A239 PATIENT OUTCOMES AFTER ENDOSCOPIC STENT INSERTION FOR MALIGNANT BILIARY OBSTRUCTION: A QUALITY ASSURANCE STUDY

Background

Management of pancreaticobiliary malignancy is complex and multi-disciplinary. Decompression of malignant biliary obstruction (MBO) is preferentially achieved with endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement. This may improve the quality of life for patients with unresectable disease and improve outcomes in resectable/borderline-resectable disease.

Purpose

To assess quality outcomes in patients undergoing biliary stenting for MBO.

Method

This is a retrospective chart audit of patients referred to the University of Alberta Hospital (UAH) for suspected or confirmed MBO. The primary outcome was clinical success (reduction in bilirubin of >50% at 30 days). Secondary outcomes were technical success, type of stent used, need for re-intervention, adverse events (AEs), time from stent placement to surgery or cancer centre assessment, and survival.

Result(s)

Between January 2020 and June 2022, 222 patients (102 female, 46%) with a mean age of 70±1 years (range 34-93 years) underwent 290 ERCPs. The cause of MBO was pancreatic cancer in 130 (59%), cholangiocarcinoma in 32 (14%), ampullary cancer in 9 (4%), and others in 51 (23%).

Technical success for stent insertion on first ERCP was achieved in 180/222 patients (81%) with only brushings performed in 2. Of the 40 patients (18%) with unsuccessful ERCP, further success was achieved by repeat ERCP (8), percutaneous transhepatic drainage (PTC, 15), PTC with rendezvous ERCP (1), surgical decompression (3), and endoscopic ultrasound-guided biliary drainage (1). No biliary drainage was performed in 12 patients. Overall, ERCP with stent insertion was technically successful in 188/222 patients (85%).

A total of 233 biliary stents were inserted (38 plastic, 195 metal). Clinical success was achieved in 20/38 patients (53%) with plastic stents and 151/181 patients (83%) with metal stents (Χ2 17.4 p<0.05).

Adverse events were encountered in 33 patients (11%) with stent migration occurring in 8 (3%), cholangitis in 7 (2%), post-ERCP pancreatitis in 7 (2%), post-sphincterotomy bleeding in 4 (1%), and death in 2 (1%). Re-intervention was required in 36 patients (20%) after initial ERCP with successful stent placement. The re-intervention rate was significantly higher with plastic stents (14/27, 52%) than with metal stents (22/153, 14%) after initial ERCP (Χ2 20.1 p<0.001).

The overall survival was a mean of 249±16 days (5-967) for patients with plastic stents and 248± 16 days (1-959) for those with metal stents. Survival was significantly worse in patients with unresectable disease vs resectable/borderline-resectable disease (Log rank 38.89, p<0.001), Figure 1.

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Conclusion(s)

In MBO, metal stents appear to provide significantly better biliary drainage, with less need for re-intervention, but do not appear to be associated with any survival benefit over plastic stents. We hope that this quality assurance project will help in the development of a regional management pathway for optimizing the care of patients presenting with MBO.

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Disclosure of Interest

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A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Background

Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.

Aims

To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.

Methods

Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.

Conclusions

The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

Partial symptom-response to proton pump inhibitors in patients with non-erosive reflux disease or reflux oesophagitis - a post hoc analysis of 5796 patients

BACKGROUND

Although most patients with gastro-oesophageal reflux disease (GERD) benefit from proton pump inhibitor (PPI) therapy, some experience only partial symptom relief.

AIM

To determine the prevalence of partial heartburn response to PPIs and its impact on health-related quality of life.

METHODS

Four randomised, double-blind studies in adults with reflux disease compared esomeprazole 40 mg/day or 20 mg/day with omeprazole 20 mg/day, or esomeprazole 40 mg/day with pantoprazole 40 mg/day. Patients with heartburn on ≥4 days during the 1-week recall period at baseline were included. Partial response was defined as heartburn on ≥3 days during the last treatment week and reduced heartburn frequency after 4 weeks of treatment compared with baseline.

RESULTS

The analysis included 2645 patients with non-erosive reflux disease (mean age: 48.8 years; 54.4% women) and 3151 patients with reflux oesophagitis (mean age: 50.6 years; 37.1% women). At baseline, most patients reported heartburn on 5-7 days (non-erosive reflux disease: 82.2%; reflux oesophagitis: 86.8%). Partial heartburn response occurred in 19.9% of patients with non-erosive reflux disease and 14.0% with reflux oesophagitis. Defining partial response as heartburn on ≥2 days increased these rates to 26.2% and 19.3%, respectively; defining partial response as heartburn of moderate or severe intensity on ≥3 days decreased these rates to 6.4% and 5.3%, respectively. Nonresponse to PPIs was rare (non-erosive reflux disease: 2.4%; reflux oesophagitis: 1.4%).

CONCLUSION

Using our conservative definition, partial heartburn response to proton pump inhibitor therapy occurred in 14-20% of gastro-oesophageal reflux disease patients, more commonly in non-erosive reflux disease than in reflux oesophagitis.

Systematic review: faecal transplantation for the treatment of Clostridium difficile-associated disease

BACKGROUND

Management of recurrent Clostridium difficile-associated disease (CDAD), particularly in elderly patients, remains clinically challenging. Faecal transplantation (FT) may restore normal microbiota and break the cycle of recurrent CDAD.

AIM

To critically appraise the clinical research evidence on the safety and effectiveness of FT compared with standard care in the treatment of patients with CDAD.

METHODS

A comprehensive literature search was conducted by a research librarian to identify relevant studies published between 2000 and 2011. The Cochrane Library, PubMed, EMBASE, CINAHL, Biological Abstracts, BIOSIS Previews and Web of Science were searched using the following Medical Subject Headings (MeSH) terms and keywords, alone or in combination: Clostridium infections/Clostridium difficile/pseudomembranous/colitis/faeces/rectal/colon flora/gastrointestinal/nasogastric tube/enema/donor/transplant/infusion/bacteriotherapy/human probiotic infusion. Methodological quality of the included case series studies was assessed in terms of patient selection criteria, consecutive recruitment, prospective data collection, reporting of lost to follow-up, and follow-up rates.

RESULTS

No controlled studies were found. Based on the weak evidence from seven full-text case series studies of 124 patients with recurrent/refractory CDAD, FT appears to be a safe and effective procedure. In most cases (83%) symptoms improved immediately after the first FT procedure, and some patients stayed diarrhoea free for several months or years.

CONCLUSIONS

Although these results appear to be promising, the treatment effects of faecal transplantation cannot be determined definitively in the absence of a control group. Results from randomised controlled trials that compare faecal transplantation to oral vancomycin without or with a taper regimen will help to better define the role of faecal transplantation in the management of recurrent CDAD.

Randomised clinical trial: the burden of illness of uninvestigated dyspepsia before and after treatment with esomeprazole--results from the STARS II study

BACKGROUND

Patients with dyspepsia often experience troublesome symptoms.

AIM

To assess the burden of uninvestigated dyspepsia (symptoms, health-related quality of life [HRQL] and work productivity) before and after 8 weeks' esomeprazole treatment.

METHODS

Patients (n=1250) with uninvestigated dyspepsia (no endoscopy within 6 months and ≤ 2 endoscopies within 10 years) underwent a 1-week esomeprazole acid-suppression test before randomisation to 7 weeks' esomeprazole or placebo. The Reflux Disease Questionnaire (RDQ), Quality of Life in Reflux and Dyspepsia (QOLRAD) and Work Productivity and Activity Impairment (WPAI) questionnaires were completed at baseline (1-week off-treatment) and 8 weeks. WPAI results were further analysed among patients who responded to the acid-suppression test.

RESULTS

The highest baseline symptom score was for the RDQ dyspepsia domain, and the highest disease burden was for QOLRAD vitality and food/drink problems. After 8 weeks, significant improvements vs. placebo were observed for all RDQ and QOLRAD domains. The sub-population of acid-suppression test responders, but not the total WPAI population, had a significant work productivity improvement vs. placebo.

CONCLUSIONS

Uninvestigated dyspepsia is associated with high symptom load and impacts on HRQL and work productivity. Esomeprazole improves HRQL among such patients, and improves work productivity among 1-week acid-suppression trial responders. ClinicalTrials.gov identifier: NCT00251992.

Helicobacter pylori infection in Canadian and related Arctic Aboriginal populations

In 2006, the Canadian Helicobacter Study Group identified Aboriginal communities among Canadian population groups most at risk of Helicobacter pylori-associated disease. The objective of this systematic review was to summarize what is known about the H pylori-associated disease burden in Canadian and related Arctic Aboriginal populations to identify gaps in knowledge. Six health literature databases were systematically searched to identify reports on H pylori prevalence in Canadian population groups, or any topic related to H pylori in Canadian Aboriginals, Alaska Natives or Aboriginals of other Arctic regions. Identified reports were organized by subtopic and summarized in narrative form. Key data from studies of H pylori prevalence in defined populations were summarized in tabular form. A few Arctic Aboriginal communities were represented in the literature: two Canadian Inuit; one Canadian First Nation; two Greenland Inuit; one Russian Chutkotka Native; and several Alaska Native studies. These studies uniformly showed elevated H pylori prevalence; a few studies also showed elevated occurrence of H pylori-related diseases and high rates of treatment failure. Based on the evidence, it would be warranted for clinicians to relax the criteria for investigating H pylori and related diseases in patients from Arctic Aboriginal communities, and to pursue post-therapy confirmation of eradication. Additional community-based research is needed to develop public health policies for reducing H pylori-associated health risks in such communities.

Systematic review of the use of patients' own medications in acute care institutions

BACKGROUND

Patients' own medications (POM) are medications that patients have obtained in the community setting and bring to the hospital when admitted. The practice of using POMs has not been well studied.

OBJECTIVE

To identify benefits, risks and other impacts on the use of POM in hospitals.

METHODS

A systematic search of the literature and internet was conducted for articles in the English language dated from 1984 to 2004. PubMed, CINAHL, IPA, and Embase databases were searched with combinations of the following text words: patient, own, drug, medication, medicine. References of relevant articles and specific journals were hand-searched.

RESULTS

Nineteen primary studies that provided information on the benefits and risks of POMs were identified. Benefits included decreased wastage of POMs, improving the accuracy of admission orders, opportunities for patient counselling and continuity of care between acute and primary care. Hospitals must address liability and workload concerns but may benefit from savings to their drug budget.

DISCUSSION

Only a limited number of studies were found that addressed the benefits, risks and costs of using POMs in hospitals. These studies had small sample sizes with limitations in the quality of the study design. Nevertheless, the literature contained examples of benefits to the patient and hospital, as well as assistance with practical issues. Further research is needed to evaluate the benefits and risks of using POMs. Hospital policies should describe identification, storage and documentation procedures to address liability and risk concerns. Implementation of policies to use POMs should include an evaluation component, which could include a comprehensive economic analysis of drug costs and staff workload.

Review article: the changing epidemiology of hepatocellular carcinoma in Canada

The aim of this study was to examine the incidence of and mortality caused by hepatocellular carcinoma over the last 20 years in Canada, including the associated risk factors hepatitis C, diabetes and obesity. Databases from the Surveillance & Risk Assessment Division of Health Canada & Statistics Canada were analysed for trends in both age-adjusted incidence of and mortality due to hepatocellular carcinoma from 1984 to 2001. The epidemiological impact of hepatitis C, diabetes and obesity on hepatocellular carcinoma was also assessed. The incidence of hepatocellular carcinoma increased from 4.0 per 100,000 in 1984 to 5.5 in 2,000 for males, and from 1.6 per 100,000 in 1984 to 2.2 in 2,000 for females. Mortality rates showed a 48% increase in males and 39% increase in females. The incidence of hepatitis C increased sharply in 1995 and remained elevated until 2,000 with an average value of 85.4 per 100,000 in males and 45.4 per 100,000 in females. This increase is likely due to the widespread testing for hepatitis C. The prevalence of obesity and diabetes has increased in recent years and probably contributes to the increased incidence of hepatocellular carcinoma. The incidence of hepatocellular carcinoma in Canada has increased in the past 20 years and is associated with a rise in the incidence of hepatitis C, obesity and diabetes.

Systematic review: the efficacy of intermittent and on-demand therapy with histamine H2-receptor antagonists or proton pump inhibitors for gastro-oesophageal reflux disease patients

AIM

To perform a systematic review on the efficacy of intermittent and on-demand therapy with either histamine H2-receptor antagonists or proton pump inhibitors for patients with erosive oesophagitis or symptomatic heartburn.

METHOD

We conducted randomized-controlled trials of non-continuous therapy in gastro-oesophageal reflux disease patients.

RESULTS

Fourteen studies met inclusion criteria. Because of variation in outcome measures statistical pooling of results was not possible. Results were analysed qualitatively. Four studies evaluated intermittent therapy of treatment 3 days a week with omeprazole 20 mg or daily with ranitidine which were not efficacious compared to a daily proton pump inhibitor. Famotidine 10 and 20 mg, ranitidine 75 mg and cimetidine 200 mg were efficacious in five on-demand studies for relief of symptomatic heartburn episodes. In three of four studies, evaluating only non-erosive (endoscopy-negative) gastro-oesophageal reflux disease patients, esomeprazole 20 and 40 mg and omeprazole 10 and 20 mg a day were efficacious using willingness to continue as an endpoint. Lansoprazole 30 mg and omeprazole 20 mg maintained symptom control in 60-70% of healed oesophagitis patients.

CONCLUSIONS

Intermittent proton pump inhibitor or H2-receptor antagonist therapy is not effective in maintaining control in oesophagitis patients. H2-receptor antagonists are effective for relief of heartburn episodes. On-demand proton pump inhibitor therapy may work in a proportion of non-erosive gastro-oesophageal reflux disease patients.

Association of Helicobacter pylori genotype with gastroesophageal reflux disease and other upper gastrointestinal diseases

OBJECTIVE

Helicobacter pylori (H. pylori) is a recognized pathogen, but it may also have a protective effect for gastroesophageal reflux disease (GERD). We compared the prevalence of potential virulence factors (cagA, cagE, vacA genotypes) in GERD to other upper gastrointestinal diseases and controls.

METHODS

A total of 405 patients underwent gastroscopy with H. pylori isolation and serum testing. Patient diagnostic subgroups were prospectively defined. Genotypes were determined by amplification using polymerase chain reaction. CagA antibodies were determined by western blot, enzyme-linked immunosorbent, and flow microsphere immunofluorescent assays.

RESULTS

Patients were grouped as follows: nonulcer dyspepsia (26%), GERD (20%), gastric ulcer (17%), duodenal ulcer (12%), gastric cancer (6%), or controls (19%). The cagA gene was present in 94-97% of subjects in all categories, but the cagA antibody was less prevalent in nonulcer dyspepsia (69%, 95% CI: 48-86%, p = 0.02) and GERD (69%, CI: 39-91%, p < 0.05) than in those with gastroduodenal pathology including gastric ulcer, duodenal ulcer, and gastric cancer (92%, CI: 81-98%). The cagE gene and vacA S1 genotype were more frequent in patients with gastroduodenal pathology (p < 0.01). GERD was associated with a significantly lower rate of vacA S1 genotype than controls (29% (CI: 10-56%) versus 80% (CI: 59-93%), p < 0.01). The vacA S1 genotype was associated with the presence of cagA antibodies.

CONCLUSIONS

The cagE and vacA S1 genotypes are more prevalent in patients with peptic ulcer or gastric cancer, suggesting a potential function in virulence for these genes. However, the vacA S1 genotype was also more prevalent in controls than GERD, suggesting a potential protective effect against GERD.

Omeprazole, amoxycillin and metronidazole for the cure of Helicobacter pylori infection

OBJECTIVE

In two studies, different regimens of omeprazole-amoxycillin-metronidazole were assessed for the eradication of Helicobacter pylori.

DESIGN

Randomized, international, multicentre studies with parallel groups.

SETTING

The studies were performed at centres in Canada, Czech Republic, France, Germany, Hungary, Sweden and UK.

PARTICIPANTS AND INTERVENTIONS

H. pylori-positive patients with duodenal ulcer disease (active or in remission) were randomized to 7-day treatment with: omeprazole 40 mg once daily, amoxycillin 500 mg three times daily and metronidazole 400 mg three times daily (OAMtid; n = 242); omeprazole 20 mg twice daily, amoxycillin 1000 mg twice daily and metronidazole 800 mg twice daily (OAM800; n = 247); or omeprazole 20 mg twice daily, amoxycillin 1000 mg twice daily and metronidazole 400 mg twice daily (OAM400; n = 127).

MAIN OUTCOME MEASURES

Eradication of H. pylori.

RESULTS

Intention-to-treat analysis revealed H. pylori eradication rates of 76% (184/242) with OAMtid, 80% (198/247) with OAM800, and 76% (97/127) with OAM400. There was considerable variation in the levels of primary resistance to metronidazole in different countries. The overall eradication rate in patients infected with metronidazole-sensitive H. pylori strains was 85% (313/370), compared with 60% (56/94) in patients harbouring metronidazole-resistant strains (P<0.001). All regimens were generally well tolerated, with mild adverse events occurring in 4-26% of patients (mainly diarrhoea, reversible increase in liver enzymes and headache).

CONCLUSION

The OAM combination is effective in curing H. pylori infection. Primary metronidazole resistance may reduce its effectiveness, but an increased daily dosing of metronidazole may partly overcome this problem.

Problems in measurement of quality of life in dyspepsia trials

In this review methodological problems in the measurement of quality of life in non-ulcer dyspepsia (NUD) patients are discussed. To date very few validated outcome measures are available for NUD-trials. It is unclear whether non GI-related symptoms need to be measured by these instruments in addition to GI-symptoms. Another important issue is how overlap with patients who suffer from gastro-esophageal reflux disease can be avoided.

Quality of Life in Reflux and Dyspepsia patients. Psychometric documentation of a new disease-specific questionnaire (QOLRAD)

OBJECTIVE

To develop a disease-specific QOL instrument (QOLRAD) addressing patient concerns in gastroesophageal reflux disease (GERD) and dyspepsia. Patients. 759 male (45%) and female (55%) patients with a mean age of 48.4 years (sd 15.2) were used in the psychometric evaluation.

MAIN OUTCOME MEASURES

A pilot version of QOLRAD, the Gastrointestinal Symptoms Rating Scale (GSRS) and the SF-36 were completed prior to endoscopy. Items with a high ceiling effect, items measuring a different construct, i.e. with a low squared multiple correlation (R < 0.5) with the other items, items that showed redundancy by a high correlation (>0.80) with another item were removed. A confirmatory factor analysis was also performed.

RESULTS

The final questionnaire included 25 items depicting problems with emotions, vitality, sleep, eating/drinking, and physical/social functioning. The internal consistency reliability was high (alpha value overall 0.97, dimensions 0.89-94). Construct validity, i.e. the associations between similar constructs in the QOLRAD, the SF-36 and the GSRS scores was confirmed. Pain and symptom severity were markers of impaired QOL. The impact on health-related QOL was similar across the functional gastrointestinal disorders with the exception of patients with a normal endoscopy, who did slightly worse.

CONCLUSION

The QOLRAD is a short and user-friendly instrument with excellent psychometric properties. Its responsiveness to change in (AVMC1) clinical trials is currently being explored.

Adding once-daily omeprazole 20 mg to metronidazole/amoxicillin treatment for Helicobacter pylori gastritis: a randomized, double-blind trial showing the importance of metronidazole resistance

OBJECTIVE

We compared the Helicobacter pylori eradication rate after a 14-day treatment with amoxicillin 500 mg t.i.d. and metronidazole 500 mg t.i.d. with or without omeprazole 20 mg once daily.

METHODS

This was a randomized, controlled trial in which omeprazole was given in double-blind fashion. Patients with H. pylori-associated gastritis were enrolled in four centers in Canada from July 1991 to January 1994. Eradication of H. pylori was assessed by histological evaluation and culture of endoscopic biopsies obtained from the antrum and corpus of the stomach.

RESULTS

The H. pylori eradication rate was 73% (33 of 45) in the omeprazole-amoxicillin-metronidazole group, compared with 66% (31 of 47) in the amoxicillin-metronidazole group. This 7% difference was not statistically significant (p = 0.43, 95% confidence interval for difference -11% to 26%). Metronidazole primary resistance in the prestudy cultures was found more frequently in the omeprazole-amoxicillin-metronidazole group than in the amoxicillin-metronidazole group. Resistance to metronidazole was an important predictor of treatment failure. The H. pylori eradication rate was 61% (19 of 31) for patients infected with metronidazole-resistant H. pylori strains, compared with 91% (30 of 33) eradication for those infected with metronidazole-sensitive strains (p < 0.01). Vaginal candidiasis was reported in four patients.

CONCLUSIONS

The H. pylori eradication rate was higher (73%) for omeprazole-amoxicillin-metronidazole than for the dual antibiotic therapy given without omeprazole (66%); however, this difference was not statistically significant. Metronidazole resistance significantly reduces H. pylori eradication rates.

Eradication of Helicobacter pylori using one-week triple therapies combining omeprazole with two antimicrobials: the MACH I Study

BACKGROUND

Eradication of Helicobacter pylori provides potential cure in the majority of patients with peptic ulcer disease, and eradication rates of more than 90% have been reported, using omeprazole in combination with two antimicrobials. The choice of antimicrobials, dose regimen and duration of treatment have varied between studies, however, and an optimal treatment still has to be established.

MATERIALS AND METHODS

We conducted an international, randomized, double-blind, placebo-controlled study involving more than 100 patients in each of six treatment groups in 43 hospital gastrointestinal units in Canada, Germany, Ireland, Sweden, and the United Kingdom. Patients (n = 787) with proved duodenal ulcer disease were randomized to treatment twice daily for 1 week with omeprazole, 20 mg (O), plus either placebo (P) or combinations of two of the following antimicrobials: amoxicillin, 1 gm (A), clarithromycin, 250 or 500 mg (C250, C500), or metronidazole, 400 mg (M). Eradication of H. pylori was evaluated by 13C-UBT, performed before and 4 weeks after treatment cessation.

RESULTS

The eradication rates for the all-patients-treated analysis were 96%, OAC500; 95%, OMC250; 90%, OMC500; 84%, OAC250; 79%, OAM; and 1%, OP. OAC500 and OMC250 achieved eradication rates with lower 95% confidence interval limits exceeding 90%. All regimens were well-tolerated, 96% of patients complied with their dose regimen, and 2.3% of the patients discontinued treatment owing to adverse events.

CONCLUSIONS

Omeprazole triple therapies given twice daily for 1 week produce high eradication rates, are well-tolerated, and are associated with high patient compliance. The two most effective therapies were those combining omeprazole, 20 mg, with either amoxicillin, 1 gm, plus clarithromycin, 500 mg, or metronidazole, 400 mg, plus clarithromycin, 250 mg, all given twice daily.