening of children with recurrent epigastric pain. Paediatric Clinic and Istituto di Anatomia Patologica, IRCCS Policlinico S. Matteo, 27100 Pavia, Italy
We had not previously seen such a cluster of young women with vulvar vestibulitis. Could this "epidemic" be a reflection of current interest in genital papillomavirus infections and their treatment? The ailment is not just "a name"; it is clinically well defined and treatable. We were at first reluctant to offer vestibular ablation to these young women but their gratitude after the operation has ’caused us to reconsider. We must emphasise, however, that careful selection and counselling of women offered surgery for vulvar vestibulitis are essential.
C. DE GIACOMO
G. MAGGIORE R. FIOCCA
Department of Obstetrics and Gynaecology, University Hospital, S-221 85 Lund, Sweden
C, Lisato L, Negrini R, Licardi G, Maggiore G. Serum immune response to Helicobacter pylori in children epidemiologic and clinical application. J Pediatr 1991; 119: 205-10.
LARS WESTRÖM
1. De Giacomo
1. Goetsch MF. Vulvar vestibulitis and historic features m a population. Am J Obstet Gynecol 1991; 164: 1609-16
Vulvar vestibulitis SiR,—Your Sept 21 editorial on vulvar vestibulitis ends with the depressing sentence: "One is left with a chronic skin conditionand a name". My colleagues and I think that vulvar vestibulitis is a distinct and treatable clinical entity. Furthermore, incidence seems to be increasing, and in some cases it may be a consequence of aggressive local treatment of vulvar disorders. In a referral clinic for couples with disorders related to genital infection, 68 out of 135 women complained of introital dyspareunia. Of these 68, 45 had a positive swab-touch test,’ and 17 of those 45 were eventually given a diagnosis of vulvar vestibulitis, as defined by absence of symptoms during normal daily activities, introital dyspareunia making intercourse impossible, intense pain in the vestibulum but nowhere else during a swab-touch test, reddening of
Pancreatic
I
I
at intercourse but glass rod training painless --
*No attempt
I
insufficiency after bone-marrow transplantation
SIR,-Dr Jurges and colleagues (Aug 24, p 517) describe a patient pancreatic insufficiency after bone-marrow transplantation. Many of our patients have had high serum amylase concentrations immediately after induction therapy and transplantation, which have been followed by subnormal values for a few weeks. We therefore investigated prospectively the activities of total amylase and salivary and pancreatic isoamylase in serum in 30 bone-marrow transplant patients at various intervals up to 1 year after bone’ marrow transplantation. The total serum amylase increased to a maximum of 100 (12) ukat/1 (reference value 2-5-5-3 ukat/1) on the :first day after total body irradiation and most of this increase ] reflected an increase in the salivary isoamylase concentration. In association with this, all patients had clinical symptoms of parotitis. An increase in pancreatic isoamylase was found in 27% of patients. However, none had any clinical symptoms of pancreatitis. Serum amylase returned to normal within 5 days after induction therapy and bone-marrow transplantation but then decreased to subnormal values, remaining below normal for 3 weeks. Pancreatic isoamylase returned to pre-induction therapy values 1.5 months after transplantation, whereas salivary isoamylase remained low for the rest of the observation time. Symptoms that may be linked to a subsequent pancreatic exocrine insufficiency, such as nausea, vomiting, and diarrhoea, were seen in all patients, and these symptoms were present when the levels of pancreatic isoamylase were low. It therefore seems that following induction therapy (cyclophosphamide and total body irradiation) and subsequent bone-marrow transplantation, all patients have a more or less pronounced pancreatic insufficiency during the first months. Whether the pancreatic insufficiency is caused by cyclophosphamide, total body irradiation, or a graft-versus-host effect cannot be established from our study. However, we found no with
’
CLINICAL DETAILS
general gynecologic practice
ENDOSCOPIC DIAGNOSESACCORDINGTO H PYLORISEROLOGY
the vestibulum on colposcopy, and increased lymphocytes in a punch biopsy sample from the vestibulum. 12 of these 17 women accepted treatment by modified vestibulectomy (table). Two parallel incisions-one just inside the hymen and the other at the mucocutaneous border towards the perineum-were joined laterally (at 3 and 9 o’clock) and the posterior vestibulum was removed to a depth of 5-7 mm. The wound was sutured with isolated monofilic non-resorbable sutures
DU--duodenal ulcer,
(’Prolene’) which were removed 10-14 days postoperatively. 3 weeks after the operation, the women were requested to start postoperative training by inserting blunt glass-rods with a diameter of 2-4 cm through the introitus into the vagina. Sexual activity could be resumed when such training caused little or no pain. After 5-19 months follow-up, 10 women reported no or only slight pain during sexual intercourse and 1 woman moderate pain, but not so much as to cause her to abstain from intercourse (table). Of the 12 women operated on, 8 had been treated with local laser therapy, freezing, and/or podophyllotoxin for introital "condylomas" before consulting at the clinic (table). All 12 specimens removed at operation showed chronic vestibulitis, but only 4 had koilocytosis on histopathological examination. No improvement was reported by the 5 women not operated on. 3 had been treated by laser and/or podophyllotoxin before consulting us.
+ ve = positive
of IgG or IgA. 4 patients gave false-positive IgA results: in 2 coeliac disease was found, suggesting a MALT (mucosal-associated lymphoid tissue) immune response. 2 gave false-positive IgG results, associated with duodenitis in 1. In our experience (this report and ref 1), the presence of increased concentrations of IgG and IgA in the same patient is fully predictive of H pylori infection. If the screening policy had been followed, 7 children with both IgG and IgA seropositivity would have been diagnosed as having H pylori infection without the need for endoscopy; 9 seronegative children would not have undergone endoscopy, and duodenitis in 1 and oesophagitis in 3 would have been missed. These findings show that patients with oesophagitis need appropriate management and probably a symptom-based screening strategy. This study confirms the importance of a screening policy of dyspeptic children based on age and H pylori serology. Many endoscopies could be avoided with effective screening of children with recurrent epigastric pain. Paediatric Clinic and Istituto di Anatomia Patologica, IRCCS Policlinico S. Matteo, 27100 Pavia, Italy
We had not previously seen such a cluster of young women with vulvar vestibulitis. Could this "epidemic" be a reflection of current interest in genital papillomavirus infections and their treatment? The ailment is not just "a name"; it is clinically well defined and treatable. We were at first reluctant to offer vestibular ablation to these young women but their gratitude after the operation has ’caused us to reconsider. We must emphasise, however, that careful selection and counselling of women offered surgery for vulvar vestibulitis are essential.
C. DE GIACOMO
G. MAGGIORE R. FIOCCA
Department of Obstetrics and Gynaecology, University Hospital, S-221 85 Lund, Sweden
C, Lisato L, Negrini R, Licardi G, Maggiore G. Serum immune response to Helicobacter pylori in children epidemiologic and clinical application. J Pediatr 1991; 119: 205-10.
LARS WESTRÖM
1. De Giacomo
1. Goetsch MF. Vulvar vestibulitis and historic features m a population. Am J Obstet Gynecol 1991; 164: 1609-16
Vulvar vestibulitis SiR,—Your Sept 21 editorial on vulvar vestibulitis ends with the depressing sentence: "One is left with a chronic skin conditionand a name". My colleagues and I think that vulvar vestibulitis is a distinct and treatable clinical entity. Furthermore, incidence seems to be increasing, and in some cases it may be a consequence of aggressive local treatment of vulvar disorders. In a referral clinic for couples with disorders related to genital infection, 68 out of 135 women complained of introital dyspareunia. Of these 68, 45 had a positive swab-touch test,’ and 17 of those 45 were eventually given a diagnosis of vulvar vestibulitis, as defined by absence of symptoms during normal daily activities, introital dyspareunia making intercourse impossible, intense pain in the vestibulum but nowhere else during a swab-touch test, reddening of
Pancreatic
I
I
at intercourse but glass rod training painless --
*No attempt
I
insufficiency after bone-marrow transplantation
SIR,-Dr Jurges and colleagues (Aug 24, p 517) describe a patient pancreatic insufficiency after bone-marrow transplantation. Many of our patients have had high serum amylase concentrations immediately after induction therapy and transplantation, which have been followed by subnormal values for a few weeks. We therefore investigated prospectively the activities of total amylase and salivary and pancreatic isoamylase in serum in 30 bone-marrow transplant patients at various intervals up to 1 year after bone’ marrow transplantation. The total serum amylase increased to a maximum of 100 (12) ukat/1 (reference value 2-5-5-3 ukat/1) on the :first day after total body irradiation and most of this increase ] reflected an increase in the salivary isoamylase concentration. In association with this, all patients had clinical symptoms of parotitis. An increase in pancreatic isoamylase was found in 27% of patients. However, none had any clinical symptoms of pancreatitis. Serum amylase returned to normal within 5 days after induction therapy and bone-marrow transplantation but then decreased to subnormal values, remaining below normal for 3 weeks. Pancreatic isoamylase returned to pre-induction therapy values 1.5 months after transplantation, whereas salivary isoamylase remained low for the rest of the observation time. Symptoms that may be linked to a subsequent pancreatic exocrine insufficiency, such as nausea, vomiting, and diarrhoea, were seen in all patients, and these symptoms were present when the levels of pancreatic isoamylase were low. It therefore seems that following induction therapy (cyclophosphamide and total body irradiation) and subsequent bone-marrow transplantation, all patients have a more or less pronounced pancreatic insufficiency during the first months. Whether the pancreatic insufficiency is caused by cyclophosphamide, total body irradiation, or a graft-versus-host effect cannot be established from our study. However, we found no with
’
CLINICAL DETAILS
general gynecologic practice
