Pathology of the gastric antrum and body associated with Helicobacter pylori infection in non-ulcerous patients: is the bacterium a promoter of intestinal metaplasia?

A series of 115 consecutive, non-ulcerous, dyspeptic patients were examined for Helicobacter pylori (H. pylori) colonization in the gastric antral and/or body mucosa using Giemsa staining. Findings were correlated with the presence and degree of activity of superficial gastritis, deep gastritis, atrophic gastritis and with the presence of intestinal metaplasia. The prevalence of H. pylori positivity was 61.7%. In 59 of the 71 positive patients (83%), H. pylori was detected in the antrum or in both the antral and oxyntic mucosa. In the remaining 12 positive patients, H. pylori was detected only in the oxyntic mucosa nad in all these cases, the antrum showed intestinal metaplasia associated with atrophic gastritis (25%). In both antral and oxyntic mucosa, the activity of the gastritis was significantly correlated with H. pylori colonization. Linear logistic regression analysis showed that in patients with intestinal metaplasia the presence of H. pylori infection was significant in predicting the presence of more extensive intestinal metaplasia after adjusting for age. The prevalence of intestinal metaplasia types II and III was 65.5% in the H. pylori positive and 25% in the H. pylori negative patients. The antral mucosa is thought to be the elective site for H. pylori related histological lesions. At a later stage, H. pylori can be detected only in the oxyntic area while the antral mucosa shows extensive metaplastic or atrophic lesions. We would suggest that H. pylori plays a promotional role in the morphogenesis of intestinal metaplasia.

A potential role for the vanilloid receptor TRPV1 in the therapeutic effect of curcumin in dinitrobenzene sulphonic acid-induced colitis in mice

A protective role of the transient potential vanilloid receptor 1 (TRPV1) in intestinal inflammation induced by dinitrobenzene sulphonic acid (DNBS) has been recently demonstrated. Curcumin, the major active component of turmeric, is also able to prevent and ameliorate the severity of the damage in DNBS-induced colitis. We evaluated the possibility that curcumin (45 mg kg(-1) day p.o. for 2 days before and 5 days after the induction of colitis) was able to reduce DNBS-induced colitis in mice, by acting as a TRPV1 agonist. Macroscopic damage score, histological damage score and colonic myeloperoxidase (MPO) activity were significantly lower (by 71%, 65% and 73%, respectively; P < 0.01), in animals treated with curcumin compared with untreated animals. Capsazepine (30 mg kg(-1), i.p.), a TRPV1 receptor antagonist, completely abolished the protective effects of curcumin. To extend these data in vitro, Xenopus oocytes expressing rat TRPV1 were examined. Capsaicin-evoked currents (3.3 micromol L(-1)) disappeared subsequent either to removal of the agonist or subsequent to the addition of capsazepine. However, curcumin (30 micromol L(-1)) was ineffective both as regard direct modification of cell membrane currents and as regard interference with capsaicin-mediated effects. As sensitization of the TRPV1 receptor by mediators of inflammation in damaged tissues has been shown previously, our results suggest that in inflamed, but not in normal tissue, curcumin can interact with the TRPV1 receptor to mediate its protective action in DNBS-induced colitis.

The prevalence of diarrhea and its association with drug use in elderly outpatients: a multicenter study

OBJECTIVES

To evaluate the prevalence of diarrhea and its association with drug use in elderly outpatients.

METHODS

The study was carried out by 133 general practitioners (GPs) who referred to 24 geriatric units in Italy. The demographic data, disability, gastrointestinal symptoms, and current medications were evaluated using a structured interview, including the evaluation of the activities of daily living (ADL), the instrumental activities of daily living (IADL), and the gastrointestinal symptoms rating scale (GSRS).

RESULTS

The study included 5,387 elderly subjects who regularly completed the structured interview. In total, 488 patients (9.1% of the whole population, 210 men and 278 women, mean age 75.6 +/- 6.2 yr, range 65-100 yr) reported diarrhea, that is, items 11 and 12 of the GSRS, during the 7-day period before the interview. The prevalence of diarrhea significantly increased with older age (P = 0.025), the severity of ADL (P < 0.0001) and IADL disability (P < 0.0001), and the number of drugs taken (P = 0.0002). A multivariate analysis demonstrated that the presence of diarrhea was significantly associated with the use of antibiotics (odds ratio [OR] 4.58, 95% confidence interval [CI] 1.95-10.73), proton pump inhibitors (OR 2.97, 95% CI 2.03-4.35), allopurinol (OR 2.19, 95% CI 1.26-3.81), psycholeptics (OR 1.82, 95% CI 1.26-2.61), selective serotonin reuptake inhibitors (OR 1.71, 95% CI 1.01-2.89), and angiotensin II receptor blockers (OR 1.46, 95% CI 1.08-1.99), also accounting for sex, age, and the use of antidiarrheal agents and drugs for functional gastrointestinal disorders.

CONCLUSION

Diarrhea is a common problem in elderly outpatients. Its prevalence increases with old age, the severity of disability, and the number of drugs. Monitoring the presence of diarrhea and its complications in elderly patients who need treatments with drugs significantly associated with diarrhea may be clinically useful.

Helicobacter pylori in promotion of gastric carcinogenesis

Gastric atrophy and intestinal metaplasia are considered the earliest phenotypic changes in the cascade of events leading from normal mucosa to intestinal-type gastric cancer, and epidemiological evidence links Helicobacter pylori to gastric epithelial malignancies. To evaluate any causal relationship between bacterial infection and atrophic metaplastic lesions, gastric pathology was histologically and histochemically evaluated in 267 consecutive, nonulcerous, untreated subjects, with attention given the phenotypes of intestinal metaplasia. The prevalence of Helicobacter pylori infection was 61%. Intestinal metaplasia (particularly types II and III) was significantly associated with both Helicobacter pylori detection (chi 2 LR: P < 0.002) and increasing age (chi 2 LR: P < 0.002). Using logistic regression analysis, the development of intestinal metaplasia proved more significantly linked with Helicobacter pylori infection [odds ratio = 4.55 (95% confidence interval: 1.51-13.7)], than with age [odds ratio = 1.03 (95% CI: 1.01-1.06)], with no interaction. In conclusion, Helicobacter pylori can be considered among the major causal agents of mucosal lesions involved in the multistep process of gastric carcinogenesis, justifying any attempt to eradicate this bacterial infection.

Epidemiology and risk factors of pancreatic cancer

The most frequent pancreatic cancer is pancreatic adenocarcinoma. It has high and early locally and distant invasiveness; this is the reason why it often shows little sign or symptoms in early stage and poor prognosis after the diagnosis, frequently in advanced stage. Although it is possible to detect this tumor in early stage because of its neoplastic precursor (PanINs). Epidemiological data shows that pancreatic cancer is not very common but obvious it is one of the most neoplastic death-cause in the world. The trend of incidence is quite increasing through years, proportionally to the increase of risk factors. About risk factors, it is not easy to detect in all the cases but it is known the role of some of that: there are hereditary risk factors, such as genetic pattern like HBOC, HNPCC, FAP, PJS, FAMMM, HP and CF and environmental ones (modifiable) such as smoke, alcohol consumption, chronic pancreatitis, obesity and diabetes mellitus. This narrative review aims to analyze the epidemiological data of pancreatic cancer and associated risk factors.

Mesalazine for the Treatment of Symptomatic Uncomplicated Diverticular Disease of the Colon and for Primary Prevention of Diverticulitis: A Systematic Review of Randomized Clinical Trials

BACKGROUND

Symptomatic uncomplicated diverticular disease (SUDD) is a common gastrointestinal disease, because it affects about one fourth of the patient harboring colonic diverticula.

GOAL

To assess the effectiveness of mesalazine in improving symptoms (namely abdominal pain) and in preventing diverticulitis occurrence in patients with SUDD.

STUDY

Only randomized clinical trials (irrespective of language, blinding, or publication status) that compared mesalazine with placebo or any other therapy in SUDD were evaluated. The selected endpoints were symptom relief and diverticulitis occurrence at maximal follow-up. Absolute risk reduction (ARR, with 95% confidence interval) and the number needed to treat were used as measures of the therapeutic effect.

RESULTS

Six randomized clinical trials enrolled 1021 patients: 526 patients were treated with mesalazine and 495 with placebo or other therapies. Symptom relief with mesalazine was always larger than that with placebo and other therapies. However, absolute risk reduction was significant only when mesalazine was compared with placebo, a high-fiber diet, and low-dose rifaximin. The incidence of diverticulitis with mesalazine was lower than that observed with placebo and other treatments, being significant only when compared with placebo.

CONCLUSIONS

Mesalazine is effective in achieving symptom relief and primary prevention of diverticulitis in patients with SUDD.

The role of diet in the prevention and treatment of Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD) - Crohn's disease (CD) and ulcerative colitis (UC) - are chronic conditions characterised by relapsing inflammation of the gastrointestinal tract. They represent an increasing public health concern and an aetiological enigma due to unknown causal factors. The current knowledge on the pathogenesis of IBD is that genetically susceptible individuals develop intolerance to a dysregulated gut microflora (dysbiosis) and chronic inflammation develops as a result of environmental triggers. Among the environmental factors associated with IBD, diet plays an important role in modulating the gut microbiome, and, consequently, it could have a therapeutic impact on the disease course. An overabundance of calories and some macronutrients typical of the Western dietetic pattern increase gut inflammation, whereas several micronutrients characteristic of the Mediterranean Diet have the potential to modulate gut inflammation, according to recent evidence. Immunonutrition has emerged as a new concept putting forward the role of vitamins such as vitamins A, C, E, and D, folic acid, beta carotene and trace elements such as zinc, selenium, manganese and iron. However, when assessed in clinical trials, specific micronutrients showed a limited benefit. Further research is required to evaluate the role of individual food compounds and complex nutritional interventions with the potential to decrease inflammation as a means of prevention and management of IBD. The current dietary recommendations for disease prevention and management are scarce and non evidence-based. This review summarizes the current knowledge on the complex interaction between diet, microbiome and immune-modulation in IBD, with particular focus to the role of the Mediterranean Diet as a tool for prevention and treatment of the disease.

Acid-related disorders in the elderly

Diseases of the upper gastrointestinal tract such as gastroesophageal reflux disease (GERD), peptic ulcer and gastric cancer become more common and more severe with advancing age. Older individuals also tend to have a higher prevalence of co-morbid factors, such as Helicobacter pylori infection, presence of other diseases, or use of medications (e.g., nonsteroidal anti-inflammatory drugs, bisphosphonates) that increase their risk for acid-related disorders. Unfortunately, in the elderly patient with these disorders symptom presentation may be slight or atypical, resulting in a delayed diagnosis. In general, the treatment of older individuals with peptic ulcer or GERD and its complications is similar to that of younger individuals. Proton pump inhibitors are the basis of therapy for symptom relief, healing of erosive esophagitis and peptic ulceration, reduction of the risk for NSAID induced mucosal damage, and prevention of disease relapses. The strongest prevalence of H.pylori infection in the elderly, as well as the role of H.pylori in the occurrence of gastric lesions, in particular ulcer diseases, gastric precancerous lesions and gastric cancer, make the diagnosis and the eradication of H.pylori in this population of the utmost importance. Strategies to improve the management of upper gastrointestinal diseases in older people will reduce mortality and improve quality of life.

Barrett's esophagus and adenocarcinoma risk: the experience of the North-Eastern Italian Registry (EBRA)

OBJECTIVE

To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barrett's esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)].

BACKGROUND

BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer.

METHODS

In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression.

RESULTS

HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2-4); median follow-up = 44.6 [IQR: 24.7-60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51-68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9-50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63-21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22-11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03-1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN.

CONCLUSIONS

These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

'Rescue' therapies for the management of Helicobacter pylori infection

Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcer and gastric cancer and should be considered as a major public health issue. According to several international guidelines, first-line therapy for treating H. pylori infection consists of proton pump inhibitor (PPI) or ranitidine bismuth citrate (RBC) with any two antibiotics of amoxicillin, clarithromycin or metronidazole given for 7-14 days. However, even with the recommended treatment regimens, approximately 20% of patients will fail to obtain H. pylori eradication. The proportion of patients with first-line H. pylori therapy failure may be higher in clinical practice and it may increase thanks to diffusion of H. pylori treatment. The recommended second-line therapy is the quadruple regimen composed by tetracycline, metronidazole, bismuth salts and a PPI. However, the efficacy of this regimen is limited by poor patient's compliance due to its side effects, number of tablets per day, and long duration. Moreover, bismuth and metronidazole are not available in all countries. Alternatively, a longer-lasting (i.e. 10-14 days) PPI or RBC triple therapy with two antibiotics has generally been used. In an empirical strategy, the choice of second line depends on the treatment initially used. If a clarithromycin-based regimen was administered in first line, a quadruple regimen or PPI (or RBC) triple therapy with metronidazole and amoxicillin (or tetracycline) should be suggested as a second line. In case of second-line treatment failure, the patient should be evaluated by a case-by-case approach. A susceptibility-guided strategy, if available, is recommended in order to choose the best third-line treatment. Culture can reveal the presence of H. pylori-sensitive strains to clarithromycin (the best effective) or other antimicrobials (such as amoxicillin, metronidazole and tetracycline). Conversely, in an empirical strategy, a third-line not yet used therapy, can reach a high success rate. PPI or RBC, amoxicillin and a new antimicrobial (e.g. rifabutin, levofloxacin or furazolidone) could be used. Several studies have obtained relatively good results with triple therapy combining PPI, rifabutin, and amoxicillin, although a reversible myelotoxicity as leukopenia and thrombocytopenia has been described. Preliminary good results were also achieved with triples PPI regimens combining levofloxacin and amoxicillin without important adverse effects. Furazolidone has also shown efficacy for H. pylori eradication, although untoward reactions could limit its use, especially when high doses are employed. Finally, in more than one H. pylori treatment failure, non-antimicrobial add-on medications (such as lactoferrin, probiotics and others) could be used with the aim either to improve the eradication rate or to minimize side effects.

Pantoprazole versus one-week Helicobacter pylori eradication therapy for the prevention of acute NSAID-related gastroduodenal damage in elderly subjects

AIM

To compare the efficacy of pantoprazole vs. a one-week Helicobacter pylori eradication therapy for the prevention of NSAID-related gastroduodenal damage.

METHODS

Patients over 60 years old with symptoms and/or a history of ulcer who needed NSAID treatment were evaluated by endoscopy. H. pylori positive subjects who had no severe gastroduodenal lesions were randomized to take, concomitantly with NSAID therapy, either: (i) pantoprazole 40 mg daily plus amoxycillin 1 g b.d. and clarithromycin 250 mg b.d. for 1 week (35 subjects, Group PAC) or (ii) pantoprazole 40 mg daily for 1 month (34 subjects, Group P). Endoscopy was repeated after 1 month.

RESULTS

A significantly higher incidence of severe gastroduodenal damage was found in Group PAC than in Group P (29% vs. 9%, P<0.05). The percentages of patients worsened, unchanged and improved after 1 month were, respectively: Group PAC: 46%, 46%, and 9% and Group P: 7%, 65%, and 29% (P<0.0008). The percentage of H. pylori-negative subjects was 89% in Group PAC and 52% in Group P (P=0.0009). The incidence of gastroduodenal damage was higher in Group PAC treatment failures than in cured patients (50% vs. 25.8%, P=ns).

CONCLUSION

One month of pantoprazole was more effective than a proton pump inhibitor-based triple therapy in the prevention of gastroduodenal damage in elderly H. pylori-positive NSAID users.

Usefulness of serum pepsinogens in Helicobacter pylori chronic gastritis: relationship with inflammation, activity, and density of the bacterium

We sought to study the relationship between serum pepsinogens and different histopathologic features of Helicobacter pylori-related chronic gastritis. One hundred forty-nine consecutive dyspeptic patients underwent endoscopy with biopsies; serum pepsinogens I and II were measured by immunoassay. Serum levels of pepsinogens (sPG) were significantly correlated with H. pylori density both of the corpus (sPGI: r = 0.32, P < .001; sPGII: r = 0.56, P < .001) and antrum (sPGI: r = 0.41, P < .001; sPGII: r = 0.43, P < .001) as well as with chronic inflammation (sPGI: r = 0.26, P < .001; sPGII: r = 0.49, P < .001) and activity (sPGI: r = 0.38, P < .001; sPGII: r = 0.50, P < .001) in the antrum. Only sPGII was correlated with chronic inflammation (r = 0.44, P < .001) and activity (r = 0.40, P < .001) in the corpus. SPGI was inversely correlated with atrophy (r = -0.33, P < .001) and intestinal metaplasia (r = -0.37, P < .001) in the corpus. sPGII levels could be considered as markers of gastric inflammation all over in the stomach. sPGI levels are inversely related to atrophic body gastritis.

Management of Helicobacter pylori infection: Guidelines of the Italian Society of Gastroenterology (SIGE) and the Italian Society of Digestive Endoscopy (SIED)

Helicobacter pylori infection is very common and affects more than one-third of adults in Italy. Helicobacter pylori causes several gastro-duodenal diseases, such as gastritis, peptic ulcer and gastric malignancy, and extra-gastric diseases. The eradication of the bacteria is becoming complex to achieve due to increasing antimicrobial resistance. To address clinical questions related to the diagnosis and treatment of Helicobacter pylori infection, three working groups examined the following topics: (1) non-invasive and invasive diagnostic tests, (2) first-line treatment, and (3) rescue therapies for Helicobacter pylori infection. Recommendations are based on the best available evidence to help physicians manage Helicobacter pylori infection in Italy, and have been endorsed by the Italian Society of Gastroenterology and the Italian Society of Digestive Endoscopy.

Association of keratin 8 gene mutation with chronic pancreatitis

BACKGROUND

Keratin 8 (K8) and 18 (K18) are the major components of the intermediate filament cytoskeleton of pancreatic acinar cells and play a relevant role in pancreatic exocrine homeostasis. Transgenic mice for K8 have shown to display progressive exocrine pancreas alterations, including dysplasia, loss of acinar architecture, redifferentiation of acinar to ductal cells, inflammation, fibrosis, and substitution of exocrine tissue by adipose tissue.

AIM

To investigate whether mutations in the keratin 8 gene are associated with chronic pancreatitis.

METHODS

Mutations in the keratin 8 gene were determined by polymerase chain reaction/restriction fragment length polymorphism in 67 chronic pancreatitis patients and 100 normal controls. Sequence analysis was performed when necessary.

RESULTS

Glycine-to-cysteine mutations at position 61 (G61C) of the keratin 8 gene were found in six patients (8.9 vs. 0%, p(c) < 0.003, odds ratio = 21.24, confidence interval = 2.74-164.42); none of the controls presented the mutation. No tyrosine-to-histidine mutations at position 53 (Y53H) were detected in any subject.

CONCLUSION

G61C mutation of the keratin 8 gene, together with other environmental factors and/or genetic factors, could predispose to chronic pancreatitis, by interfering with the normal organization of keratin filaments.

Helicobacter pylori infection in asymptomatic elderly subjects living at home or in a nursing home: effects on gastric function and nutritional status

Age and close living conditions are known to be risk factors for the acquisition of Helicobacter pylori (HP) infection. It is unknown whether institutionalization of asymptomatic, elderly subjects is an additional risk factor and whether gastric function and nutritional status are affected by the HP infection. The study sample comprised 102 subjects over 65 years of age: 52 living in a nursing home and 50 at home. No subject had symptoms or previous pathology related to the upper digestive tract. In all subjects, serum levels of specific anti-HP antibodies were determined. Gastric function was evaluated by levels of pepsinogen A (PGA), pepsinogen C (PGC) and gastrin. The nutritional status of the subject was evaluated by measuring: albumin, haemoglobin, iron, ferritin, transferrin, vitamin B12, and folic acid in blood, and body mass index and mid-arm muscle area. The prevalence of anti-HP antibodies was 86.5% in institutionalized subjects (men: 100%; women:76.6%, p <0.05) and 82.0% in subjects living at home (men:86.3%; women:76.3%). No differences between the two groups were observed in levels of serum anti-HP antibodies and PGC was identified. In neither group were differences observed between serum positive (HP + ve) and negative (HP - ve) subjects with respect to the biohumoral and anthropometric indices of nutritional status. We conclude: (1) the seroprevalence of the HP infection was high (82-86%) in asymptomatic elderly patients living either at home or in an institution; (2) the presence of specific IgG anti-HP antibodies in asymptomatic elderly individuals, at home or in a nursing home, was not associated with changes in PGA levels in institutionalized subjects; (3) nutritional indices were not influenced by the presence of anti-HP antibodies.

Prevalence of Helicobacter pylori infection in patients with precancerous changes and gastric cancer

Several papers suggested a role for H. pylori infection in gastric cancer. We evaluated the prevalence of H. pylori infection in an endoscopic population of patients with gastric precancerous conditions and lesions by studying biopsies from 252 patients and recording the presence and degree of H. pylori infection. Patients were subgrouped as follows: chronic non-atrophic gastritis (CG), chronic atrophic gastritis (CAG), intestinal metaplasia (IM), epithelial dysplasia (ED) and gastric cancer (K). As control populations, patients with duodenal ulcer (DU) and patients with no endoscopic and histologic damage (CO) were investigated. H. pylori infection rate increased with age, but became significantly lower (P < 0.001) with the progression of gastric mucosal damage: DU 85%, CG 72%, CAG 58%, particularly in the antral type (39%), IM 63% overall, ED 44% and K 35%. The density of colonization showed the same trend (P < 0.001). Of the K patients, only 36% were H. pylori positive in the adjacent mucosa. Anti-H. pylori antibodies (IgG, IgA and IgM) were also tested. A concordance in the diagnosis between histology and serology was obtained in 82% of the cases. In our experience, H. pylori infection correlates inversely with the presence of gastric precancerous changes and cancer. A cautious interpretation of the epidemiological data regarding H. pylori infection and gastric cancer is therefore, in our opinion, mandatory.

Confirmatory factor analysis of the Patient Assessment of Constipation-Symptoms (PAC-SYM) among patients with chronic constipation

BACKGROUND AND AIM

PAC-SYM is widely adopted to asses constipation severity. However, it has been validated in a small sample, few items have been included based on expert opinion and not on empirical grounds, and its factor structure has never been replicated. We aimed at evaluating the psychometric properties of PAC-SYM in patients with chronic constipation.

METHODS

We enrolled 2,203 outpatients with chronic constipation in two waves. We used wave I sample to test the psychometric properties of the PAC-SYM and wave II sample to cross-validate its factor structure, to assess criterion validity, responsiveness to clinical change, and its minimal clinically important difference.

RESULTS

Only a minority of patients reported any rectal tearing (38 %). Deletion of such item leads to a 11-item version (M:PAC-SYM). The remaining items in the rectal domain were moderately correlated with the stool domain. Exploratory factor analysis and confirmatory factor analysis revealed a bifactor structure with two subscales (stool and abdominal symptoms) and a general severity factor. The M:PAC-SYM demonstrated excellent reliability, moderate correlation with SF-12 and treatment satisfaction (r = 0.28-0.45), discrimination across Rome III criteria for functional constipation and abdominal pain, and responsiveness to clinical change (β = -0.49; ω (2) = 0.25). M:PAC-SYM minimal clinically important difference was 0.24.

CONCLUSION

Our analysis shows that the rectal domain may not represent a relevant cluster of symptoms for patients with chronic constipation. We developed a modified version of the PAC-SYM which might better represent symptom severity of most patients seeking care in gastroenterology referral centers.

Oesophagitis and pH of refluxate: an experimental and clinical study

This experimental and clinical study examined the relationship between oesophageal damage and optimal pH of refluxate, and whether 24-h pH monitoring at optimal pH could discriminate the severity of oesophagitis. The rabbit oesophagus was perfused in vivo with pepsin and hydrochloric acid solutions of differing pH for 60 min. Maximal oesophageal damage coincided with peptic solutions at pH 1.5-2.5. Fifty-nine patients with proven gastro-oesophageal reflux disorders were tested for manometric features of the lower oesophageal sphincter (pressure, overall length and abdominal length) and oesophageal exposure to different pH levels. They were classified into four groups according to the endoscopically demonstrated severity of oesophagitis. Supine exposure at the optimal pH level for pepsin activity (pH 1.5-2.5) and overall sphincter length were found to discriminate the severity of oesophagitis reliably in 75 per cent of cases.

Cure of Helicobacter pylori infection in the elderly: effects of eradication on gastritis and serological markers

BACKGROUND

Specific data on anti-H. pylori treatments in elderly people are very scarce. The aim of the study was to evaluate in the elderly the efficacy of different anti-H. pylori therapies and the behaviour of serum anti-H. pylori antibodies, pepsinogen A and C, and PGA/PGC ratio induced by the anti-H. pylori treatment.

METHODS

One hundred and twenty-one dyspeptic patients aged > 60 years (mean age, 73 years; range, 61-89 years) with H. pylori-positive gastric ulcers (17 patients), duodenal ulcers (33 patients) or chronic gastritis (71 patients) were treated with one of the following anti-H. pylori treatments: (A) omeprazole 20 mg/day plus azithromycin 500 mg/day for 3 days; (B) omeprazole 20 mg/day plus azithromycin 500 mg/day for 3 days plus metronidazole 250 mg q.d.s. for 7 days; (C) omeprazole 40 mg/day plus azithromycin 500 mg/day for 3 days plus metronidazole 250 q.d.s. for 7 days; (D) omeprazole 20 mg/day plus clarithromycin 250 b.d. for 7 days; (E) omeprazole 20 mg/day plus clarithromycin 250 b.d. for 7 days plus metronidazole 250 q.d.s. for 7 days; and (F) omeprazole 40 mg/day plus clarithromycin 250 mg b.d. for 7 days plus metronidazole 250 mg q.d.s. for 7 days. At the baseline and 2 months after therapy, endoscopy and serum anti-H. pylori antibodies, pepsinogen A and C, and PGA/PGC ratio were measured.

RESULTS

Ten patients (8.2%) dropped out of the study. Six patients (4.9%) reported side-effects. The eradication rates of the six regimens, expressed using intention-to-treat and per protocol analysis, were, respectively: (A) 39% and 44%; (B) 50% and 56%; (C) 65% and 77%; (D) 47% and 50%; (E) 85% and 90%; and (F) 83% and 87%. The triple therapy for regimens E and F was significantly more effective than dual therapies (regimens A and D; intention-to-treat = P < 0.007, per protocol = P < 0.001) or the triple therapy for regimens B and C (intention-to-treat = P < 0.009, per protocol = P < 0.03). Patients cured of H. pylori infection showed a significant decrease in the activity of gastritis (P < 0.0001), a significant drop in IgG anti-H. pylori (P = 0.0004) and pepsinogen C (P < 0.0001), and an increase in PGA/PGC ratio (P < 0.001), while patients remaining H. pylori-positive showed no changes in the serum parameters.

CONCLUSIONS

In the elderly, triple therapy with omeprazole+metronidazole+clarithromycin for 1 week is well tolerated and highly effective; anti-H. pylori antibody and PGC serum levels decrease soon after anti-H. pylori therapy only in patients cured of H. pylori infection.

Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation

BACKGROUND

The management of bloating is unclear and its relationship with patients' well-being and treatment satisfaction independent of other abdominal symptoms is uncharacterized. We evaluated the association of bloating with patient-reported outcomes.

METHODS

Thirty-nine centers for functional gastrointestinal disorders joined the laxative inadequate relief survey. We enrolled 2203 consecutive outpatients with functional constipation (FC) or constipation-predominant irritable bowel syndrome (IBS-C) in two cross-sectional waves. Both wave 1 and 2 included the SF-12, the patient assessment of constipation-symptoms (PAC-SYM), and the treatment satisfaction questionnaire for medication (TSQM-2). Wave 2 only included a global rating of change (GRC) scale to assess patients' assessment of efficacy concerning treatment switches occurred in the 3 months prior to the interview. Bloating in the abdomen was defined on the basis of PAC-SYM item 3.

KEY RESULTS

The average age was 50.1 years (SD, 16.7) and 82.1% of patients were women. The prevalence of bloating was 91.6% (n = 1970). Bloating was associated with SF-12 Physical Composite Score (p < 0.01), SF-12 Mental Composite Score (p < 0.01), GRC (p < 0.01), Satisfaction with treatment effectiveness (p < 0.01), convenience of administration (p < 0.01), and side effects (p < 0.01) after adjustment for possible confounders.

CONCLUSIONS & INFERENCES

Our data suggest that patients regard bloating as a key element in assessing clinical changes and treatments' efficacy as this symptom exerts a strong influence on patient-reported outcomes independent of possible confounders and other symptoms of constipation. Our data provide the rationale to investigate the efficacy and tolerability of new treatments specifically addressing this important, yet disregarded, patients' complain.

Prevention of acute NSAID-related gastroduodenal damage: a meta-analysis of controlled clinical trials

No consensus exists as to whether cotherapy is effective in the short-term prevention of severe NSAID-related gastroduodenal damage. The aim of this study was to provide a quantitative systematic review of the efficacy of gastroprotective drugs, such as misoprostol, H2-blockers, and proton pump inhibitors (PPI) in preventing the severe acute NSAID-related gastroduodenal damage. Placebo-controlled randomized clinical trials on the use of misoprostol, H2-blockers, and PPIs as preventative agents published between January 1986 and May 1999 were identified through Medline and reference lists from clinical reviews. Studies on patients or healthy subjects were considered to be eligible for data pooling if they were performed in acute NSAID users (not longer than 30 days) and with at least one endoscopic evaluation during therapy that reported results specifically for gastric and duodenal damage. Risk difference (RD), heterogeneity chi2 test, publication bias assessment and number needed to treat (NnT) were calculated for each meta-analysis by a customized program. Twenty-one trials met the inclusion criteria evaluating a total of 636 healthy subjects and 1904 patients with arthritis randomized to active drug or placebo. The baseline risk of NSAID-related gastric (68% vs 16.6%, P < 0.001) and duodenal (22% vs 8.5%, P < 0.001) damage was higher in healthy subjects compared to patients with arthritis. Meta-analysis demonstrated a significant heterogeneity between trials performed in the two populations (P < 0.0001). In healthy subjects the active drug treatment induced a significant prevention of severe gastric (misoprostol RD = 69%, 95% CI = 60.3-77.7, H2-blocker RD = 38.3%, 95% CI = 17.8-58.9 and PPI RD = 43%, 95% CI = 28.2-57.7) and duodenal damage (misoprostol RD = 22.3%, 95% CI = 13.6-31, H2-blocker RD = 13.2%, 95% CI = 5.2-21.3 and PPI RD = 17.7%, 95% CI = 3.5-31.8). NnT values were, respectively, 1, 3, and 2 for gastric and 4, 8, and 6 for duodenal damage. In patients with arthritis lower RD and higher NnT values were found compared to healthy subjects. In conclusions, cotreatment with gastroprotective drugs for short-term prevention of severe gastroduodenal NSAID-related damage was more effective in healthy subjects than in patients with arthritis; misoprostol and PPIs were more effective than H2-blockers in the prevention of both gastric and duodenal severe damage; more studies need to evaluate the role of short-term prevention in patients with arthritis who require acute NSAID treatment.

Noninvasive diagnosis of Helicobacter pylori infection in older subjects: comparison of the 13C-urea breath test with serology

BACKGROUND

The potential influence of cognitive status, physical activities, comorbidity and cotreatments on the feasibility and diagnostic accuracy of two noninvasive diagnostic tests for Helicobacter pylori (Hp) infection, i.e., the 13C-urea breath test (13C-UBT) and serology (immunoglobulin G [IgG] anti-Hp antibodies), in older subjects is not known.

METHOD

The study involved 100 consecutive symptomatic elderly subjects (mean age, 78.3 years; range, 65-96 years), who had undergone an upper gastrointestinal endoscopy. Patients were considered Hp positive if at least two of the three invasive methods, i.e. histology, culture, and/or the rapid urease test were positive for Hp infection. Patients were considered Hp negative if all three invasive methods were negative. The 13C-UBT was performed according to the European standard method and the assaying of IgG anti-Hp antibodies by enzyme-linked immunosorbent assay. Cognitive status and functional activities were determined by the Mini-Mental State Examination (MMSE), the activities of daily living (ADLs) and instrumental ADLs (IADLs).

RESULTS

According to invasive methods, 49 patients were Hp positive and 47 were Hp negative (4 subjects were excluded from the study). Hp-positive patients demonstrated a significantly higher prevalence of peptic ulcers (p =.02) and activity of chronic gastritis (p<.0001) than Hp-negative subjects. The 13C-UBT demonstrated a sensitivity of 100%, a specificity of 95.7%, and a diagnostic accuracy of 97.9%. Serology had significantly lower sensitivity (74.4%), specificity (59%), and diagnostic accuracy (67%, p<.001) than the 13C-UBT. The feasibility and the diagnostic accuracy of the 13C-UBT were not altered by the cognitive status (MMSE) and functional activities (ADL, IADL) of the patients, their drug consumption, or the prevalence of concomitant diseases.

CONCLUSIONS

In older subjects, the 13C-UBT had a significantly higher diagnostic accuracy than serology without influence of cognitive function, disability, comorbidity and cotreatments. This method may be considered an excellent, clinically useful, noninvasive test for the diagnosis of Hp infection in older subjects.

Epidemiology of gastric cancer and risk factors

Gastric cancer is, still nowadays, an important healthcare problem worldwide. In Italy, it represents the fifth tumour by frequency in both men and women over 70 years old. A crucial point is represented by the percentage of early gastric cancers usually found, which is actually very low, and it carries to a worse morbidity and mortality. The most important focus in this oncological disease, is to perform an effective detection of the most common precancerous lesion linked with this neoplasia, chronic atrophic gastritis, in order to avoid the future outcome of gastric cancer itself.

Effects of gastroesophageal reflux disease in laryngeal carcinoma

Gastroesophageal reflux disease is associated with various otolaryngological disorders. The aim of this retrospective study was to determine the role of gastroesophageal reflux disease in the development of laryngeal squamous cell carcinoma (SCC) in non-smoking and non-drinking patients. The study population consisted of 36 consecutive non-smoking and non-drinking patients with histologically confirmed SCC of the larynx. As a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects were selected. Patients with laryngeal cancer had a higher prevalence of gastroesophageal reflux disease than the control subjects (P < 0.0001). Our results confirm the fact that gastroesophageal reflux disease in itself is associated with an increased risk of laryngeal cancer.