Effectiveness of Menthacarin on symptoms of irritable bowel syndrome

Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are common functional gastrointestinal disorders with overlapping symptoms. Effectiveness and safety of Menthacarin (Menthacarin® is the active ingredient of the product Carmenthin® [Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany]) in FD treatment were already demonstrated. We assessed the effectiveness of Menthacarin in reducing concomitant IBS-associated symptoms in FD patients. A systematic search to identify eligible double-blind, randomized controlled trials (RCTs) investigating Menthacarin in FD patients and focusing on IBS-associated symptoms was performed. Three out of five identified RCTs included a total of 111 eligible subjects, which allowed for summary statistics and inclusion into subgroup analysis for FD patients with IBS-associated symptoms. With pain intensity values decreasing by 50–75% on average during 28 days of treatment in patients with accompanying IBS, the subgroup analysis indicates beneficial treatment effects of Menthacarin that are similar to those found for FD patients in the primary analyses. The reduction of IBS-associated symptoms in FD patients suggests Menthacarin as a treatment option for IBS patients.

[Gastro-Oesophageal Reflux Disease - How to Manage if PPI are not Sufficiently Effective, not Tolerated, or not Wished?]

Die Standardtherapie der GERD mit PPI ist weniger wirksam als gedacht: Mindestens 30 % der Patienten haben persistierende Symptome und Läsionen (Therapielücke). Bei persistierender Symptomatik oder Wunsch einer alternativen Behandlung ist eine stratifizierte Diagnostik erforderlich. Alginate und neue Operationsverfahren erweitern die Therapieoptionen

Modified Helicobacter test using a new test meal and a 13C-urea breath test in Helicobacter pylori positive and negative dyspepsia patients on proton pump inhibitors

AIM

To determine the sensitivity and specificity of the ¹³C-urea breath test (UBT) in patients taking proton pump inhibitors (PPIs), using a new test meal Refex.

METHODS

One hundred and fourteen consecutive patients with dyspepsia, 53 Helicobacter pylori (H. pylori) positive, 49 H. pylori negative, were included in the study. The patients were then given esomeprazole 40 mg for 29 consecutive days, and the ¹³C-UBT with the new test meal was performed the next morning.

RESULTS

The sensitivity of the ¹³C-UBT with a cut off 2.5‰ was 92.45% (95%CI: 81.79%-97.91%) by per-protocol (PP) analysis and 78.13% (95%CI: 66.03%-87.49%) by intention-to-treat (ITT) analysis. The specificity of the ¹³C-UBT test was 96.00% in the ITT population (95%CI: 86.29%-99.51%) and 97.96% in the PP population (95%CI: 89.15%-99.95%).

CONCLUSION

The new test meal based ¹³C-UBT is highly accurate in patients on PPIs and can be used in those unable to stop their PPI treatment.

[Dual Antiplatelet Therapy in the Perioperative Period - To Continue or Discontinue Treatment?]

Background For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Often, uncertainty exists with respect to surgical or diagnostic procedures in these high-risk patients: can the DAPT be continued without interruption? If not, what is the recommended withdrawal strategy? What should be considered for the perioperative management? Methods An interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology developed recommendations relevant to daily clinical practice based on the current scientific evidence. Results These recommendations include instructions for evaluating the patient- and procedure-specific risks of bleeding and ischaemia, general recommendations regarding the DAPT withdrawal strategy, and specific guidance for frequent surgical or diagnostic procedures. Discussion This article aims to facilitate the management of patients with DAPT for all medical disciplines involved, thereby ensuring optimal care of patients during the perioperative period.

Epidemiology of hepatic encephalopathy in german hospitals – the EpHE study

Background Hepatic encephalopathy (HE) is a serious complication of liver cirrhosis. The proportion of patients with liver cirrhosis attending German hospitals suffering from HE is unknown.

Methods In the first part of the study, data of 14 community hospitals and 5 university hospitals covering the years 2010 and 2011 were analyzed retrospectively for the DRG codes of liver cirrhosis and hepatic encephalopathy. In the second prospective part of the multicenter observational study, all patients with liver cirrhosis attending the departments of gastroenterology of 16 participating community hospitals within a study period of 3 months were included and screened for HE clinically according to the West Haven criteria (grades 1 – 4).

Results A diagnosis of liver cirrhosis has been coded in 6366 cases in 2010 and in 7279 cases in 2011. In the vast majority of hospitals, less than 20 % of these cases had an additional DRG code for HE. Two hundred seventy-eight patients with liver cirrhosis were included into the prospective study. A clinically detectable HE was present in 36 % of the patients (n = 99). The majority was classified as West Haven 1 (n = 59, 59.6 %). Of the patients without clinical sings of HE, 48 % (n = 134) showed a pathological NCT.

Conclusion Our data suggest that HE is underdiagnosed in German hospitals. Since treatment of HE may improve the prognosis of the patients as well as their quality of life, hospitalized patients with liver cirrhosis should be routinely screened for HE.

[Barrett's esophagus]

Barrett's esophagus is an endoscopically visible metaplasia of the columnar epithelium in the esophagus with histological detection of a specialized intestinal metaplasia. The circumferential and longitudinal extent are described endoscopically using the Prague classification. Barrett's esophagus mostly occurs as the result of gastroesophageal reflux disease. The risk of developing esophageal adenocarcinoma is increased but the absolute risk is low with 0.10-0.15 % per year. According to guideline recommendations, screening for Barrett's esophagus as well as endoscopic and biopsy surveillance should be limited to high risk groups. On detection of intraepithelial neoplasia (IEN) endoscopic therapy is indicated, whereby a second opinion must be obtained from a specialized pathologist for low-grade IEN. The influence of proton pump inhibitors on the progression to carcinoma is controversially discussed and a preventive anti-reflux operation is not indicated.

[Diagnostic and therapeutic management of helicobacter pylori: a survey among German gastroenterologists in private practice]

Purpose: The acceptance and realization of clinical guidelines in daily routine practice is unknown. The aim of this study was to evaluate the behaviour of private gastroenterologists in Germany with respect to the diagnostic and therapeutic management of H. pylori infection in times of increasing antibiotic resistance. Methods: Between 12/2014 and 02/2015 a standardized questionnaire with 19 multiple choice questions were sent to 1507 private gastroenterologists in Germany. The data were electronically captured and analyzed using SurveyMonkey. Results: The response rate was 36 % (540 questionnaires). 65 % of responders prescribe first line therapy by themselves and mainly use standard triple therapies. In patients with intolerance to penicillin, 81 % prescribe Italian triple therapy and 19 % prescribe bismuth quadruple therapy. Risk factors for primary clarithromycin resistance (migrational background, previous macrolide exposure) are routinely assessed by only a minority of responders (22 % and 17 %, respectively). Forty-one percent of responders perform eradication control by themselves mainly using a 13C urea breath test (54 %). In second line therapy, 42 % are prescribing bismuth quadruple therapy and 24 % fluoroquinolone triple therapy. After second line therapy, 58 % of responders are performing eradication control by themselves. Of those, 70 % always take biopsies for antibiotic susceptibility testing. Conclusions: The results of our survey suggest that most private gastroenterologists in Germany adhere to current guidelines for H. pylori management; however, some relevant deviations seem to exist. Our data might be useful for further developments of clinical guidelines and their communication among the medical community.

Diagnostic of Helicobacter pylori infection

There is progress in endoscopy techniques. While it is not yet possible to detect Helicobacter pylori directly in the stomach, it becomes easier to detect the mucosal changes induced by the bacteria. Some small changes can also increase the sensitivity of the invasive tests, for example culture or histology, but the wide use of proton-pump inhibitors has a negative impact on these tests. Only molecular methods are able to detect a limited load of bacteria, especially by using real-time PCR but also with new methods, for example dual-priming oligonucleotide-based PCR, loop-medicated isothermal amplification, droplet-digital PCR or a multiple genetic analysis system. Among the noninvasive tests, urea breath test remains a test of major interest, while there are attempts to develop an ammonia breath test and other nanosensor devices. A new antigen stool test, a chemoluminescence immunoassay using the LIAISON apparatus has also been tested for the first time with success. Despite its limitations, serology remains the most popular test to detect H. pylori antibodies. It also allows pepsinogen dosage which is of interest for detecting atrophy.

[Bleeding in patients receiving dual antiplatelet therapy after acute coronary syndrome - significance, prevention and interdisciplinary management]

For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Premature discontinuation of dual antiplatelet therapy is associated with an increased risk of ischaemic events. However, antiplatelet therapy is also associated with an increased risk of bleeding that should not be under- or overestimated. To ensure an optimal care of patients receiving dual antiplatelet therapy after an acute coronary syndrome, an interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology gathered bleeding-related information and developed recommendations relevant to daily clinical practice. These include the significance of bleeding events in the course of treatment, measures for bleeding prevention and the adequate care of patients with bleedings.

[Insufficient symptom control under long-term treatment with PPI in GERD - fact or fiction?]

BACKGROUND

Randomized controlled trials show that patients with gastroesophageal reflux disease (GERD) and treatment with proton pump inhibitors (PPI) in about 30% of the cases complain about persisting reflux symptoms (heartburn, regurgitation). The aim of the study was to evaluate the efficacy of PPI long-term treatment in patients with GERD in the family doctor's office.

METHOD

Patients with GERD and a PPI therapy of at least one year participated in a prospective, multicenter observational study. The patients obtained a questionnaire together with a further prescription of PPI. They were asked about the intensity and frequency of heartburn, regurgitation and sleep disorders due to reflux symptoms, satisfaction with PPI therapy, diagnostics performed up to now (endoscopy, pH monitoring, manometry) and surgical consultation. The questionnaire included a validated instrument for the diagnosis of GERD (GerdQ). Patients with the diagnosis "GERD " according to the questionnaire who were very dissatisfied with their current PPI therapy (score 1 or 2 on a 5-point Likert scale) were defined as "lost patients " (LOPA).

RESULTS

39% of the patients still suffered from heartburn at least two days a week, 30% of regurgitation. In 22% of the patients, reflux symptoms led to sleep disorder at least two days a week. 20% of the patients were very dissatisfied with the current PPI therapy. 70% of them (= 14% of the total patient population) were "lost patients " according to the definition. An endoscopy was performed in 86% of the patients and function diagnosis (pH monitoring ± manometry) in 8%. A surgeon was consulted in 8% of the patients, a third of which had received function diagnosis before.

CONCLUSIONS

A poor symptom control can often be found in GERD patients with PPI long-term therapy, but does not stand out in the daily routine. So diagnosis will not continue and treatment alternatives will not be searched for. In the future quality of treatment should be verified e. g. by questionnaires.

[S2k-guideline Helicobacter pylori and gastroduodenal ulcer disease]

In the line "bismuth-containing quadruple therapy" of Table 7 (p 342), in the column "dosage" incorrectly at the three antibiotics respectively 1-1-1-1. The correct is: 3-3-3-3.

Management of reflux esophagitis: does the choice of proton pump inhibitor matter?

BACKGROUND

Proton pump inhibitors (PPIs) are the treatment of choice for reflux esophagitis (RE). The effectiveness of PPIs throughout RE management, from healing to maintenance, has not been fully studied.

AIM

To compare esomeprazole with lansoprazole or pantoprazole for RE management using a management model.

METHODS

Data from six studies comparing esomeprazole with lansoprazole or pantoprazole for healing (4-8 weeks) or maintenance of healing (6 months) of RE were incorporated into hypothetical management models to determine the proportion of patients in endoscopic remission after sequential healing and maintenance therapy, assuming that patients received the same PPI throughout. The number needed to treat (NNT) to achieve one more patient in remission with esomeprazole vs. other PPIs was estimated. The hypothetical model was validated using results from the EXPO study, which compared esomeprazole with pantoprazole for RE healing and maintenance.

RESULTS

Overall, esomeprazole 40 mg produced higher rates of healing (life-table estimates) than lansoprazole 30 mg (82.4-92.6% vs. 77.5-88.8%; p < 0.01) or pantoprazole 40 mg (95.5% vs. 92.0%; p < 0.001) and higher rates of endoscopic and symptomatic remission at 6 months than lansoprazole (83.0-84.8% vs. 74.0-75.9%; p < 0.001; life-table estimates) or pantoprazole (70.9% vs. 59.6%; p < 0.0001; observed rates). In the hypothetical management model, the NNT for esomeprazole was 9 vs. lansoprazole and 8 vs. pantoprazole. The actual NNT for esomeprazole vs. pantoprazole in the EXPO study was 9 (95% confidence interval: 6; 16).

CONCLUSIONS

In this management model, esomeprazole was more effective than either lansoprazole or pantoprazole for maintaining remission after sequential healing and 6 months' maintenance therapy for RE.

The epidemiology, diagnosis, and treatment of Barrett's carcinoma

BACKGROUND

Roughly 3000 new cases of Barrett's carcinoma arise in Germany each year. In view of recent advances in the epidemiology, diagnosis, and treatment of this disease, an update of the clinical recommendations is in order.

METHODS

This review is based on selected relevant publications, including current reviews, meta-analyses, and guidelines.

RESULTS

The risk of progression of Barrett's esophagus to carcinoma lies between 0.10% and 0.15% per year. Risk factors for progression include male sex, age over 50 years, obesity, longstanding and frequent reflux symptoms, smoking, length of the Barrett's esophagus, and intraepithelial neoplasia. Well-differentiated carcinomas that are confined to the esophageal mucosa can be resected endoscopically with a cure rate above 90%. For more advanced, but still locally confined tumors, surgical resection is the treatment of choice. In stages cT3/4, the prognosis can be improved with neo-adjuvant chemo - therapy or combined radiotherapy and chemotherapy. Metastatic Barrett's carcinoma can be treated by endoscopic, chemotherapeutic, radiotherapeutic, and palliative methods.

CONCLUSION

Early carcinoma can often be cured by endoscopic resection. Locally advanced carcinoma calls for multimodal treatment. Current research focuses on means of preventing the progression of Barrett's esophagus, the scope of applicability of endoscopic techniques, and the optimization of multimodal treatment strategies for advanced disease.

Endoscopic procedures in patients under clopidogrel or dual antiplatelet therapy: a survey among German gastroenterologists and current guidelines

BACKGROUND

Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy.

METHODS

A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK.

RESULTS

73 (33 %) chief gastroenterologists returned completed questionnaires, 35 (48 %) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85 %) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41 %) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49 %) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5 %) in the case of combined antiplatelet therapy. However, in emergency situations more than 60 % of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44 %) under clopidogrel monotherapy, but only in 4 (5.5 %) under dual antiplatelet therapy.

CONCLUSION

Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.