An Interactive Web-Based Educational Tool Improves Detection and Delineation of Barrett's Esophagus-Related Neoplasia

BACKGROUND & AIMS

Endoscopic detection of early Barrett's esophagus-related neoplasia (BORN) is a challenge. We aimed to develop a web-based teaching tool for improving detection and delineation of BORN.

METHODS

We made high-definition digital videos during endoscopies of patients with BORN and non-dysplastic Barrett's esophagus. Three experts superimposed their delineations of BORN lesions on the videos using special tools. In phase one, 68 general endoscopists from 4 countries assessed 4 batches of 20 videos. After each batch, mandatory feedback compared the assessors' interpretations with those from experts. These data informed the selection of 25 videos for the phase 2 module, which was completed by 121 new assessors from 5 countries. A 5-video test batch was completed before and after scoring of the four 5-video training batches. Mandatory feedback was as in phase 1. Outcome measures were scores for detection, delineation, agreement delineation, and relative delineation of BORN.

RESULTS

A linear mixed-effect model showed significant sequential improvement for all 4 outcomes over successive training batches in both phases. In phase 2, median detection rates of BORN in the test batch increased by 30% (P < .001) after training. From baseline to the end of the study, there were relative increases in scores of 46% for detection, 129% for delineation, 105% for agreement delineation, and 106% for relative delineation (all, P < .001). Scores improved independent of assessors' country of origin or level of endoscopic experience.

CONCLUSIONS

We developed a web-based teaching tool for endoscopic recognition of BORN that is easily accessible, efficient, and increases detection and delineation of neoplastic lesions. Widespread use of this tool might improve management of Barrett's esophagus by general endoscopists.

Fibrinogen Metabolism in Healthy Dogs and in Dogs with CCI4-Induced Liver Damage and with Portal Vein Occlusion

The metabolism of dog fibrinogen, labelled with radioactive iodine was studied in 16 healthy dogs on 28 occasions, in 12 dogs with CCl4-induced chronic liver damage and in 5 dogs with interruption of the hepatoportal blood flow by occlusion of the portal vein.

Results in healthy control dogs were: plasma volume 48±12 ml/kg ; plasma fibrinogen concentration 316±102 mg%; total plasma fibrinogen pool 168±42 mg/kg, representing 0.72±0.08 of the total body pool; fibrinogen half-life 2.54±0.23 day; fractional catabolic rate 0.39±0.05 of the plasma pool per day; absolute catabolic rate 58±25 mg/kg per day.

Results in dogs with CCl4-induced liver damage were: plasma volume 46 ± 12 ml/kg ; plasma fibrinogen concentration 334±97 mg%; total plasma fibrinogen pool 152±55 mg/kg, representing 0.70±0.04 of the total body pool; fibrinogen half-life 2.15±0.26 days; fractional catabolic rate 0.47±0.06 of the plasma pool per day; absolute catabolic rate 71±21 mg/kg per day.

Results in dogs with longstanding portal vein occlusion were: plasma volume 41 ±8 ml/kg; plasma fibrinogen concentration 330±23 mg%; total plasma fibrinogen pool 142±36 mg/kg, representing 0.70±0.06 of the total body pool; fibrinogen half-life 2.60 ±0.36 days; fractional catabolic rate 0.40 ±0.04 of the plasma pool per day; absolute catabolic rate 56±14 mg/kg per day.

A significant difference between control dogs and dogs with liver disease was observed for the fibrinogen half-life and the fractional catabolic rate. All fibrinogen turnover data in dogs with portal vein occlusion were comparable to control values.

Heparinization did not influence the fibrinogen half-life in most of the control dogs and in the dogs with portal vein occlusion ; however in 2 control dogs, a prolongation of their rather short fibrinogen survival occurred during anticoagulation. In contrast, a general trend towards prolongation and occasionally normalization of the fibrinogen life span during heparinization was observed in the dogs with liver damage, supporting the concept of accelerated fibrinogen consumption by a process of disseminated intravascular coagulation in liver disease.

No Helicobacter pylori, no Helicobacter pylori-associated peptic ulcer disease

Virtually all duodenal ulcers (DUs) and the vast majority of gastric ulcers (GUs) are the consequence of Helicobacter pylori-associated inflammation. In DUs, the inflammation is maximal in the antrum and is associated with gastric metaplasia in the bulb. Gastrin homeostasis is disturbed by H. pylori gastritis and there is robust acid secretion. Successful eradication of the infection cures the ulcer diathesis. Amalgamated figures for ulcer relapse per year in H. pylori-positive DUs are > 60% compared with 2.6% for H. pylori-negative DU patients. The corresponding figures for GU are > 50% for H. pylori-positive and 2.0% for H. pylori-negative individuals. This striking difference in relapse rate persists, as the re-infection rate in the developed world is < 1% per year. Recurrent bleeding in bleeding-prone DUs is essentially abolished after cure of the infection. Proton pump inhibitors (PPIs) are increasingly used in eradication regimens. PPIs have intrinsic antimicrobial activity. MICs for lansoprazole (LAN) are lower than for omeprazole (OME). Two weeks of triple therapy (bismuth, tetracycline, imidazole) has, on average, a superior eradication efficacy (> or = 90%) compared with dual therapy (PPI, amoxycillin or clarithromycin) (> or = 80%). When a combination of PPI and two antibiotics has been used, results comparable to triple therapy have been reported. However, the side-effects profile and patient acceptability of PPI plus one or two antibiotic regimens are better than for traditional triple therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

New algorithm for the treatment of gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is associated with a variety of typical and atypical symptoms. Patients often present in the first instance to a pharmacist or primary care physician and are subsequently referred to secondary care if initial management fails. Guidelines usually do not provide a clear guidance for all healthcare professionals with whom the patient may consult.

AIM

To update a 2002-treatment algorithm for GERD, making it more applicable to pharmacists as well as doctors.

METHODS

A panel of international experts met to discuss the principles and practice of treating GERD.

RESULTS

The updated algorithm for the management of GERD can be followed by pharmacists, for over-the-counter medications, primary care physicians, or secondary care gastroenterologists. The algorithm emphasizes the importance of life style changes to help control the triggers for heartburn and adjuvant therapies for rapid and adequate symptom relief. Proton pump inhibitors will remain a prominent treatment for GERD; however, the use of antacids and alginate-antacids (either alone or in combination with acid suppressants) is likely to increase.

CONCLUSION

The newly developed algorithm takes into account latest clinical practice experience, offering healthcare professionals clear and effective treatment options for the management of GERD.

Impaired drinking capacity in patients with functional dyspepsia: intragastric distribution and distal stomach volume

The water drink test is a good tool to evoke dyspeptic symptoms. To what extent these symptoms are related to altered gastric distribution is not clear. Therefore, we determined gastric volumes after a drink test using SPECT. After a baseline scan 20 healthy volunteers (HV) and 18 patients with functional dyspepsia (FD) underwent a drink test (100 mL min(-1)) followed by five scans up to 2 h. Dyspeptic symptoms were scored before every scan. A Wilcoxon signed rank test (P < 0.05) and a mixed effects model were used for statistical analyses. Fasting volumes were significantly higher in FD compared to HV for total, proximal and distal stomach (P < 0.001). Functional dyspeptic patients ingested significantly less water (P < 0.001) and had an impaired filling of the distal part of the stomach (P = 0.001) after the drink test. In FD, bloating (prox. 80%, dist. 56%), pain (prox. 87%, dist. 62%) and fullness (prox. 80%, dist. 59%) were determined more by proximal stomach volume rather than distal stomach volume. These data suggest that drinking capacity is mainly determined by antral volume, with a reduced antral filling in FD compared to HV. The persisting symptoms of bloating, pain and fullness in FD are predominantly associated with proximal stomach volume.

Significance of Campylobacter pylori

There is an explosion of interest in the role of Campylobacter pylori as a cause of active chronic gastritis. This curved spiraled microorganism can readily be detected within the mucus gel covering the stomach mucosa, especially in patients suffering from peptic ulcer disease or non-ulcer dyspepsia. To what extent this intriguing microorganism is causally related to peptic ulcer disease remains to be elucidated, but all the evidence which is available so far supports a pathogenetically important role. There appears to be a striking discordance between in-vitro sensitivity and in-vivo efficacy of antibiotic therapy. At present, the combination of colloidal bismuth subcitrate and amoxycillin or tinidazole appears most effective in temporary elimination of these microorganisms.

The influence of the novel 5-HT1A agonist R137696 on the proximal stomach function in healthy volunteers

As fundic dysaccommodation represents one of the pathophysiological mechanisms underlying functional dyspepsia, gastric relaxant agents may serve as a new treatment of this disorder. Previous studies have suggested the involvement of 5HT1 receptors in the control of gastric tone. Our aim was to study the effect of R137696, a novel 5HT1A agonist, on fundus sensorimotor function in healthy volunteers. The effect of single oral doses (1-2 mg) R137696 was evaluated in a double-blind, placebo-controlled manner on fasting fundic volume, visceral perception, distension-evoked symptoms and fundic compliance in 21 healthy male subjects. R137696 increased the proximal stomach volumes in a dose-dependent manner. Distention-evoked symptoms or distention and discomfort threshold were not altered by R137696. A logistic regression model, characterizing the relationships between the volume and the visual analogue scale score for dyspeptic symptoms (nausea, fullness, discomfort, pain and satiety) as a sigmoidal curve, revealed that R137696 had no effect on distension-induced discomfort, fullness, pain and satiety compared to placebo. R137696 relaxes the gastric fundus in fasting conditions but has no effect on distension-evoked dyspeptic symptoms in healthy volunteers.

Potential impact of EUS-FNA staging of proximal lymph nodes in patients with distal esophageal carcinoma

BACKGROUND AND STUDY AIMS

Distal esophageal carcinomas can be resected using transthoracic esophagectomy or transhiatal esophagectomy. Accurate diagnosis of subcarinal and supracarinal lymph-node metastases is important for selecting the surgical strategy. The impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) on the preoperative diagnosis of subcarinal and supracarinal lymph-node metastases in patients with distal esophageal carcinoma was therefore investigated.

PATIENTS AND METHODS

Patients with a resectable distal esophageal carcinoma and subcarinal and/or supracarinal lymph nodes visualized on preoperative EUS were prospectively included. The lymph nodes were sampled using EUS-FNA, and if they were found to have metastases, transthoracic resection was offered; by contrast, patients without metastases were offered a transhiatal resection.

RESULTS

Lymph-node metastases were found with EUS-FNA in 11 of the 48 patients included (23 %). Thirteen patients had suspicious nodes on EUS, in four of whom (31 %) the diagnosis was changed into nonmalignant nodes with FNA. Thirty-five patients had nonsuspicious nodes on EUS, in three of whom (9 %) the FNA procedure revealed malignant cells.

CONCLUSIONS

EUS with the addition of the FNA procedure has a significant impact on decision-making in patients with esophageal carcinoma in whom transhiatal esophagectomy would otherwise be planned.

Prevalence and management of abdominal cramping and pain: a multinational survey

BACKGROUND

Though functional gastrointestinal complaints are recognised as being common throughout the world, there have been few comparative studies of prevalence.

AIM

To compare the prevalence and management of abdominal cramping/pain in nine countries.

METHODS

In a two-stage community survey, approximately 1000 subjects were interviewed in each of nine countries to establish the demographics of individuals with abdominal cramping/pain (stage 1) followed by market research-driven interviews with >or=200 sufferers per country (stage 2).

RESULTS

9042 subjects were interviewed in stage 1. Mexico (46%) and Brazil (43%) had the highest prevalence of abdominal cramping/pain; Japan the lowest (10%). Abdominal cramping/pain was more common in women (12-55%) than in men (7-38%). About 1717 subjects participated in stage 2; 65% were women and the average age at symptom onset was 29 years. The frequency of episodes differed between countries, being highest in the US (61% suffered at least once in a week). Sufferers in the US and Latin America reported a higher usage of medications (around 90%) than those in Europe (around 72%). In most countries over-the-counter drugs were principally used. Antispasmodic drugs were most popular in Latin America and Italy, antacids in Germany and the UK. Drug therapy decreased the duration of episodes (by up to 81% in Brazil).

CONCLUSIONS

The community prevalence, severity, healthcare seeking and medication usage related to abdominal cramping/pain are high overall, but vary considerably between countries.

Placebo- and paracetamol-controlled study on the efficacy and tolerability of hyoscine butylbromide in the treatment of patients with recurrent crampy abdominal pain

AIM

To compare the efficacy and tolerability of oral hyoscine butylbromide (hereafter hyoscine) 10 mg t.d.s., paracetamol 500 mg t.d.s. and their fixed combination against placebo in patients with recurrent crampy abdominal pain.

METHODS

A total of 1637 patients were entered into a four-arm double-blind study. After a 1 week placebo run-in, they were randomized to 3 weeks of treatment with one of the four therapies with assessments after 1, 2 and 3 weeks. Pain intensity (Visual Analogue Scale) and pain frequency (Verbal Rating Scale) were self-assessed daily.

RESULTS

Pain intensity on the Visual Analogue Scale decreased in all treatment groups; the adjusted mean changes from baseline were 2.3, 2.4 and 2.4 cm for the hyoscine, paracetamol and combination groups, respectively, compared with 1.9 cm for the placebo group (all P < 0.0001). The Verbal Rating Scale also showed a statistically significant decrease of 0.7, 0.7 and 0.7 in the hyoscine, paracetamol and combination groups compared with 0.5 in placebo (all P < 0.0001). All treatments were well tolerated: 16%, 14%, 17% and 11% of patients on hyoscine, paracetamol, combination and placebo reported at least one adverse event.

CONCLUSIONS

Hyoscine, paracetamol and their fixed combination are effective in the treatment of recurrent crampy abdominal pain and well tolerated if used three times daily continuously for 3 weeks.

Review article: from gastrin to gastro-oesophageal reflux disease--a century of acid suppression

To commemorate Edkins' discovery of gastrin in 1905, we review a century of progress in the physiology and pathobiology of gastrin and acid secretion especially as it pertains to clinical aspects of gastro-oesophageal reflux disease. Although initially ignored, Edkins' observations eventually led to the enthusiastic investigation of gastrin and acid regulation in peptic ulcer disease, culminating in important therapeutic advances in the management of acid peptic disease. Following the improved understanding of gastric secretory physiology, and the development of acid suppressants with increasing efficacy, the use of surgical intervention for peptic ulcer disease was almost eliminated. Surgery became obsolete with the discovery of Helicobacter pylori. Three other advances are also influencing modern practice: the gastrotoxicity of aspirin and non-steroidal anti-inflammatory drugs is now increasingly appreciated, the role of endoscopy in the diagnosis and therapy of upper gastrointestinal bleeding, and the use of intravenous acid-suppressive agents. The major issue for the future resides within the epidemic of gastro-oesophageal reflux disease. How to diagnose, categorize and treat this condition and how to identify and prevent neoplasia, are the challenges of the new century.

Clinical and laboratory studies of the antacid and raft-forming properties of Rennie alginate suspension

BACKGROUND

Acid pockets at the gastro-oesophageal junction escape buffering from meals in the stomach. Combining high-dose antacid with alginate may therefore be of benefit in gastro-oesophageal reflux disease.

AIM

To characterize the antacid and raft-forming properties of Rennie alginate suspension (containing high-dose antacid and alginate; Bayer Consumer Care, Bladel, the Netherlands).

METHODS

The in vitro acid-neutralizing capacity of Rennie algniate was compared with Gaviscon (Reckitt Benckiser, Slough, UK) by pH-recorded HCl titration. Alginate raft weight formed in vitro at different pH was used to evaluate the pH dependency of raft formation with each product. A double-blind, placebo-controlled, randomized crossover study also compared the antacid activity of Rennie alginate vs. placebo in vivo using continuous intragastric pH monitoring in 12 healthy fasting volunteers.

RESULTS

Compared with Gaviscon, Rennie alginate had a higher acid-neutralizing capacity, greater maximum pH and longer duration of antacid activity in vitro. However, the two products produced comparable alginate rafts at each pH evaluated. In vivo, Rennie alginate provided rapid, effective and long-lasting acid neutralization, with an onset of action of <5 min, and duration of action of almost 90 min.

CONCLUSIONS

The dual mode of action of Rennie alginate offers an effective treatment option for mild symptomatic gastro-oesophageal reflux disease particularly considering recent findings regarding 'acid pockets'.

Possible role of nitric oxide in visceral hypersensitivity in patients with irritable bowel syndrome

Visceral hypersensitivity is a consistent finding in a considerable proportion of patients with irritable bowel syndrome (IBS), and may provide a physiological basis for the development of IBS symptoms. In this study, we aimed to confirm the hypothesis that nitric oxide (NO) is involved in maintaining visceral hypersensitivity in IBS. Ten healthy volunteers (HV) and 12 IBS patients with documented hypersensitivity to rectal distension underwent a rectal barostat study. The effect of placebo and the specific NO synthase inhibitor NG -monomethyl-L-arginine (L-NMMA) on resting volume, rectal sensitivity to distension and rectal compliance was evaluated in a double-blind, randomized, cross-over fashion. NG -monomethyl-L-arginine did not alter resting volumes in HV or IBS patients. In HV, l-NMMA did not alter rectal sensory thresholds compared to placebo (45 +/- 3 and 46 +/- 3 mmHg, respectively). In contrast, L-NMMA significantly increased the threshold for discomfort/pain in IBS patients (placebo: 18 +/- 2, l-NMMA: 21 +/- 3 mmHg, P < 0.05). Rectal compliance was not affected by L-NMMA. Although NO does not seem to play a major role in normal rectal sensation or tone, we provide evidence that NO may be involved in the pathophysiology of visceral hypersensitivity in IBS.

Relationship between symptoms and hypersensitivity to rectal distension in patients with irritable bowel syndrome

BACKGROUND

Visceral hypersensitivity is considered an important pathophysiological mechanism in irritable bowel syndrome, yet its relationship to symptoms is unclear.

AIM

To detect possible associations between symptoms and the presence of hypersensitivity to rectal distension in patients with irritable bowel syndrome.

METHODS

Ninety-two irritable bowel syndrome patients and 17 healthy volunteers underwent a rectal barostat study. The association between specific irritable bowel syndrome symptoms and the presence of hypersensitivity was examined using Area under the Receiver Operating Characteristic curves.

RESULTS

Irritable bowel syndrome patients had significantly lower thresholds for discomfort/pain than healthy volunteers: 24 (18-30) and 30 (27-45) mmHg above minimal distending pressure, respectively. Forty-one patients (45%) showed hypersensitivity to rectal distension. Proportions of patients with different predominant bowel habits were similar in hypersensitive and normosensitive subgroups (diarrhoea predominant: 39 and 41%, respectively; alternating type: 27 and 28%, respectively; constipation predominant: 34 and 31%, respectively). Severe abdominal pain was more frequent in hypersensitive, compared with normosensitive patients (88% vs. 67%, P = 0.02), but none of the individual irritable bowel syndrome symptoms could accurately predict the presence of hypersensitivity, as assessed by Area under the Receiver Operating Characteristic curve analysis.

CONCLUSIONS

Hypersensitive and normosensitive irritable bowel syndrome patients present with comparable, heterogeneous symptomatology. Therefore, selection based on clinical parameters is unlikely to discriminate individual irritable bowel syndrome patients with visceral hypersensitivity from those with normal visceral sensitivity.

Review article: drugs interfering with visceral sensitivity for the treatment of functional gastrointestinal disorders--the clinical evidence

At present, the concept of visceral hypersensitivity provides the leading hypothesis regarding the generation of symptoms in functional gastrointestinal disorders. This paper discusses the current clinical evidence for drugs that have been proposed to interfere with visceral sensitivity in functional gastrointestinal disorders. Several possible pharmacological targets have been identified to reduce visceral pain and to reverse the processes underlying the persistence of visceral hypersensitivity. However, most of the available evidence comes from experimental animal models and cannot simply be extrapolated to patients with functional gastrointestinal disorders. In this review, we selected five drug classes that have been shown to exhibit visceral analgesic properties in experimental studies, and of which data were available regarding their clinical efficacy. These included opioid substances, serotonergic agents, antidepressants, somatostatin analogues and alpha(2)-adrenergic agonists. Although clinical trials show a limited benefit, in particular for serotonergic agents, the evidence illustrating that these effects result from normalization of visceral sensation is currently lacking. Therefore, we conclude that the concept of targeting visceral hypersensitivity as a treatment for functional gastrointestinal disorders is still controversial. Future evaluations require patient selection based on the presence of visceral hypersensitivity and application of compounds that exhibit 'true' viscerosensory effects.

Outcome of patients with esophageal carcinoma and suspicious celiac lymph nodes as determined by endoscopic ultrasonography

BACKGROUND AND STUDY AIMS

The management of patients with esophageal cancer with malignant celiac lymph nodes (CLNs) is controversial. In this study we evaluated the management and survival of patients with positive CLN findings on endoscopic ultrasonography (EUS) and compared the outcome in surgically treated patients with that of nonsurgically treated patients.

PATIENTS AND METHODS

The EUS database of the Academic Medical Center was retrospectively searched for patients with esophageal carcinoma and EUS-positive CLN. Follow-up comprised the review of medical charts and contact with general practitioners.

RESULTS

From 1993 through 2000, 78 patients with esophageal carcinoma and suspicious CLN were eligible for inclusion in this study. The median survival of patients with CLN size < 2 cm was 13.5 months vs. 7.0 months for patients with CLN size >2 cm ( P = 0.01). In a multivariate model, CLN size was the only predictive factor for poor patient survival. Of the 78 study patients, 13 underwent a surgical resection and 65 received nonsurgical treatment. The surgical group was significantly younger and all patients in this group had CLN size < 2 cm. The median survival for the surgical group was 13.7 months vs. 13.5 months for the nonsurgical group with CLN size < 2 cm ( P = 0.63).

CONCLUSIONS

In this retrospective study, CLN size was a significant predictor for poor survival. The surgically treated patients had a medium-term survival similar to that of nonsurgically treated patients with a CLN size < 2 cm. These findings underline the prognostic value of CLN size in patients with esophageal carcinoma.

[Barrett's esophagus: new developments in endoscopic surveillance]

The current surveillance strategies for patients with a Barrett's oesophagus are hampered by the poor endoscopic visibility of early neoplastic lesions, the sampling error of random biopsies, the subjectivity of the histological evaluation, and the low incidence of carcinoma. New endoscopic techniques are available for a more reliable evaluation of a Barrett's oesophagus: high-resolution endoscopy, chromoendoscopy, fluorescence endoscopy and optical coherence tomography. The use of molecular markers will probably lead to a better risk stratification of patients. Detection of aneuploid cell populations and assessment of an increase of the number of cells in the S- and G2-phase are possible with DNA flow cytometry; flow cytometric abnormalities may be a more reliable predictor of carcinoma than histological assessment. A combined approach with the new endoscopic techniques and molecular markers may lead to a more efficient and cost-effective surveillance programme.

[Barrett's esophagus: endoscopic treatment of high-grade dysplasia and early cancer]

In a Barrett's oesophagus without dysplasia, endoscopic control every 3-5 years is sufficient. If low-grade dysplasia is encountered in the surveillance biopsies, then endoscopy should be repeated within 3-6 months and yearly thereafter if the low-grade dysplasia persists. Antacid medication must be prescribed in cases with extensive inflammation. The endoscopic treatment of patients with high-grade dysplasia and/or early cancer of the mucosa in a Barrett's oesophagus (tissue ablation and/or mucosa resection) seems a promising alternative to surgery in view of the combination of effectiveness, limited invasiveness compared to surgical resection, and the preservation of a functional oesophagus. Data from long-term follow-up are still limited. Strict endoscopic surveillance will probably detect metachronic abnormalities in an early and still curable stage, creating a new opportunity for endoscopic treatment.

Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting

BACKGROUND

Gastro-oesophageal reflux disease (GERD) and constipation have a major impact on public health; however, the wide variety of treatment options presents difficulties for recommending therapy. Lack of definitive guidelines in pharmacy and general practice medicine further exacerbates the decision dilemma.

AIMS

To address these issues, a panel of experts discussed the principles and practice of treating GERD and constipation in the general population and in pregnancy, with the aim of developing respective treatment guidelines.

RESULTS

The panel recommended antacids 'on-demand' as the first-line over-the-counter treatment in reflux, and as rescue medication for immediate relief when reflux breaks through with proton pump inhibitors. Calcium/magnesium-based antacids were recommended as the treatment of choice for pregnant women because of their good safety profile. In constipation, current data do not distinguish a hierarchy between polyethylene glycol (PEG)-based laxatives and other first-line treatments, although limitations are associated with stimulant- and bulk-forming laxatives. Where data are available, PEG is superior to lactulose in terms of efficacy. In pregnancy, PEG-based laxatives meet the criteria for the ideal treatment.

CONCLUSIONS

The experts developed algorithms that present healthcare professionals with clear treatment options and management strategies for GERD and constipation in pharmacy and general practice medicine.

Barrett oesophagus and adenocarcinoma: an overview of epidemiologic, conceptual and clinical issues

A steady increase in the incidence of adenocarcinoma of the oesophagus and oesophagogastric junction has been observed in Western countries. Patients with distinctive-type Barrett oesophagus are predisposed to developing adenocarcinoma of the oesophagus. Distinctive-type Barrett oesophagus is defined by the presence of intestinal-like goblet cells anywhere in the oesophagus. Adenocarcinomas of the oesophagogastric junction may be associated with short segments of intestinal-type columnar epithelium in the distal oesophagus. Prognosis after surgical resection for cancer of the oesophagus or oesophagogastric junction is strongly affected by the extent of the disease at the time of diagnosis. The identification of Barrett oesophagus as a premalignant condition, the recognition of a stepwise neoplastic progression, along with the poor survival rates of advanced oesophageal adenocarcinoma have initiated the practice of endoscopic biopsy surveillance for patients with Barrett oesophagus. There is supporting evidence that endoscopic biopsy surveillance of Barrett oesophagus permits detection of malignancy at an early stage with favourable results after oesophageal resection. Endoscopic treatment modalities should at this time not be generally adopted in the management of patients with early invasive adenocarcinoma of the oesophagus or oesophagogastric junction.

Suppression of Helicobacter pylori infection during intensive care stay: related to stress ulcer bleeding incidence?

PURPOSE

To assess the prevalence of active Helicobacter pylori infection in patients admitted to the intensive care unit, to determine the effect of selective gut decontamination on the persistence of this organism, and to explore the possible relationship between H. pylori infection and stress ulcer bleeding incidence.

MATERIALS AND METHODS

We determined in a prospective observational study of 300 consecutive, mechanically ventilated patients the activity of H. pylori infection and the incidence of stress ulcer-related upper gastrointestinal bleeding over time. H. pylori infection was detected by Laser-Assisted Ratio Analyzer (LARA)- (13)C-urea breath test (Alimenterics, Inc., NJ) and serology. Stress ulcer prophylaxis was not prescribed. Endoscopy was performed in cases of upper gastrointestinal bleeding.

RESULTS

The prevalence of active H. pylori infection on admission was 38% as detected by urea breath test, and declined to 8% on the third day, and to 0% on the seventh day after admission as a result of antibiotic treatment. Stress ulcer-related upper gastrointestinal bleeding occurred in 1.0% (3 of 300) of the patients; none were infected with H. pylori on admission or at the time of bleeding.

CONCLUSIONS

H. pylori infection monitored by LARA- (13)C-urea breath test was rapidly suppressed during intensive care treatment, which can be explained by the routine use of antibiotics for gut decontamination.The low incidence of stress ulcer-related bleeding might be related to the prevention of H. pylori-associated stress lesions by effective suppression of this microorganism, but further studies are warranted to test this hypothesis.

A patient with hereditary hemochromatosis, ulcerative colitis, and primary sclerosing cholangitis: genetic aspects

This report describes a family in which the rare combination of hereditary hemochromatosis, ulcerative colitis and primary sclerosing cholangitis was found. Subsequent to the index patient, who had all three diseases, a screening was done in his parents and siblings that included HLA-DR, HLA-DQ and HFE typing, ANCAs, liver tests and sigmoidoscopy with histology. On the basis of HLA and HFE typing, three probable haplotypes could be distinguished. The genetics of inflammatory bowel disease and hereditary hemochromatosis are discussed.

Red streaks in the oesophagus in patients with reflux disease: is there a histomorphological correlate?

BACKGROUND

The Los Angeles classification of reflux oesophagitis includes sharply demarcated areas of erythema without any associated slough within the definition of reflux-induced mucosal breaks, though there is uncertainty as to whether these "red streaks" actually represent such a mucosal lesion. This study evaluates the histopathology of these red streaks.

METHODS

Forty patients with one or more red streaks on the tops of the mucosal folds in the distal oesophagus were included in a multinational, multicentre prospective study. All patients were referred for upper gastrointestinal endoscopy to investigate chronic heartburn and acid regurgitation. Biopsies were taken from the red streaks and from control biopsies from more normal appearing mucosa 1 cm lateral to the red streaks. A two-sided probability test using normal approximation assessed differences in the histological findings at the two biopsy locations.

RESULTS

Compared to control biopsies, biopsies of red streaks had a significantly thicker basal cell layer (mean +/- s 41% +/- 32% versus 18% +/- 23% of mucosal thickness, P=0.001) and longer papillae (mean +/- s 71% +/- 19% versus 49% +/- 24% of mucosal thickness, P= 0.001). Of the red streak biopsies, 25% had either newly re-epithelized lesions or granulation tissue beneath squamous epithelium. Only 10% of the control biopsies had moderate or more marked regenerative changes (based on elongation of papillae and basal cell hyperplasia), compared to 65.1% of red streak biopsies. Of the biopsies from the red streak itself, 7% showed no abnormality and 27.9% only slight changes. In comparison, 25% of the biopsies from control biopsies showed no regenerative changes and 62.5% only slight change due to gastro-oesophageal reflux disease.

CONCLUSION

The histomorphological counterpart to the endoscopically visible red streaks of the distal oesophagus is marked regenerative changes of the squamous epithelium and/or capillary rich granulation tissue beneath the squamous epithelium. Red streaks are validated as being indicative of acid/peptic mucosal injury, but they do not satisfy a strict definition of a mucosal break.

Should anti-Helicobacter therapy be different in patients with dyspepsia compared with patients with peptic ulcer diathesis?

Physicians should try to reach an optimal cure rate with initial anti-Helicobacter therapy. Helicobacter pylori infection in patients with peptic ulcer disease (PUD) is more likely to be cured then in patients with 'functional' dyspepsia (FD). Differences in cure rates of 5-15% are usually reported, which is considered to be clinically relevant. Different strains (virulent v. non-virulent) in PUD and FD may induce different alterations in the gastric mucosa, and thereby either facilitate or impair antimicrobial efficacy. A study in this journal showed that triple therapy with ranitidine bismuth citrate (RBC) was superior to triple therapy with a proton pump inhibitor (PPI), but only in the more-difficult-to-cure FD patients. Clinicians should be aware that most published treatment studies have included only PUD patients. This means that in clinical practice the cure rates obtained in patients with FD or even uninvestigated dyspepsia will usually be lower then those reported in the literature. One way to deal with this is to consider prolonging the duration of an initial anti-Helicobacter therapy from 7 to 10 or 14 days in patients without ulcers.

Impaired drinking capacity in patients with functional dyspepsia: relationship with proximal stomach function

BACKGROUND & AIMS

Impaired fundic accommodation to a meal and hypersensitivity to distention are increasingly recognized as important mechanisms underlying functional dyspepsia (FD). In the present study, we evaluated whether a drink test can predict such abnormalities and thus represent a noninvasive tool to study proximal stomach motor function.

METHODS

Healthy volunteers (HV), nonconsulters with mild dyspeptic symptoms (MS), and patients with FD filled out a disease-specific questionnaire and underwent a drink test with either water or with a high calorie fluid. The maximal ingested volume and the subsequent symptoms were meticulously recorded. In addition, all subjects underwent a gastric barostat study assessing meal-induced relaxation and sensation to distention.

RESULTS

Drinking capacity was not significantly related to any particular dyspeptic symptom. FD were able to consume less water (893 +/- 70 mL) and caloric liquid (767 +/- 50 mL) compared with HV (water, 1764 +/- 120 mL; caloric liquid, 1308 +/- 96 mL) or MS (water, 1645 +/- 120 mL; caloric liquid, 973 +/- 45 mL). Approximately half of the FD had an abnormal water or Nutridrink test compared with 9% of MS and 4% of HV. Furthermore, FD developed significantly more symptoms than MS or HV after both drink tests. The drinking capacity did not predict impaired fundic accommodation or visceral hypersensitivity.

CONCLUSIONS

FD, but not MS, have an impaired drinking capacity to both water and a nutrient liquid. The drinking capacity is not related to a specific dyspeptic symptom and does not predict proximal stomach motor function.

Review article: long-term use of proton pump inhibitors in GORD--help or hindrance?

Many patients with gastro-oesophageal reflux disease (GORD) experience chronic relapses and require maintenance therapy for symptomatic relief. This article reviews possible mechanisms for chronic relapse in GORD, and discusses the risks and benefits of proton pump inhibitors as maintenance therapy for this disease. Recent medical literature was reviewed to gather information about proton pump inhibitor therapy and GORD. The reports indicated that the tendency to relapse in GORD is probably related to ongoing motor defects and to the acid rebound that follows successful healing therapy. Proton pump inhibitors are very effective in maintaining symptomatic and endoscopic remission in GORD. Limitations of proton pump inhibitor therapy have largely so far been clinically irrelevant. Most side-effects are inherent consequences of any form of acid suppression therapy, and include hypergastrinaemia and rebound hyperacidity upon discontinuation of therapy. We conclude that the therapeutic balance tips toward proton pump inhibitors for treatment of GORD because their limitations are largely surpassed by excellent clinical efficacy, tolerance, and lack of serious adverse effects.

Long-term follow-up after biliary stent placement for postoperative bile duct stenosis

BACKGROUND

The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated with the main aim of assessing long-term complications after stent removal.

METHODS

ERCP was performed between 1981 and 1991 in 74 patients with postoperative bile duct stenoses. Two 10F stents were inserted for a maximum of 12 months with stent exchange every 3 months to avoid cholangitis caused by clogging.

RESULTS

Stent insertion failed in 11 patients with complete and 4 patients with incomplete biliary obstruction. Early complications occurred in 14 patients (19%) including 2 deaths. Therefore 57 patients were included in the stent phase of the study. In 10 patients the referring physician did not adhere to the treatment protocol, and nonelective stent exchange for jaundice and/or cholangitis was necessary in 7 (70%). Of the 47 patients treated according to protocol, complications developed in 40% during the period with stents in situ. Stents were eventually removed in 44 patients who were subsequently followed for a median of 9.1 years. Late complications developed in 15 patients (34%) including recurrent stenosis in 9 (20%). All cases of recurrent stenosis occurred within 2 years of stent removal.

CONCLUSIONS

Endoscopic treatment is feasible in 80% of patients who undergo an ERCP for postoperative bile duct stenosis. After stent insertion and during the time with stents in situ, complications occur at a significant rate but are usually mild or reflect the patient's underlying condition. After stent removal, recurrent stenosis develops in 20% of patients within 2 years of stent removal. Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.

Sonic hedgehog regulates gastric gland morphogenesis in man and mouse

BACKGROUND & AIMS

Gastric epithelial renewal is an asymmetric process. A stem cell located halfway up the tubular unit gives rise to both a basal gland region and a luminal pit compartment, but the mechanisms responsible for the maintenance of this asymmetry are obscure. We investigated whether Sonic hedgehog (Shh), an established polarizing signal protein during development, is expressed and functional in the adult human and murine stomach.

METHODS

Expression of Shh and putative transcriptional targets was investigated using immunoblot and immunohistochemistry. Mice were treated with the Shh inhibitor cyclopamine and examined for expression levels of Shh targets and proliferation of gastric epithelial cells.

RESULTS

Shh was expressed in the stomach. In cyclopamine-treated mice, we observed decreased expression of HNF3beta, Islet (Isl)-1 and BMP4, 3 putative Shh target genes. Inhibition of Shh markedly enhanced gastric epithelial proliferation and affected the cell cycle of gastric epithelial gland cells, whereas pit cells remained unaffected.

CONCLUSIONS

Shh controls the expression of at least 3 factors important for epithelial differentiation and is a negative regulator of gastric gland cell proliferation. Shh is a candidate polarizing signal in the maintenance of gastric pit-gland asymmetry.

Arrest of chronic acid suppressant drug use after successful Helicobacter pylori eradication in patients with peptic ulcer disease: a six-month follow-up study

BACKGROUND

It remains controversial whether successful H. pylori eradication leads to relief of dyspepsia and the subsequent arrest or tapering of acid-suppressant drug therapy, or to an aggravation of acid-related dyspepsia requiring more acid-suppressant drug intake.

AIM

To evaluate prospectively the effect of H. pylori eradication on the requirement of acid-suppressant drug or antacids and the evolution of dyspeptic symptoms in chronic acid-suppressant drug users with peptic ulcer disease.

MATERIALS AND METHODS

The use of acid-suppressant drugs, rescue antacids and predominant symptoms were recorded prospectively during 24 weeks after H. pylori eradication therapy in 75 peptic ulcer disease patients.

RESULTS

In 71 patients with complete follow-up, ulcers were healed at follow-up endoscopy and H. pylori was successfully eradicated. After 6 months, 93% (66 out of 71) of chronic acid-suppressant drug users had stopped acid-suppressant drug intake. The mean daily acid-suppressant drug dosage per patient decreased from 1.72 at entry to 0.03 units acid-suppressant drug (98%; P < 0.0001) during follow-up. The mean number of antacid tablets/day/patient was 0.26 during follow-up for the relief of mild inter-current dyspeptic symptoms. Medication use was not different in peptic ulcer disease patients with or without gastro-oesophageal reflux disease at baseline. The prevalence of gastro-oesophageal reflux disease decreased from 42% before to 35% after H. pylori eradication (N.S.).

CONCLUSION

Successful H. pylori eradication in peptic ulcer disease patients almost completely eliminates the need for acid-suppressant drug regardless of the presence or absence of gastro-oesophageal reflux disease at entry.

Clarithromycin-susceptible and -resistant Helicobacter pylori isolates with identical randomly amplified polymorphic DNA-PCR genotypes cultured from single gastric biopsy specimens prior to antibiotic therapy

Of the Helicobacter pylori populations from 976 patients, six contained clarithromycin-resistant as well as -susceptible colonies. In each heterogeneous H. pylori population, resistant H. pylori colonies harbored identical 23S ribosomal DNA (rDNA) mutations associated with clarithromycin resistance, while the susceptible H. pylori colonies all had wild-type 23S rDNA. The resistant and susceptible colonies of each of the heterogeneous H. pylori populations had identical randomly amplified polymorphic DNA-PCR genotypes. In conclusion, evaluation of antimicrobial susceptibility can be misinterpreted if only a single colony from the primary H. pylori population is used to test for clarithromycin susceptibility.

Guidelines for adults on self-medication for the treatment of acute diarrhoea

Acute uncomplicated diarrhoea is commonly treated by self-medication. Guidelines for treatment exist, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice. In general it is recognized that treatment of acute episodes relieves discomfort and social dysfunction. There is no evidence that it prolongs the illness. Self-medication in otherwise healthy adults is safe. Oral loperamide is the treatment of choice. Older anti-diarrhoeal drugs are also effective in the relief of symptoms but carry the risk of unwanted adverse effects. Oral rehydration solutions do not relieve diarrhoea, and confer no added benefit for adults who can maintain their fluid intake. Probiotic agents are, at present, limited in efficacy and availability. Antimicrobial drugs, available without prescription in some countries, are not generally appropriate for self-medication, except for travellers on the basis of medical advice prior to departure. Medical intervention is recommended for the management of acute diarrhoea in the frail, the elderly (> 75 years), persons with concurrent chronic disease, and children. Medical intervention is also required when there is no abatement of the symptoms after 48 h, or when there is evidence of deterioration such as dehydration, abdominal distension, or the onset of dysentery (pyrexia > 38.5 degrees C and/or bloody stools).

Comparison of precancerous conditions: atrophy and intestinal metaplasia in Helicobacter pylori gastritis among Chinese and Dutch patients

AIM-Atrophy and intestinal metaplasia (IM) as precancerous conditions consistently begin in the antrum and are most severe along the lesser curvature. The aim of this study was to investigate discrepancies in the prevalence, the severity of atrophy, and IM in antral mucosa of Helicobacter pylori infected gastritis and difference in age of onset among Chinese and Dutch patients. METHODS-Two hundred and sixty five Chinese patients and 261 Dutch patients with H pylori infection were enrolled. The degrees of atrophy and IM were graded according to the updated Sydney system. RESULTS-The overall prevalences of atrophy and IM were lower in Dutch patients (42% and 26%, respectively) than in Chinese patients (52% and 32%, respectively). Only the difference in atrophy reached significance (p = 0.028). However, in both Chinese and Dutch patients, the degrees of atrophy and IM were low and severe degrees were rare. The mean ages of Chinese and Dutch patients with atrophy and IM were higher than those without atrophy and IM (with atrophy (Chinese patients): mean, 42.12; SD, 9.80; with IM (Chinese patients): mean, 42.56; SD, 9.96; with atrophy (Dutch patients): mean, 55.16; SD, 12.20; with IM (Dutch patients): mean, 57.79; SD, 11.13; without atrophy (Chinese patients): mean, 39.71; SD, 10.16; without IM (Chinese patients): mean, 40.19; SD, 9.99; without atrophy (Dutch patients): mean, 45.70; SD, 12.44; without IM (Dutch patients): mean, 46.89; SD, 12.68). Atrophy and IM occurred earlier and were more severe in Chinese patients, with both reaching a peak value in patients over 60 years. CONCLUSIONS-There are geographical differences in the prevalence and severity of H pylori infected gastritis, in particular with respect to atrophy and IM, which suggests that infection with H pylori occurs earlier in life and has a higher prevalence in CHINA:

Enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the beneficial effect of acid suppression

BACKGROUND

The high mortality rate in patients with upper gastrointestinal bleeding appears to be particularly related to re-bleeding. The haemostatic mechanisms that may influence the re-bleeding of ulcers are largely unknown.

AIM

We studied and analysed fibrinolytic activity in bleeding ulcer patients and the effect of acid suppression on this activity.

METHODS

Fibrinolytic activity was analysed in mucosal biopsies from 29 bleeding gastroduodenal ulcer patients and six controls. We analysed levels of D-Dimer, fibrin plate lysis area, plasminogen activator activity, plasminogen activator inhibitor activity, and plasmin antiplasmin complexes.

RESULTS

Significantly more fibrinolytic activity was detected in biopsies from patients with bleeding ulcers compared to controls. Moreover, in patients with endoscopic stigmata of recent haemorrhage, mucosal fibrinolytic activity was higher compared to patients without stigmata of recent haemorrhage. In mucosal biopsies of patients that had used acid suppression before admission, a decreased fibrinolytic activity was found compared to patients without such therapy. This effect of acid suppression on fibrinolytic activity was confirmed in nine patients before and after a 24-h ranitidine infusion.

CONCLUSIONS

Fibrinolytic activity is enhanced in patients with bleeding gastroduodenal ulcers. Acid suppressive therapy decreases this increased activity, which may be one of the mechanisms explaining the potential beneficial effect of this therapy.

Is endoscopic balloon dilation for removal of bile duct stones associated with an increased risk for pancreatitis or a higher rate of hyperamylasemia?

BACKGROUND AND STUDY AIMS

We studied the rate of pancreatitis and asymptomatic hyperamylasemia after endoscopic balloon dilation (EBD) and endoscopic sphincterotomy (EST) for removal of bile duct stones.

PATIENTS AND METHODS

Patients with bile duct stones of all sizes were randomly allocated to undergo EBD (8-mm dilation balloon) or EST. Pancreatitis was defined as epigastric pain combined with at least a threefold rise in serum amylase at 24 hours after the endoscopic retrograde cholangiopancreatography (ERCP). Asymptomatic hyperamylasemia was defined as a threefold rise in serum amylase without epigastric pain.

RESULTS

There were 180 patients (67 men, 113 women; mean age 67, SD 16.2) available for analysis. Complete stone removal after a single ERCP was achieved in 82 (88%) of 93 EBD patients and in 81 (93%) of 87 EST patients (P = 0.38). Mechanical lithotripsy was used more frequently in the EBD group (31% vs. 13%, P = 0.005). Early complications occurred in 16 EBD patients (17%) and in 19 EST patients (22%) (P = 0.46). Pancreatitis was observed in seven patients in each group (8%). Logistic regression identified no significant predictors for the occurrence of pancreatitis. Asymptomatic hyperamylasemia occurred in 21 EBD patients (23%) vs seven EST patients (8%) (P = 0.008). Logistic regression identified EBD as the only significant predictor for asymptomatic hyperamylasemia: odds ratio 2.9 (95% confidence interval (CI) 1.1 to 7.3, R2 = 0.02).

CONCLUSIONS

We did not observe a difference in the rate of pancreatitis between EBD and EST. Asymptomatic hyperamylasemia was observed more frequently after EBD. Although asymptomatic hyperamylasemia is not a clinical entity, this finding may indicate that EBD causes more irritation of the pancreas than EST.

Shortcomings of the first-generation proton pump inhibitors

Proton pump inhibitors (PPIs) are widely prescribed for the treatment of gastro-oesophageal reflux disease (GORD) as well as gastric and duodenal ulcers, and these agents are now considered the drugs of choice for managing such acid-related disorders. Despite their well-documented efficacy and safety, first-generation PPIs (omeprazole, pantoprazole and lansoprazole) have notable limitations. These drugs exhibit substantial interpatient variability in pharmacokinetics and may have significant interactions with other drugs. The time of dosing and ingestion of meals may also influence the pharmacokinetics of these agents as well as their ability to suppress gastric acid secretion. First-generation PPIs also have a relatively slow onset of pharmacological action and may require several doses to achieve maximum acid suppression and symptom relief, possibly limiting their usefulness in on-demand GORD therapy. First-generation PPIs may also fail to provide 24-h suppression of gastric acid, and noctural acid breakthrough can occur even with twice-daily dosing. Both first- and second-generation PPIs may be associated with adverse events consequent to gastric acid suppression, but newer PPIs have the potential to overcome some critical pharmacokinetic, pharmacodynamic, and clinical limitations of the first-generation drugs.

Autofluorescence endoscopy: feasibility of detection of GI neoplasms unapparent to white light endoscopy with an evolving technology

BACKGROUND

Case studies are presented of fluorescence endoscopy in the upper and lower GI tract to illustrate the ability to detect early-stage lesions that were not observable with white light endoscopy or those in which the assessment of the stage or extension of the lesion were equivocal.

METHODS

A new fluorescence imaging system was used in which blue light excites the naturally-occurring fluorescence of tissues (autofluorescence). The system produces real-time, false-color images that combine green and red fluorescence intensities. In general, abnormal lesions are seen to have an increase in the red-to-green fluorescence intensity compared with surrounding tissue. This system was evaluated in patients at 4 participating institutions, concurrently with standard white light endoscopy, with or without dye staining.

RESULTS

Selected cases are presented in which fluorescence imaging identified specific lesions including focal high-grade dysplasia in Barrett's mucosa, signet ring carcinoma of the stomach, and flat adenoma in the colon.

CONCLUSIONS

The capability of autofluorescence endoscopy to detect the presence and extent of occult malignant and premalignant GI lesions has been demonstrated. The future development and evaluation of this technology are discussed.

Prevalence of Helicobacter pylori infection in stress-induced gastric mucosal injury

OBJECTIVE

To determine the role of Helicobacter pylori infection in critically ill patients admitted to the intensive care unit in the formation of gastric and duodenal mucosal injury in these patients.

DESIGN AND SETTING

Prospective cohort analysis in an 18-bed mixed medical and surgical closed format ICU in a teaching hospital.

PATIENTS

Fifty consecutive patients admitted to the intensive care unit for emergency reasons and requiring mechanical ventilation were included.

INTERVENTIONS

H. pylori infection was detected by the laser-assisted ratio analyzer [13C]urea breath test (UBT). Gastric and duodenal mucosal lesions were assessed by upper gastrointestinal endoscopy and classified as minor (up to five erosions or submucosal hemorrhages) or major (more than five erosions or submucosal hemorrhages) mucosal injury.

MEASUREMENTS AND MAIN RESULTS

Six patients were not eligible because the UBT could not be processed. Of the 44 eligible patients 22 were H. pylori positive by UBT and 22 H. pylori negative. Either minor or major gastric mucosal injury was found on endoscopy in 66 %. Of the 29 patients with minor mucosal injury 10 (34.5 %) were infected with H. pylori as indicated by positive LARA 13C-UBT. In contrast, of the 15 patients with major mucosal injury 12 (80%) were infected with H. pylori (p = 0.004). H. pylori was the only risk factor significantly associated with major mucosal injury in a multiple regression analysis (p = 0.019).

CONCLUSION

The severity of gastric and duodenal mucosal injury in critically ill patients during mechanical ventilation is significantly correlated with the presence of H. pylori infection.

A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy

BACKGROUND

A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation.

METHODS

Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST.

RESULTS

All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05).

CONCLUSIONS

A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients.

Gut decontamination of critically ill patients reduces Helicobacter pylori acquisition by intensive care nurses

The prevalence of Helicobacter pylori is increased in healthcare workers and in intensive care nurses. Exposure to H. pylori from gastric secretions and faeces are probably the main sources of transmission to healthcare workers. Routine use of selective decontamination of digestive tract (SDD) in an intensive care unit suppresses H. pylori in critically ill patients. It was questioned whether this suppression and the subsequent decreased exposure to H. pylori for intensive care nurses would lead to a lower prevalence of H. pylori infection. Helicobacter pylori infection prevalence in intensive care nurses from a unit routinely using SDD (group I) was compared to that of nurses from a unit not using SDD (group II). Heathcare workers from other departments of the hospital where no SDD was used (group III) served as a control group. Persons using proton pump inhibitors were excluded. Helicobacter pylori was detected by Laser Assisted Ratio Analyser(13)C-urea breath test (UBT) and serology. This could not be performed in three out of 64 in group I, five out of 55 in group II and five out of 55 in group III (total UBTs = 169). The prevalence of H. pylori infection was 11% (7/61) in group I and 25.5% (14/50) in group II (P= 0.027). In group III, the prevalence of H. pylori infection was 16% (8/45), which was not significantly different from both group I and II. Sero-prevalence in group I was 18.6%, 27% in group II (ns) and 24% in group III. Mean age in the three groups was 35.9, 37.8 and 36.6 years, respectively (ns). In conclusion, the prevalence of H. pylori infection among intensive care nurses is lower in nurses from a unit using SDD compared to a non SDD-using unit. Acquisition of H. pylori by transmission from critically ill patients appears to be diminished through SDD use.

Comprehensive Cancer Centre Amsterdam Barrett Advisory Committee: first results

BACKGROUND

Treatment and follow-up policy for Barrett's oesophagus are dependent on the grade of dysplasia. However, sampling error of random biopsy protocols and subjectivity of pathological grading may hamper endoscopic surveillance.

METHODS

The Amsterdam Comprehensive Cancer Center Barrett Advisory Committee (BAC) is a regional multidisciplinary consultative working-group, offering revision of pathology, revision of pathology plus additional endoscopic diagnostics, or referral for treatment.

RESULTS

Between July 1998 and July 1999 30 patients were referred to the B.A.C for advice; eighteen patients were referred because of suspicion of high grade dysplasia. Reassessment of biopsies, including additional quantitative pathology, with or without additional endoscopic diagnostics, led to adjustment of the grading of dysplasia in 15 patients (50%). A suspicion of low grade dysplasia was rejected in nine out of ten cases. Adjustment of the original diagnosis often influenced further therapy or follow-up.

CONCLUSIONS

reassessment of conventional pathology, quantitative pathology, and additional diagnostic procedures might improve the accuracy of diagnosis and staging of malignant degeneration of Barrett's oesophagus, although experience is still limited. The complexity of the management of these patients demands a specialised multidisciplinary approach. A Barrett Advisory Committee can offer valuable contributions to the treatment of patients with Barrett's oesophagus.

Management in peptic ulcer hemorrhage: a Dutch national inquiry

BACKGROUND AND STUDY AIMS

There is no consensus as to what endoscopic hemostatic therapy and pharmacotherapy should be used in peptic ulcer hemorrhage (PUH). We conducted a mail survey to investigate current management of ulcer hemorrhage in the Netherlands.

METHODS

A questionnaire was sent to gastroenterologists or, if not present, to internists, performing endoscopies, in every hospital in the Netherlands (n = 123). Endoscopic hemostatic therapy, pharmacotherapy, endoscopic reintervention, and management of Helicobacter pylori were evaluated.

RESULTS

90/123 (73%) questionnaires were returned. Endoscopic hemostatic therapy is given in ulcers classified as Forrest Ia, Ib, IIa, IIb, and IIc by, respectively, 89%, 93%, 83%, 47%, and 19% of respondents. Gastroenterologists perform endoscopic therapy more often in Forrest Ib (P=0.03), IIa (P=0.002), and IIb (P=0.001) ulcers when compared with internists. Endoscopic injection therapy is used by 93% of respondents as first modality. Epinephrine combined with polidocanol is most commonly used (60%). Pharmacotherapy is given by 97%. A total of 71% use proton pump inhibitors (PPIs), and 26% use H2-receptor antagonists (H2RAs), both mainly initially given intravenously. In case of suspected rebleeding, endoscopic reintervention is performed by 76%, including a significantly greater percentage of gastroenterologists (89% of gastroenterologists vs. 60% of internists, P=0.005), whereas the others refer the patient directly for surgery. Almost all respondents investigate for H. pylori. Eradication is confirmed by only 64% (80% of gastroenterologists vs. 50% of internists, P=0.004).

CONCLUSIONS

There are important differences in management of peptic ulcer hemorrhage between gastroenterologists and internists in the Netherlands. Management is only partly in accordance with evidence-based medicine.

A new quadruple therapy for Helicobacter pylori using tripotassium dicitrato bismuthate, furazolidone, josamycin and famotidine

BACKGROUND

In our previous study, a triple therapy using tripotassium dicitrato bismuthate (TDB), josamycin and furazolidone achieved a suboptimal cure rate of Helicobacter pylori infection.

AIM

To investigate whether the addition of an antisecretory agent raises the cure rate using this regimen.

METHODS

One hundred and twenty H. pylori positive patients with peptic ulcer disease or functional dyspepsia were randomly assigned to receive 1-week quadruple therapy of TDB 240 mg b.d., furazolidone 100 mg b.d., josamycin 1000 mg b.d. and famotidine 20 mg b.d. (BFJF group), or triple therapy of TDB 240 mg b.d., furazolidone 100 mg b.d. and clarithromycin 250 mg b.d. (BFC group). H. pylori status was assessed by histology and culture of gastric biopsy specimens before and at least 4 weeks after completion of therapy.

RESULTS

Seven patients (three in the BFJF group and four in the BFC group) dropped out. Eradication rates (intention-to-treat/per protocol) were 90%/95% in the BFJF group and 82%/88% in the BFC group, respectively (P > 0.05). Duodenal ulcer healing rates were 94% (16/17) in the BFJF group and 80% (20/25) in the BFC group, respectively (P > 0.05). Mild side-effects occurred in 11 (18%) patients in the BFJF group and 10 (17%) in the BFC group (P > 0.05).

CONCLUSIONS

One-week quadruple therapy consisting of TDB, furazolidone, josamycin and famotidine achieves a high cure rate of H. pylori infection.

EUS imaging of the arteria lusoria: case series and review

BACKGROUND

The arteria lusoria is an aberrant right subclavian artery that passes dorsally between the esophagus and spine after branching off from the aortic arch. The role of endoscopic ultrasonography (EUS) in the diagnosis of the arteria lusoria has not been established. The possibility of demonstrating this vascular anomaly with EUS and estimating its prevalence was assessed.

METHODS

From December 1991 to September 1998, EUS of the upper gastrointestinal tract was performed in 3334 consecutive patients for various reasons. After imaging of the target organ(s), the echoendoscope was slowly pulled back while imaging the mediastinum proximally to the superior aspect of the aortic arch. In every patient, the area of the aortic arch was carefully inspected and special attention was given to vessels crossing from left to right between the esophagus and spine.

RESULTS

During the study period, an arteria lusoria was discovered in 12 of 3334 patients (0.36%: 95% CI [0.16%, 0.56%]). There were 6 men and 6 women; mean age was 64+/-14.7 years. In all 12 patients the arteria lusoria passed between the esophagus and spine. In none of the patients could symptoms be attributed to the presence of this anatomic variant.

CONCLUSIONS

An arteria lusoria can be detected with upper gastrointestinal EUS and was found in 0.36% of patients. EUS can accurately demonstrate this vascular anomaly.

In vitro susceptibility of Helicobacter pylori to, and in vivo suppression by, antimicrobials used in selective decontamination of the digestive tract

The incidence of bleeding related to stress ulcers is reduced in critically ill patients in whom gut decontamination has been performed; this may be a result of suppression of Helicobacter pylori infection. We determined the susceptibility of H. pylori to the applied antibiotics. In nine of 10 critically ill patients (using intravenous cefotaxime and topical polymyxin, tobramycin and amphotericin B (PTA) given by nasogastric tube) and all six volunteers (using PTA alone), H. pylori was suppressed as long as the topical antibiotics were ingested. The in vitro studies revealed that all strains were susceptible to cefotaxime and tobramycin. The strains were not susceptible to polymyxin or amphotericin B.

Review article: Helicobacter pylori: where are we and where are we going?

This paper contains a personal view on what has been achieved in Helicobacter pylori research and what the expectations might be for further developments. Knowledge about the organism is already extensive. Particularly intriguing are the differences in genetic make-up in the various geographical regions. Sadly, detailed knowledge on how the organism spreads is still lacking. The clinical spectrum of the disease in man is largely known, but as H. pylori is disappearing worldwide, the relative frequency of H. pylori-negative ulcer disease is increasing. To what extent H. pylori disappearance and eradication is responsible for the decreasing incidence of gastric cancer remains uncertain. Antimicrobial therapy is dominated by proton pump inhibitor triple therapy as first line with quadruple therapy as second-line therapy. The long-term consequences of the rising resistance to the 'key' antimicrobials are so far unknown and speculative.

Evidence for VIP(1)/PACAP receptors in the afferent pathway mediating surgery-induced fundic relaxation in the rat

We previously reported activation of an inhibitory adrenergic and a non-adrenergic non-cholinergic (NANC) pathway during abdominal surgery relaxing the rat gastric fundus. In the present study, we investigated the possible role of nitric oxide (NO) and vasoactive intestinal polypeptide (VIP) in the NANC part of the surgery-induced fundic relaxation. The effect of the NO biosynthesis inhibitor N(G)-nitro-L-arginine (L-NOARG), the non-selective VIP receptor antagonist [D-p-Cl-Phe(6),Leu(17)]-VIP and the selective VIP(1) receptor antagonist [Acetyl-His(1),D-Phe(2),Lys(15),Arg(16), Leu(17)]-VIP was investigated on the non-adrenergic fundic relaxation induced by manipulation of the small intestine followed by resection of the caecum. Guanethidine partly reduced the manipulation-induced fundic relaxation. Addition of L-NOARG reduced this non-adrenergic component, whereas the non-selective VIP receptor antagonist had no significant effect. Combination of L-NOARG and the non-selective VIP antagonist however further reduced the relaxation to manipulation. The selective VIP(1) receptor antagonist reduced the mean and maximal relaxation induced by abdominal surgery in the presence of guanethidine. When combined with L-NOARG, the relaxation of the gastric fundus was almost completely abolished. The VIP(1) receptor antagonist alone had no significant effect on the mean and maximal relaxation, but enhanced recovery of fundic tone. In conclusion, as VIP(1) receptors are not present in the rat gastric fundus, these results suggest that the NANC inhibitory pathway activated during abdominal surgery involves VIP(1) receptors, most likely in the afferent limb. The inhibitory neurotransmitters released at the level of the gastric fundus smooth muscle are NO and a substance different from VIP.