Nonulcer dyspepsia and Helicobacter pylori, with comment on posteradication symptoms

In two London hospitals during five months in 1997, among patients referred for esophago-gastroduodenoscopy, 250 complained of dyspepsia for more than two days per week. Of these, 190 gave informed consent to enter a study of H. pylori infection in nonulcer dyspepsia, but only 42 (22%) were found to have H. pylori infection without a peptic ulcer. At the time of this interim report, of these patients, 26 had been treated with omeprazole, amoxicillin, and clarithromycin, four weeks had elapsed since treatment, and H. pylori had been eradicated. Of these 26 patients, 15 (58%) had lost nearly all their symptoms. This is the first report of loss of symptoms in patients with nonulcer dyspepsia after treatment with omeprazole, amoxicillin and clarithromycin with early follow-up after four weeks. However, this was not a placebo-controlled study and the number of patients was small, so it is not possible to conclude whether H. pylori could be one cause of nonulcer dyspepsia. The increasing incidence of posteradication esophagitis is discussed as is the possible need for more sophisticated management of nonulcer dyspepsia.

Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey

Since there are now several ways to treat symptomatic gallstone disease, one is able to select treatment on the basis of the patient's comfort, the practicability, effectiveness, and side effects of the technique, and the relative costs. In order to assess the present status of contact dissolution with methyl tert-butyl ether with regard to these aspects, the present enquiry reports the data of 21 European hospitals. Eight hundred three patients were selected for contact litholysis of cholesterol gallbladder stones using methyl tert-butyl ether. Percutaneous transhepatic puncture of the gallbladder was performed under x-ray or ultrasound guidance. Dissolution rate, side effects, and treatment times of 268 patients from one single center were compared to those of 535 patients from the other 20 centers. Two hundred sixty-four patients were followed for five years to assess stone recurrence. Physicians were asked how they assessed the expenditure of the method, the discomfort to the patients, and the staffing situation. Patients were asked to indicate their acceptance on an analog scale. Puncture was successful in 761 (94.8%) patients. Prophylactic administration of antibiotics was not necessary. Stones were dissolved in 724 (95.1%) patients. In 315 (43.5%) sludge remained in the gallbladder. The most severe complication was bile leakage, which led 12 (1.6%) patients to have elective cholecystectomy. Toxic injuries due to the ether were not reported. Method-related lethality amounted to 0%, 30-day-lethality to 0.4%. Stone recurrence rate was about 40% in solitary stones and about 70% in multiple stones over five years. Patients with multiple stones developed recurrent stones almost twice as often as those with solitary stones. The probability of stone recurrence in patients with sludge in the gallbladder after catheter removal was not statistically significantly different from those without sludge. Seventy to 90% of the centers found the puncture to be simple and not distressing for patients and the relation between expenditure and therapeutic success to be acceptable. The acceptance of contact litholysis by the patients was excellent. Contact litholysis when applied by an experienced team provides real advantages in the treatment of gallstone disease. The method is technically simple, well accepted by the patients, and can be easily applied in community hospitals. Contact litholysis may be of particular value in patients who are not suitable for anesthesia or surgery.

The impact of direct access endoscopy, Helicobacter pylori near patient testing and acid suppressants on the management of dyspepsia in general practice

Direct access endoscopy services, Helicobacter pylori infection and more effective acid suppression therapy have influenced the management of dyspepsia in the past decade. Three hundred and ten GPs in south London were surveyed via postal questionnaire to determine the impact of these factors on the management of dyspepsia in general practice. Ninety-one per cent of GPs prescribed simple antacids as initial treatment for simple dyspepsia and referred only if symptoms did not improve. When acid suppressants were used, 41% used H2 antagonists compared with 11% for proton pump inhibitors (p = 0.0001). Risk factors for underlying malignancy were the most frequent reason for hospital referral at first consultation. Long outpatient waiting times result in about 90% of GPs choosing direct access endoscopy as the route of referral for all patients with dyspepsia, while only 36% would refer patients with sinister symptoms to direct access endoscopy if waiting times were similar to that of outpatients. H. pylori near patient testing did not seem to influence the management of dyspepsia in general practice.

Prospective screening of dyspeptic patients by Helicobacter pylori serology

Helicobacter pylori infection is associated with 95% of duodenal ulcers and more than 80% of gastric ulcers. Several reports have indicated that screening for H pylori may avoid subsequent endoscopic examination. We screened 183 dyspeptic patients, aged under 45, by taking a history of sinister symptoms and regular use of non-steroidal anti-inflammatory drugs (NSAIDs), together with serological testing for H pylori. Endoscopy was performed on 113 patients, of whom 90 (49%) were seropositive, 14 (8%) had sinister symptoms, and 9 (5%) had used NSAIDs regularly. In 34 (19%) patients we detected peptic ulceration. The remaining 70 (38%) patients who were H pylori seronegative, had no sinister symptoms, and had not taken NSAIDs (screen-negative), did not undergo endoscopy but were returned to their primary care physician for treatment of symptoms. At subsequent reassessment (of the non-endoscoped group), symptom severity (p = 0.002), interference with life events (p = 0.01), and medication (p = 0.0002) were all significantly lower in the 6 months after screening than in the 6 month period before screening. Only three screen-negative patients were re-referred after screening but their endoscopic findings were normal. Thus, 67 (36%) endoscopies were avoided. When the non-endoscoped screen-negative patients were compared with a cohort of endoscoped screen-negative patients, the groups did not differ in terms of symptom severity (odds ratio 1.12, 95% CI 0.53-2.35, p = 0.77) or interference with life events (0.82, 0.38-1.76, p-0.61). However, medication use was significantly less (0.37, 0.17-0.80, p = 0.01) in those who did not have an endoscopy. Our study indicates that colonisation screening based on H pylori serology, a history of sinister symptoms, or a history of NSAID use was worthwhile in dyspeptic patients. We avoided 37% of endoscopies and reduced drug usage without disadvantaging those not endoscoped.

Use of a gamma-labeled bile acid (75SeHCAT) as a test of ileal function. Methods of improving accuracy

The object of the present study was to improve the accuracy of measurements of ileal function obtained by abdominal scanning and fecal counting after oral administration of the gamma-labeled bile acid 75seleno-homocholic acid-taurine (75SeHCAT), as current techniques do not distinguish between retention of the bile acid within the enterohepatic circulation from retention within the colon, and are also affected by incomplete stool collection when using the fecal method. We have therefore introduced the following modifications: (a) simultaneous ingestion of 51CrCl3 as a nonabsorbable correction marker for both the abdominal scanning and fecal counting methods; and (b) the use of 75SeHCAT counts over the gallbladder area on abdominal scanning, because these counts should be independent of colonic retention. We have studied 42 subjects, including 6 healthy controls, 6 ileal resection subjects, 15 ulcerative colitis patients, and 15 patients with unresected ileal Crohn's disease. Colonic retention (0%-68% per day) caused a variable overestimate of 75SeHCAT absorption. Corrected measurements of the fecal absorption index determined by a gamma-counter and of the abdominal absorption coefficient determined by a gamma-camera correlated well with each other (r = 0.92, p less than 0.0001), providing an internal validation of the 51CrCl3 modification. The fecal absorption index could also be determined from the carmine-rich stool collection of a single day, and this also correlated well with the abdominal absorption coefficient (r = 0.81, p less than 0.0001). Gallbladder scanning alone was simpler, involving only one isotope, but it correlated less well with the fecal absorption index than did the abdominal absorption coefficient (r = -0.64, p less than 0.001).