European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Management of lesions detected in colorectal cancer screening

Multidisciplinary, evidence-based guidelines for quality assurance in colorectal cancer screening and diagnosis have been developed by experts in a project coordinated by the International Agency for Research on Cancer. The full guideline document covers the entire process of population-based screening. It consists of 10 chapters and over 250 recommendations, graded according to the strength of the recommendation and the supporting evidence. The 450-page guidelines and the extensive evidence base have been published by the European Commission. The chapter on management of lesions detected in colorectal cancer screening includes 32 graded recommendations. The content of the chapter is presented here to promote international discussion and collaboration by making the principles and standards recommended in the new EU Guidelines known to a wider professional and scientific community. Following these recommendations has the potential to enhance the control of colorectal cancer through improvement in the quality and effectiveness of the screening process, including multi-disciplinary diagnosis and management of the disease.

European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Quality assurance in endoscopy in colorectal cancer screening and diagnosis

Multidisciplinary, evidence-based guidelines for quality assurance in colorectal cancer screening and diagnosis have been developed by experts in a project coordinated by the International Agency for Research on Cancer. The full guideline document covers the entire process of population-based screening. It consists of 10 chapters and over 250 recommendations, graded according to the strength of the recommendation and the supporting evidence. The 450-page guidelines and the extensive evidence base have been published by the European Commission. The chapter on quality assurance in endoscopy includes 50 graded recommendations. The content of the chapter is presented here to promote international discussion and collaboration by making the principles and standards recommended in the new EU Guidelines known to a wider professional and scientific community. Following these recommendations has the potential to enhance the control of colorectal cancer through improvement in the quality and effectiveness of endoscopy and other elements in the screening process, including multidisciplinary diagnosis and management of the disease.

Appropriateness of colonoscopy in Europe (EPAGE II). Surveillance after polypectomy and after resection of colorectal cancer

BACKGROUND AND STUDY AIMS

To summarize the published literature on assessment of appropriateness of colonoscopy for surveillance after polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II.

METHODS

A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resection of CRC was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions.

RESULTS

Most CRCs arise from adenomatous polyps. The characteristics of removed polyps, especially the distinction between low-risk adenomas (1 or 2, small [< 1 cm], tubular, no high-grade dysplasia) vs. high-risk adenomas (large [> or = 1 cm], multiple [> 3], high-grade dysplasia or villous features), have an impact on advanced adenoma recurrence. Most guidelines recommend a 3-year follow-up colonoscopy for high-risk adenomas and a 5-year colonoscopy for low-risk adenomas. Despite the lack of evidence to support or refute any survival benefit for follow-up colonoscopy after curative-intent CRC resection, surveillance colonoscopy is recommended by most guidelines. The timing of the first surveillance colonoscopy differs. The expert panel considered that 56 % of the clinical indications for colonoscopy for surveillance after polypectomy were appropriate. For surveillance after CRC resection, it considered colonoscopy appropriate 1 year after resection.

CONCLUSIONS

Colonoscopy is recommended as a first-choice procedure for surveillance after polypectomy by all published guidelines and by the EPAGE II criteria. Despite the limitations of the published studies, colonoscopy is also recommended by most of the guidelines and by EPAGE II criteria for surveillance after curative-intent CRC resection.

Reprocessing in digestive endoscopy units in Lombardy: results of a regional survey

BACKGROUND AND AIM

Inadequate disinfection of endoscopes and associated instrumentation can result in transmission of infections to patients. The aim of this study is to assess cleaning and disinfection practice in gastrointestinal endoscopy units in public and private institutions in the Lombardy region.

METHODS

We drafted a questionnaire which we e-mailed to all gastrointestinal centers in Lombardy.

RESULTS

A total of 79 centers responded (77%). All endoscopy units perform manual cleaning before disinfection. Automated endoscope reprocessors are available in 84.4% of the centers. Glutaraldehyde-based disinfectants are the most common employed (67% of centers). The time of exposure to the disinfectant is of 10 min in only 9.8% of the centers. The majority of endoscopy units modify their disinfection procedures in the case of infectious disease patients. In 59% of centers disposable material is only used once. In 37% of the endoscopy units instruments are dried with propanol.

CONCLUSIONS

The data collected suggest that cleaning and disinfection practices have improved in recent years, and that there is a good compliance with standard guidelines. There is still room for improvement in equipment, disinfection protocols, and traceability of instruments in order to improve safety for patients and staff.

Colonoscopy practice in Italy: a prospective survey on behalf of the Italian Association of Hospital Gastroenterologists

BACKGROUND

Examining the current practice is important for the benchmarking of quality of colonoscopy and the comparison with the standards and recommendations expected by professional societies.

AIM

To describe colonoscopy practice in Italy, on the basis of prospective analysis of a large number of examinations performed by operators with different levels of expertise in a wide range of unselected centres.

DESIGN AND SETTING

Cross-sectional, prospective and multicentre study.

METHODS

The main features of each endoscopy centre (structure indicators) were collected through the use of a standardised questionnaire. A second questionnaire was used to prospectively record details of all the consecutive colonoscopies performed in a 2-week study period.

RESULTS

Data from 278 centres and 12,835 consecutive colonoscopies were evaluated. Centres were uniformly distributed throughout Italy - north, centre and south - as was their organizational complexity and workload. Overall, adequate facilities (i.e. cleaning area for disinfection/reprocessing, equipped recovery room), and safety equipment (i.e. pulse oximetry, equipment for emergency cardiopulmonary resuscitation) were lacking in a considerable amount of centres, especially in those with a lower degree of organizational complexity. Written informed consent was routinely required in 87% of the centres, but a specific consent for colonoscopy, including detailed information on adverse events, was adopted by 66%. Regular programs for recording some quality indicators (i.e. cecal intubation, quality of bowel cleansing, patients' satisfaction and complications) were implemented in a minority of centres. About 93% of the colonoscopies were performed for diagnostic purpose; screening and surveillance accounted for 13.7% and 25.3% of the indications, respectively. Sedation and/or analgesia was administered in about half of the patients. Overall, colonoscopies were completed to the cecum in 80.7% of cases, and only 22.1% of the centres reported a cecal intubation rate >or=90%; this figure was reported in 33.1% of centres with high-organizational complexity and in 14.4% of outpatient units. The overall incidence of immediate complications was low (2 perforations, 26 bleedings and 32 serious cardiorespiratory complications).

CONCLUSIONS

This study documented a wide variation in colonoscopy practice between centres and highlighted problem areas where interventions are needed to improve performance and safety of the examinations.

Prospective multicenter quality assessment of endotherapy of biliary stones: does center volume matter?

BACKGROUND AND STUDY AIMS

To study the effectiveness of endoscopic treatment for biliary stones in a large case list of patients treated in units with different experience and different workloads in a region of northern Italy.

PATIENTS AND METHODS

We prospectively studied 700 patients undergoing endoscopic retrograde cholangiopancreatography or sphincterotomy, in 14 units (> or < 200 examinations/year), for their first treatment of biliary stones. The difficulty of the examinations, the results in terms of clearance of the stones, and the late outcomes (24 months) were recorded. A questionnaire (GHAA-9modified) was administered 24 hours and 30 days after the procedure to measure patient satisfaction.

RESULTS

There were six units with a heavy workload and eight with a light schedule. There were 176 (25.1 %) difficult examinations (Schutz grades 3, 4, and 5). Stones were found in 580 (82.9 %) and were cleared in 504 of these patients (86.9 %). No differences were observed in the clearance of stones for the different groups of difficulty and high- and low-volume centers. Over the 24-month follow-up period, 96 patients (13.7 %) complained of recurrent symptoms and 44 (6.3 %) had proof of stones. In all, 603 questionnaires were evaluable and more than 80 % of patients expressed satisfaction.

CONCLUSIONS

Our findings confirm the effectiveness of endoscopic treatment of biliary stones. However, the number of patients with symptoms (13.7) after 24 months, with or without persistence of stones, was not insignificant. It is feasible to record patient satisfaction, and in this series patients stated they were satisfied. Criticism mostly concerned pain control and explanations provided before the examination.

Effectiveness of a continuous quality improvement program on colonoscopy practice

BACKGROUND AND STUDY AIM

Continuous quality improvement (CQI) is recommended by professional societies as part of every colonoscopy program, but little is known with regard to its effectiveness for colonoscopy outcomes. We prospectively assessed whether the implementation of a CQI program in routine clinical practice influences the quality performance of colonoscopy.

METHODS

In an open-access endoscopy unit at a secondary care center in Northern Italy, 6-monthly audit cycles were carried out over a 4-year period, to identify reasons for poor colonoscopy outcomes and institute appropriate changes to improve performance. The colonoscopy completion rate and the polyp detection rate as detected by endoscopists were considered to be key measures for improvement.

RESULTS

The initial crude colonoscopy completion rate was 84.6%, with a range for individual endoscopists 80.4%-94%. Four endoscopists had a completion rate lower than 90%. The overall polyp detection rate was 34%, with a wide variation among endoscopists (range 14%-42%). Poor patient tolerance and differences in colonoscopist expertise were the main determinants of lack of completion and variation in polyp detection rate. Changes to sedation practice, greater access to endoscopy sessions for the endoscopists with the lowest performance rates, and other organizational arrangements, were implemented to improve quality performance. The crude completion rates improved consistently, up to 93.1%, over the study period. This trend was confirmed even when adjusted completion rates were calculated. All endoscopists reached a crude completion rate of 90% or more and a polyp detection rate of over 20%. The introduction of CQI did not significantly change the overall incidence of procedure-related complications.

CONCLUSIONS

The effectiveness of colonoscopy can be improved by implementing a CQI program in routine colonoscopy practice.

Segmental colitis associated with diverticula: a 7-year follow-up study

BACKGROUND AND STUDY AIMS

We performed a long-term follow-up study of patients with segmental colitis associated with diverticula, in order to clarify the natural history of this disease.

PATIENTS AND METHODS

We identified 15 patients who were diagnosed as having segmental colitis associated with diverticula during 1997. We assessed these patients by means of periodic follow-up visits from 1997 to 2004.

RESULTS

Eight of the 15 patients had no clinical recurrence during follow-up. Five patients had sporadic recurrences that were clinically mild (on average, one in 5 years), which responded to topical therapy and often to self-medication. Only two patients were diagnosed during the follow-up period as having Crohn's disease; notably, these were the only patients who did not have hematochezia as the main symptom at onset.

CONCLUSION

The course of this disease appears to be substantially benign.

Is the supine position as safe and effective as the prone position for endoscopic retrograde cholangiopancreatography? A prospective randomized study

BACKGROUND AND STUDY AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed with the patient lying in the prone position, on the assumption that this position is optimal for cannulation of the papilla and for obtaining good-quality radiographic images. The supine position, however, may be more comfortable for the patient and may facilitate airway management, and this study aimed to compare the two positions in terms of procedure outcome, safety, and patient tolerance.

PATIENTS AND METHODS

Consecutive patients who were undergoing ERCP were randomized to start the procedure in either the prone position or the supine position. Patients under the age of 18 years, intubated patients, and those who had already undergone endoscopic sphincterotomy were excluded. The difficulty of cannulation was assessed using the Freeman score (1=one to five attempts; 2=six to 15 attempts; 3=more than 15 attempts; 4=failure of cannulation). Total procedure time, patient tolerance, willingness to undergo ERCP in the future, and procedure-related adverse cardiorespiratory events (oxygen desaturation, tachycardia, bradycardia) were also recorded.

RESULTS

A total of 34 patients were evaluated (21 men, 13 women; mean age 68, range 20-96), 17 patients in each group. Demographic and clinical features, and the indications for the procedure were similar for the two patient groups. The median Freeman score was significantly lower in the prone group compared with the supine group (1 vs. 3, P=0.0047, rank sum test). Biliary cannulation was achieved in all patients in the prone group, but was not achieved in five patients (29%) in the supine group (P=0.052). In four of these five patients, biliary cannulation was successfully achieved after turning the patient into the prone position. The percentage of patients unwilling to repeat the ERCP procedure in the future was higher in the supine group (29% vs. 6%, P=0.087); the mean tolerance score and mean total procedure time were similar in the two groups. Seven patients in the supine group experienced at least one adverse cardiorespiratory event, compared with only one patient in the prone group (41% vs. 6%, P=0.039).

CONCLUSIONS

ERCP performed with the patient in the supine position is technically more demanding for operators used to working with patients in the prone position and carries a greater risk of adverse cardiorespiratory events in nonintubated patients.

Increased prevalence of migraine in patients with uninvestigated dyspepsia referred for open-access upper gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS

The association between gastrointestinal symptoms and headache is frequently unrecognized. The aim of the present study was to determine the prevalence of migraine in dyspeptic outpatients referred for upper gastrointestinal endoscopy.

PATIENTS AND METHODS

Patients aged 18 - 55 years undergoing upper gastrointestinal endoscopy for dyspeptic symptoms in three endoscopic units were recruited consecutively. All of the patients were given a validated questionnaire on headache symptoms in order to determine the prevalence of migraine. Patients were divided into four groups (ulcer-like dyspepsia, reflux-like dyspepsia, dysmotility-like dyspepsia, only nausea and/or vomiting). Age-matched blood donors were given the same questionnaires and served as controls.

RESULTS

A total of 378 patients (mean age 40 +/- 11, 52 % men) and 310 controls (mean age 39 +/- 11, 56 % men) were enrolled. No differences were observed between the two groups in the prevalence of migraine (15 % vs. 11 %; P = 0.12). A higher prevalence of migraine was found among women in both groups (P < 0.006). In patients with reflux-like and ulcer-like dyspepsia, the prevalence of migraine did not differ from that in the control individuals (8 % and 7 %, respectively), whereas a higher prevalence of migraine was noted in patients with dysmotility-like dyspepsia (23 %; P < 0.02 vs. controls, those with ulcer-like dyspepsia and those with reflux-like dyspepsia) and in patients with nausea and/or vomiting alone (53 %; P < 0.002 vs. all other groups). The multivariate analysis confirmed that the symptom pattern and sex were the only variables independently associated with migraine.

CONCLUSIONS

A diagnosis of migraine should be considered in young patients referred for upper gastrointestinal endoscopy due to nausea and/or vomiting or for dysmotility-like dyspepsia.

Ischemic colitis associated with rofecoxib

Rofecoxib is a selective cyclooxygenase-2 inhibitor that has been approved for the treatment of osteoarthritis and management of acute pain. Recent debate has emerged regarding the prothrombotic potential and the cardiovascular safety of this new drug, especially at doses greater than 25mg. We describe two extensively investigated cases of self-limited ischemic colitis in patients who were briefly treated with 50mg rofecoxib daily for acute pain. In both cases, the onset of symptoms correlated temporally with rofecoxib use and symptoms abated with drug discontinuation. There was no evidence of other possible causes of colon ischemia. A causal relationship between the start of rofecoxib treatment and the colon ischemia cannot be definitely established on the basis of the evidence, but the temporal relationship is striking and the pathophysiological rationale could be founded.

Viral clearance in HCV viraemic patients with normal alanine aminotransferase after combination therapy: a controlled, open-labelled study

BACKGROUND

In patients with chronic hepatitis C virus infection and persistently normal alanine aminotransferase levels, liver fibrosis has been reported in 0-22% of cases and advanced liver disease in 5-10% of cases.

AIM

To determine whether patients with persistently normal alanine aminotransferase levels clear infection after anti-viral therapy at equal or different rates from infected patients with raised alanine aminotransferase levels.

METHODS

Thirty-five hepatitis C virus RNA-positive patients with fibrosis at liver histology (Group 1) were matched for genotype, sex, age and histology with patients with raised alanine aminotransferase levels (Group 2). Both groups were treated with 3 MU interferon-alpha2b plus ribavirin (1000-1200 mg) for 12 months.

RESULTS

End-of-therapy response was achieved in 71.4%[95% confidence interval (CI), 56.4-86.3] of patients in Group 1 and in 52.3% (95% CI, 42.8-61.9) of those in Group 2 (P = 0.04). At week 72, 22 patients (62.8%; 95% CI, 46.8-78.1) in Group 1 and 50 patients (47.5%; 95% CI, 38.0-57.1) in Group 2 showed a sustained virological response (P = 0.11). Non-1 genotype was the only independent predictor of sustained response (P = 0.002), with an odds ratio of 3.45 (95% CI, 1.58-7.50). At month 3 of therapy, the positive predictive values for non-response were 100% and 96% in Groups 1 and 2, respectively.

CONCLUSIONS

Interferon and ribavirin induce comparable sustained virological response in patients with persistently normal or raised alanine aminotransferase levels. Stage 1 fibrosis, rather than alanine aminotransferase levels, may be the criterion on which to decide whether or not to treat patients with persistently normal alanine aminotransferase levels.

A multi-centre North Italian prospective survey on some quality parameters in lower gastrointestinal endoscopy

BACKGROUND AND AIM

To record prospectively, in a multi-centre survey, the adherence to some quality parameters of lower digestive endoscopy in everyday practice, focusing in particular on sedation and monitoring; choice of extension of endoscopic examination by the operator and relative performance in intubation of the caecum; behaviour, in some particular clinical circumstances, such as fresh haematochezia, screening and surveillance situations, functional symptoms, management of polyps.

PATIENTS AND METHODS

Twenty-five centres located in Lombardia, Italy took part in the study; the duration of the survey was 2 weeks. 1,406 consecutive cases were recorded.

RESULTS

The main indications to colonoscopy were fresh haematochezia (21%). abdominal pain (11.7%) and surveillance after surgery for tumours or endoscopic polyp removal (24.3%). Screening examinations accounted for 7.1% of all examinations. Conscious sedation was administered in 63.9% of patients; pulse oxymetry and cardiac frequency monitoring was used in 44.2% of cases. Total colonoscopy was planned in 84.2% of cases; the actual rate of intubation of the caecum in the cases submitted to the procedure was 84.1%. Normal results were obtained in 24.3%. In 24.3% of patients, one or more polyps were identified; 84.2% of these were removed during the first examination. Four complications (accounting for 0.28% of cases) were recorded, all after polypectomy and all successfully treated conservetively.

CONCLUSIONS

The present study has shown that some attitudes in lower digestive endoscopy are sub-optimal: in particular, screening examinations are still infrequent; conscious sedation and monitoring have probably been used too rarely; intubation of the caecum was achieved in <90% of cases; the endoscopic removal of many polyps has been delayed for unexplained reasons. On the other hand, timing of surveillance after surgery for tumours or endoscopic removal of polyps has, overall, been adequate; the rate of normal examinations and the rate of complications have been satisfactorily low.

Virtual colonoscopy

Computed axial colonography, usually called virtual colonoscopy, is a new diagnostic method potentially useful for investigating polyps and tumors of the colon and rectum. It uses spiral axial tomography data to build up images similar to those given by conventional colonoscopy, offering advantages in that it causes no adverse reactions, and is accepted well by patients, who do not need to be sedated. Reports to date show its sensitivity and specificity vary in identifying polyps in the colon, and there are still many problems with the new method, such as its cost, its learning curve, the identification of flat lesions, and detection of extracolonic abnormalities. There is a pressing need to establish the accuracy and cost-effectiveness of virtual colonoscopy as a screening method for colorectal tumors, and for post-polypectomy surveillance.

Diagnostic yield of open access colonoscopy according to appropriateness

BACKGROUND

Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. Evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this study was to assess the appropriate use of colonoscopy in an open-access system and to establish the yield of diagnostic information relevant to patient care.

METHODS

Overall, 1123 consecutive patients referred for open-access colonoscopy were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between the appropriate use of colonoscopy and the presence of relevant endoscopic findings.

RESULTS

The rate of colonoscopies "generally not indicated" according to ASGE guidelines was 29% (39% for primary care physicians and 23% for specialists; p < 0.0001). A relevant endoscopic finding was detected in 338 examinations (35%). The diagnostic yield was significantly higher for "generally indicated" colonoscopies (43%) compared with "generally not indicated" procedures (16%) (p < 0.001).

CONCLUSIONS

Although the rate of inappropriate use of colonoscopy was high, open-access colonoscopy was effective in detecting neoplastic lesions. Because most of these were detected during examinations performed for appropriate indications, the appropriateness of the indication emerges as crucial to the cost-effectiveness of an open-access system.

Routine versus "on demand" sedation and analgesia for colonoscopy: a prospective randomized controlled trial

BACKGROUND

The safety and tolerance of routine sedation and analgesia versus "on demand" sedation were compared in patients undergoing colonoscopy.

METHODS

Two hundred forty-nine outpatients were randomly assigned to one of two groups. Group A (n = 125) received midazolam, 0.07 mg/kg intravenously plus meperidine, 0.77 mg/kg intravenously immediately preceding the colonoscope insertion. Group B (n = 124) received the same medication upon request during the procedure. Tolerance was assessed 24 hours later by phone interview performed by a nurse blinded to the medication regimen administered.

RESULTS

Eighty-three patients (66%) in Group B required sedation during colonoscopy. Among men in Group B more than 60 years of age, only 23% required sedation. The proportion of patients reporting moderate or severe pain (34% vs. 12.1%, p < 0.001) and of those stating they would not be willing to undergo colonoscopy again in the future (22% vs. 9.7%, p < 0.005) was significantly higher in the "on demand" sedation group. By multivariate analysis the randomization group was the single variable independently associated with both such outcomes. The frequency of side effects was similar in the two groups.

CONCLUSIONS

Administration of sedative and analgesic drugs routinely before colonoscopy is superior to "on demand" sedation in terms of tolerance and is not associated with an increase in side effects.

Routine versus "on demand" sedation and analgesia for colonoscopy: a prospective randomized controlled trial

BACKGROUND

The safety and tolerance of routine sedation and analgesia versus "on demand" sedation were compared in patients undergoing colonoscopy.

METHODS

Two hundred forty-nine outpatients were randomly assigned to one of two groups. Group A (n = 125) received midazolam, 0.07 mg/kg intravenously plus meperidine, 0.77 mg/kg intravenously immediately preceding the colonoscope insertion. Group B (n = 124) received the same medication upon request during the procedure. Tolerance was assessed 24 hours later by phone interview performed by a nurse blinded to the medication regimen administered.

RESULTS

Eighty-three patients (66%) in Group B required sedation during colonoscopy. Among men in Group B more than 60 years of age, only 23% required sedation. The proportion of patients reporting moderate or severe pain (34% vs. 12.1%, p < 0.001) and of those stating they would not be willing to undergo colonoscopy again in the future (22% vs. 9.7%, p < 0.005) was significantly higher in the "on demand" sedation group. By multivariate analysis the randomization group was the single variable independently associated with both such outcomes. The frequency of side effects was similar in the two groups.

CONCLUSIONS

Administration of sedative and analgesic drugs routinely before colonoscopy is superior to "on demand" sedation in terms of tolerance and is not associated with an increase in side effects.

Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial

BACKGROUND

Pharmacological prophylaxis of post-ERCP pancreatitis is costly and not useful in most non-selected patients, in whom the incidence of pancreatitis is 5% or less. However, it could be useful and probably cost-effective, in patients at high risk for this complication, where the post-procedure pancreatitis rate is 10% and more.

AIM

To assess the efficacy of octreotide in reducing the incidence and severity of post-ERCP pancreatitis and procedure-related hospital stay, in subjects with known patient-related risk factors.

METHODS

A total of 120 patients were randomly allocated to receive octreotide or not, in a multicentre, randomized, controlled trial. The drug was given subcutaneously, 200 microg t.d.s., starting 24 h before the ERCP procedure, in patients with either sphincter of Oddi dysfunction, or a history of relapsing pancreatitis or post-ERCP pancreatitis, or who were aged under 35 years, or who had a small common bile duct diameter (< 8 mm).

RESULTS

A total of 114 patients (58 in the octreotide group and 56 in the control group) completed the trial. Post-procedure pancreatitis occurred in seven octreotide-treated patients (12.0%) and eight controls (14.3%). The two groups showed no significant differences in the incidence or severity of pancreatitis. Twenty-four hours after the procedure, severe hyperamylasemia (more than five times the upper normal limit) without pancreatic-like pain was recorded in three octreotide-treated patients (5.2%) and six controls (10.7%), the difference being not significant.

CONCLUSION

Twenty-four-hour prophylaxis with octreotide proved ineffective in preventing post-ERCP pancreatitis and in avoiding 24-h severe hyperamylasemia in high-risk patients.

Helicobacter pylori seroprevalence in hepatitis C virus positive patients with cirrhosis. The Como cross-sectional study

BACKGROUND

Liver cirrhosis is a significant cause of death in Italy and one of the most frequent causes of hospitalization. Acute peptic ulcer and upper gastrointestinal bleeding reportedly occur in over 15% of cirrhotic patients. Since Helicobacter pylori (H. pylori) infection strongly correlates with peptic ulcer, we sought to ascertain the seroprevalence of H. pylori infection in cirrhotic patients.

METHODS

In a cross-sectional study, we examined 52 consecutive patients (31 female and 21 male, age range 54-82, mean 68.7 years) suffering from hepatitis C virus (HCV)-related cirrhosis attending the Unit of Gastroenterology of the Valduce Hospital of Como (Italy).

RESULTS

The prevalence of antibodies against H. pylori was 86.5% (45/52) in the cirrhotics. Of female patients 28/31 (90.3%) were seropositive as compared to 17 of 21 (80.9%) of male patients.

CONCLUSIONS

The very high prevalence of H. pylori infection may explain the frequent occurrence of gastroduodenal ulcer in cirrhotic patients.

Hepatocyte proliferation and risk of hepatocellular carcinoma in cirrhotic patients

OBJECTIVES

High hepatocyte proliferation has been recently proposed as a risk factor for the development of hepatocellular carcinoma (HCC). The aim of this study was to assess whether hepatocyte proliferation is an independent risk factor for HCC when considered together with clinical and demographic characteristics.

METHODS

We retrospectively evaluated 97 consecutive patients with a histological diagnosis of cirrhosis and preserved liver function, enrolled in a surveillance program for early diagnosis of HCC. Hepatocyte proliferation was evaluated by flow-cytometric analysis in liver samples collected at the time of histological diagnosis of cirrhosis. All patients were followed with abdominal US and serum alpha-fetoprotein (AFP) assays every 6 months.

RESULTS

During a mean follow-up of 53 months (range, 12-120 months), 12 patients developed HCC, giving an annual incidence of 2.8%. The mean S-phase fraction was 2.5%+/-1.6 in patients who developed HCC and 0.9%+/-0.6 in those who did not (p < 0.0001). By univariate analysis, S-phase fraction 1.8% or higher and AFP higher than 20 ng/ml were the only two variables significantly correlated with the development of HCC (p < 0.0001, p < 0.0001). Multivariate analysis found that both variables were independently associated with HCC development (p < 0.003 and p < 0.005, respectively), with hazard ratios of 8.0 and 7.3 (confidence intervals, 2.1-31.2 and 1.8-29.2). Among patients with high AFP and/or high S-phase fraction, 11 (39%) developed HCC, compared with only one (1%) with a low S-phase fraction and normal AFP, corresponding to HCC yearly incidences of 9.5% and 0.3% (p < 0.00009).

CONCLUSIONS

Patients with high S-phase fraction and/or above-normal serum AFP are at higher risk of developing HCC and should be offered a close surveillance program.

Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

OBJECTIVES

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study.

METHODS

One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists.

RESULTS

Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (< or = 60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater.

CONCLUSIONS

The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.

Complications of diagnostic and therapeutic ERCP: a prospective multicenter study

OBJECTIVES

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP/ES) can be associated with unforeseeable complications, especially when involving postprocedural pancreatitis. The aim of the study was to investigate risk factors for complications of ERCP/ES in a prospective multicentric study.

METHODS

One hundred fifty variables were prospectively collected at time of ERCP/ES and before hospital discharge over 2 years, in consecutive patients undergoing the procedure in nine endoscopic units in the Lombardy region of Italy. More than 150 ERCPs were performed in each center per year by a single operator or by a team of no more than three endoscopists.

RESULTS

Two thousand four hundred sixty-two procedures were performed; 18 patients were discharged because the papilla of Vater was not reached (duodenal obstruction, previous gastrectomy, etc.). Two thousand four hundred forty-four procedures were considered in 2103 patients. Overall complications occurred in 121 patients (4.95% of cases): pancreatitis in 44 patients (1.8%), hemorrhage in 30 (1.13%), cholangitis in 14 (0.57%), perforation during ES in 14 (0.57%), and others in 14 (0.57%); deaths occurred in three patients (0.12%). In multivariate analysis, the following were significant risk factors: a) for pancreatitis, age (< or = 60 yr), use of precutting technique, and failed clearing of biliary stones, and b) for hemorrhage, precut sphincterotomy and obstruction of the orifice of the papilla of Vater.

CONCLUSIONS

The results of our study further contribute to the assessment of risk factors for complications related to ERCP/ES. It is crucial to identify high risk patients to reduce complications of the procedures.

Computed tomographic colonography and conventional colonoscopy for colon diseases: a prospective, blinded study

OBJECTIVES

Computed tomographic (CT) colonography or virtual colonoscopy is a new diagnostic method for the colon and rectum, developed on the basis of spiral computed axial tomography and employing virtual reality technology. The aim of this study was to determine the sensitivity, specificity, and diagnostic accuracy of CT colonography compared with colonoscopy in a prospective, blinded study in one single institution in Italy.

METHODS

Ninety-nine patients randomly selected among those attending the open-access endoscopy unit for diagnostic colonoscopy underwent colonoscopy and spiral CT. The images obtained were transmitted to generate the virtual colonoscopy pictures. A supervisor compared the results with the findings of conventional colonoscopy.

RESULTS

CT colonography diagnosed seven of eight tumors, one being missed because the patient had been inadequately prepared. In 28 patients, CT colonography identified 26 polyps of 45 (57.8% sensitivity, 92.6% specificity, 86.7% positive predictive value), regardless of their size. The sensitivity in detecting colonic polyps was 31.8% (7/22) in the first 25 cases and 91.6% (11/12) in the last 20 patients. CT colonography missed one flat adenoma, some angioectasias and colonic lesions because of portal hypertension in one patient, Crohn's disease ulcers in two patients, and ulcerative colitis lesions in three.

CONCLUSIONS

CT colonography shows poor sensitivity for identifying colonic polyps and does not always detect neoplastic lesions. Flat lesions are impossible to see by this method.

The ASGE guidelines for the appropriate use of colonoscopy in an open access system

BACKGROUND

Appropriateness of indications is essential to the rational utilization of resources. The aim of this study was to evaluate the appropriate use of colonoscopy in an open access system and to assess whether the American Society for Gastrointestinal Endoscopy (ASGE) guidelines are useful in clinical practice.

METHODS

The indication for colonoscopy was assessed on 3000 consecutive examinations performed at 7 institutions.

RESULTS

The rate of colonoscopies "generally not indicated" according to the ASGE guidelines was 24.5% for outpatients and 15.5% for inpatients; the rates of examinations performed for an indication not listed in the ASGE guidelines were 12% and 20.1%, respectively. Generally not indicated colonoscopies were significantly less frequent for procedures requested by gastroenterologists or family physicians than those requested by other specialists, but were similar. Most generally not indicated examinations requested by gastroenterologists were for routine follow-up of patients with inflammatory bowel disease; when these patients were excluded, the rate of generally not indicated endoscopies requested by gastroenterologists was also lower than the corresponding rate for examinations requested by family physicians.

CONCLUSIONS

In Italy, the rate of colonoscopies performed for generally not indicated reasons is high, particularly among examinations not requested by a gastroenterologist. Many colonoscopies are performed for indications not listed in the ASGE guidelines.

Reevaluation of duodenal endoscopic markers in the diagnosis of celiac disease

BACKGROUND

Loss or reduction of duodenal folds, scalloping of Kerkring folds and a micronodular or mosaic duodenal mucosal pattern have been described in celiac disease (CD), endoscopic findings that are considered reliable in the diagnosis of this disorder. However, most data have been obtained in patients with suspected or certain disease. We assessed the accuracy of the above markers in diagnosing CD in patients with nonulcer dyspepsia.

METHODS

In this prospective study, in 705 consecutive dyspeptic patients (284 men, 421 women, mean age 51 +/- SD 15.8 years) duodenal biopsies were obtained only in the presence of typical endoscopic markers, whereas in another 517 (207 men, 310 women, mean age 49.9 +/- SD 16 years) duodenal biopsies were done irrespective of macroscopic findings. CD was diagnosed histologically and on the basis of positive antiendomysium antibody.

RESULTS

Endoscopic markers were found in 4 patients of the first group but CD was ruled out. In the second group 5 patients had an endoscopic pattern that was consistent and CD was diagnosed in 3, whereas 3 others with normal endoscopic findings were eventually diagnosed as having CD. Endoscopic markers had a sensitivity of 50% and a specificity of 99.6% (95% CI [11.8, 88.2 and 98.6, 99.9], respectively) with positive and negative predictive values of 60% and 99.4%, respectively.

CONCLUSION

The accuracy of endoscopic markers in the diagnosis of CD must be reevaluated in relation to the characteristics of the population studied.

Increased prevalence of celiac disease in patients with dyspepsia

BACKGROUND

Although 30% to 40% of patients with celiac disease (CD) (which affects 1 in 200 individuals) have dyspeptic symptoms, there is a lack o data concerning the prevalence of CD in patients with dyspepsia.

METHODS

In this prospective series, we enrolled all consecutive outpatients undergoing endoscopy of the upper gastrointestinal tract for dyspepsia at our centers between January and June 1998. The exclusion criteria were age younger than 12 years, workup or follow-up of an already known disease of the gastrointestinal tract, suspected CD, malabsorption, and/or iron-deficiency anemia.

RESULTS

Of the 3019 patients who were evaluated, 517 (17%) were eligible for the study. Endoscopic findings suggested CD in 5 cases. Celiac disease was histologically diagnosed in 6 patients (5 women and 1 man; mean age, 31.3 years; age range, 20-46 years), 3 of whom had a normal endoscopic pattern and 3 of whom had an endoscopic pattern that was consistent with CD. In the patients with histologically diagnosed CD, antiendomysium antibody positivity supported the diagnosis. The relative risk for CD was 2.32 (95% confidence interval, 1.06-5.07) in comparison with the general population and higher among females (3.22; 95% confidence interval, 1.37-7.56).

CONCLUSIONS

The present results indicate that the prevalence of CD in patients with dyspepsia is twice that of the general population. Thus, serological screening for CD should be considered in the early workup of these patients to allow diagnosis and treatment of an eminently treatable disease.

Segmental colitis associated with diverticula: a prospective study. Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII)

OBJECTIVE

Little is known about the clinical features and natural history of segmental colitis associated with diverticula. Our aim was to evaluate the incidence of segmental colitis associated with diverticula in patients undergoing colonoscopy, its clinical picture, and its outcome.

METHODS

This was a multicenter, prospective study. Patients with inflammatory bowel disease (IBD)-like lesions limited to colonic segments with diverticula were enrolled. Patients were treated with oral and topical 5-aminosalicylic (5-ASA) until remission was achieved; clinical and endoscopic follow-up was planned at 6 wk and 12 months.

RESULTS

A total of 5457 consecutive colonoscopies were recorded at five participating institutions; 20 patients (0.36%) met the endoscopic criteria for segmental colitis associated with diverticula. All had lesions in the left colon, and one also had lesions in the right colon. In six cases, a specific diagnosis was made thereafter. The remaining 14 patients (0.25% of colonoscopies; eight men; age range, 49-80 yr) were in clinical and endoscopic remission at the first follow-up visit. At onset, 13/14 had hematochezia, seven had diarrhea, and five had abdominal pain; only one had weight loss. No subject had fever. In all but one case, blood chemistries were normal. Five patients had had similar symptoms previously. Thirteen of 14 patients were in clinical and endoscopic remission at 12 months.

CONCLUSIONS

This endoscopic picture is not an exceptional finding. Hematochezia was the main clinical feature, and no relation with gender, age, or smoking habit was found. Blood chemistries were generally normal and the rectum was spared. The histological features were not diagnostic and most patients did not complain of any abdominal symptoms 12 months after enrollment.

Hepatitis C virus genotypes in a non-cirrhotic Italian population with chronic hepatitis C: correlation with clinical, virological and histological parameters. Results of a prospective multicentre study

To identify correlations between the distribution of hepatitis C virus (HCV) genotypes and demographic, pathological and virological parameters of HCV-infected patients, we prospectively recruited 650 patients with biopsy-proven chronic hepatitis C without histological aspects of cirrhosis; none had been treated with antiviral therapy. Data regarding gender, age, mode of HCV transmission, alanine aminotransferase (ALT) and HCV RNA levels, immunoglobulin M (IgM) anticore values, liver histology and histological activity were obtained from each patient and correlated on multivariate analysis with infecting HCV genotype. Fifty-five per cent of the patients were infected with HCV genotype 1, 20% with HCV genotype 2, 18% with HCV genotype 3 and 7% with HCV genotype 4. Non-transfusional HCV transmission, low ALT levels, IgM anticore reactivity and a low histological grading score were independent variables associated with HCV genotype 1. Older age, female gender, post-transfusional transmission and a high histological grading score were related to HCV genotype 2, whilst younger age, history of current/previous drug abuse, high ALT values, low IgM anticore reactivity and high viraemic levels were associated with HCV genotype 3. History of illicit use of intravenous drugs and low HCV RNA levels were the only independent variables correlated with HCV genotype 4. Genotype 1 remains predominant in Italy but the prevalence of HCV genotypes is changing in relation to age and mode of transmission: Italian patients with HCV genotype 3 are younger and exhibit higher levels of ALT and HCV RNA than patients with other genotypes.

Seven-day triple therapy with ranitidine bismuth citrate or omeprazole and two antibiotics for eradication of Helicobacter pylori in duodenal ulcer: a multicentre, randomized, single-blind study

AIM

To investigate the efficacy of a 1-week triple therapy with amoxycillin, clarithromycin, and omeprazole or ranitidine bismuth citrate (RBC) in curing Helicobacter pylori infection and healing duodenal ulcers.

METHODS

One hundred and ninety-two consecutive out-patients with duodenal ulcer, in whom H. pylori infection was confirmed by histology and a urease biopsy test, were randomly assigned to a 1-week treatment with either 400 mg b.d. ranitidine bismuth citrate (RAC group) or 20 mg omeprazole b.d. (OAC group) in combination with 1 g amoxycillin b.d. and 500 mg clarithromycin b.d.

RESULTS

Eradication of H. pylori was successful in 77% (per protocol) and 61% (intention-to-treat) of the patients in the RAC group and in 79% (per protocol) and 70% (intention-to-treat) of those in the OAC group. The difference was not significant. Per protocol analysis showed ulcers were healed in 97% of patients in the RAC group and 96% in the OAC group. Adverse effects were seen in four patients in each group: they caused discontinuation of the therapy in one patient of the OAC group.

CONCLUSIONS

Eradication rates obtained in this study were lower than those expected on the basis of previously reported studies. The two 1-week treatment regimens were equally effective in healing H. pylori associated duodenal ulcer disease.

Prospective randomized trial comparing Tannenbaum Teflon and standard polyethylene stents in distal malignant biliary stenosis

BACKGROUND

Our aim was to compare the clinical efficacy of the Tannenbaum (TB) biliary prostheses, a recently designed Teflon stent without side holes, with the Cotton-Huibregtse (CH) polyethylene stent.

METHODS

Fifty-seven patients (26 men, mean age 75.5 years) with unresectable malignant tumors and distal biliary stenosis were included (38 pancreatic head cancer, 17 cholangiocarcinoma, 2 ampullary cancer). Patients were prospectively randomized to have a 10F, 7 cm long TB (29 patients) or CH (28 patients) stent inserted endoscopically. Four patients (2 TB and 2 CH) were excluded: 3 because of the failure of stent insertion and 1 because of a protocol violation. The patients were evaluated clinically and, if necessary, with biochemical tests every month until death or until they needed surgery for symptoms of gastric outlet obstruction. When occlusion or dislocation occurred, the stent was replaced with one of the same type. Cumulative stent patency and patient survival were estimated with the Kaplan-Meier life-table analysis and compared by log-rank chi-square test.

RESULTS

The two groups were comparable in mean age, gender, and diagnosis. The patients were followed for a mean of 145.5 days (range 24 to 613); by the end of the study 47 patients (81%) had died or developed symptoms of gastric outlet obstruction. Median survival was 88 days (range 24 to 613) in the TB group and 75.6 days (23 to 486) in the CH group. Stent exchange (occlusion 16, dislocation 3) was necessary for 5 patients in the TB group and 7 in the CH group. No statistical difference was found on comparing the mean duration of function of the first, second, and third stents (analysis of variance, p = 0.80). The median duration of stent function was 96 days (range 11 to 613) in the TB group and 75.5 days (range 23 to 323) in the CH group. No significant difference was found in either survival time (p = 0.48) or stent patency (p = 0.12).

CONCLUSION

This study found no significant advantage of the Tannenbaum prostheses over the standard polyethylene stent in the palliation for patients with distal malignant biliary stenosis with regard to survival or length of stent patency.

Quality assurance and colonoscopy

BACKGROUND AND STUDY AIMS

Little is known concerning the usefulness and feasibility of quality assurance programs in gastrointestinal departments. The aim of this study was to identify the indicators of quality in colonoscopy, to check their use in clinical practice, and to identify their threshold values.

MATERIALS AND METHODS

A prospective study was performed in four endoscopic units. In the first phase, a questionnaire was used to identify the indicators that were considered important and easy to record; in the second phase, the selected items were prospectively recorded.

RESULTS

Data from 603 colonoscopies were evaluated. The selected indicators were: rate of cecal intubation, rate of examinations with normal findings, rates of complications, appropriateness of indications, use of a washing machine for disinfection, duration of the disinfection procedure, rate of procedures repeated due to poor colon cleansing, rate of operative procedures, length of waiting time, rate of procedures performed for follow-up of known disease, experience of the operator, and rate of procedures performed with the patient under conscious sedation. A striking difference emerged between the technical standards at three centers, which were fairly good, and the standard at the fourth center, which was less satisfactory. The length of the waiting time was high in all centers, as well as the rate of examinations conducted with an inappropriate indication. The rate of procedures performed under conscious sedation varied widely between the centers.

CONCLUSIONS

The study of the indicators of quality of colonoscopy is feasible and easy to perform in clinical practice, and can be useful for quality assurance programs.

Acute self-limiting jejunitis as the first manifestation of microscopic polyangiitis associated with Sjogren's disease: report of one case and review of the literature

We report a case of acute self-limiting ulcerative jejunitis of unknown aetiology in a 72-year-old female patient in which a subsequent diagnosis of microscopic polyangiitis and Sjogren's syndrome was made. All known causes of jejunal ulceration and inflammation were excluded. Previously reported cases of acute self-limiting jejunitis are reviewed and the possibility that acute jejunitis in this patient had been the first manifestation of systemic vasculitis is discussed.

[Topical beclomethasone dipropionate (BDP) in intestinal inflammatory diseases: the results of a multicentre trial]

The authors assessed the efficacy and tolerability of BDP in an open protocol using rectal enemas and suppositories and in a double-blind protocol vs mesalazine using rectal enemas. A total of 47 patients suffering from ulcerous rectocolitis were enrolled in the study and treated for 42 days while undergoing endoscopic, histologic and clinical controls. In conclusion, the authors affirm that BDP may represent a useful new therapeutic instrument in the treatment of slight to moderately severe forms of inflammatory intestinal disease.

Granulomatous gastritis presenting as gastric outlet obstruction: a case report

The clinico-pathologic entity of idiopathic granulomatous gastritis is a form of granulomatous gastritis, distinct from Crohn's disease, sarcoidosis, infections, foreign bodies, malignancy or vasculitis. The case of a 61-year-old female is described who was admitted on account of progressive weight loss, diffuse abdominal pains, post-prandial vomiting. Gastroscopy revealed a pyloric stenosis managed surgically. Pathological examination of the resected stomach showed numerous non-caseating granulomas in the lamina propria. No definite aetiological factor could be detected. A diagnosis of idiopathic granulomatous gastritis was made. She remains well 5 years later and has not developed regional enteritis, sarcoidosis, or any other generalized diseases.

[Dyspepsia: a reappraisal problem]

Dyspepsia is a major public problem. It occurs in 25-40% of the general population negatively affecting the quality of life. 2-3% of the patients visited by the GP and up to 30% of those visited by the gastroenterologist have dyspepsia. Both diagnostic procedure and therapy are expensive. Definition, aetiology and pathogenesis of the disorder are not clear cut. The aim of this review is to outline the main trends in the relevant area of the clinical practice. The authors choose the most comprehensive definition among the thirty of the medical literature. To rule out, the most commonly and frequently wrong opinions risk factors have been examined. The authors distinguished between symptoms of function and organic dyspepsia and those of Irritable Bowel Syndrome and Gastro-Esophageal Reflux Disease, which often overlap and make difficult the management of the patient. The aetiology and pathogenesis have also been discussed, with particular emphasis on Hp. Advantages and drawbacks of different diagnostic approaches have been investigated. An age and symptoms related approach of the cases with dyspepsia is proposed, which allows to manage the patient without the necessity of invasive procedures. It is finally suggested that are cases which can be managed by the GP and others for whom the gastroenterologist intervention is mandatory.

A simplified urea breath test for the diagnosis of Helicobacter pylori infection using the LARA System. Laser Assisted Ratio Analyzer

Helicobacter pylori, one of the most prevalent human pathogens, is associated with chronic gastritis, peptic ulcer disease, and possibly gastric cancer and primary gastric lymphoma. The need to treat these patients has necessitated the development of improved methods to diagnose H. pylori infection. We present the preliminary assessment of a 13C-urea breath test (UBT) in which the expired 13CO2 is detected in a rapid, simple, inexpensive way by the LARA (Laser Assisted Ratio Analyzer) System (Alimenterics, Inc., Morris Plains, NJ). Eighty-seven consecutive patients, examined for upper gastrointestinal symptoms, underwent endoscopy. H. pylori infection was established by antral biopsies and a rapid urease test (CLOtest). The UBT was performed between 2 and 24 hours after endoscopy. Of the 84 analyzable patients, 70 were found to be H. pylori-positive either by histology or by CLOtest. All 70 were positive by the LARA UBT, yielding a sensitivity of 100%. Fourteen patients were negative for H. pylori by histology and the CLOtest. Of these, 12 were negative by the LARA UBT and 2 were positive, yielding a specificity of 85.7%; because of the limitations of H. pylori detection by histology or urease assays, however, the specificity of the UBT may have been underestimated. Our study demonstrates the feasibility of a nonradioactive, rapid UBT based on the LARA system and suggests the need for its more detailed evaluation.

Comparison of omeprazole and lansoprazole in short-term triple therapy for Helicobacter pylori infection

BACKGROUND

Effective anti-Helicobacter pylori therapies with few side-effects are needed.

AIM

To study the effectiveness of short-term triple therapy with amoxycillin, clarithromycin and either omeprazole or lansoprazole for eradication and healing of peptic ulcers.

METHODS

Patients with gastric or duodenal ulcers received amoxycillin (1 g b.d.), clarithromycin (500 mg b.d.) and lansoprazole (30 mg b.d.) (LAC) or omeprazole (20 mg b.d.) (OAC) for 7 days. Endoscopic examinations were performed before treatment and at least 4 weeks after completion of therapy. H. pylori status was confirmed by rapid urease test and histological examination (Giemsa stain) from gastric biopsies taken from both the antrum and the body.

RESULTS

A total of 356 patients were randomized in this single-blind study. On a per protocol basis, H. pylori was eradicated in 134 of 170 patients (79%) in the lansoprazole group and in 105 of 146 (72%) in the omeprazole group (P = 0.189); and in intention-to-treat analysis 72% and 62%, respectively (P = 0.043). Healing of the ulcers was obtained in 166 of 186 (98%), and in 139 of 146 patients (95%), respectively (P = 0.357). Side-effects occurred in two patients in the LAC group and in six in the OAC group B (four stopped therapy).

CONCLUSIONS

This study has shown that the two regimens are highly effective in healing duodenal ulcers and are well tolerated. Neither treatment achieves the ideal cure rate for H. pylori. Lansoprazole does not appear to have a significant advantage over omeprazole either in ulcer healing or in H. pylori eradication.