Ectopic opening of the common bile duct into various sites of the upper digestive tract: a case series

BACKGROUND

Ectopic opening of the common bile duct (CBD) into the GI tract is an extremely rare congenital anomaly. The clinical implications and frequency of this anomaly are not clearly known.

OBJECTIVE

To present a case series of ectopic opening of the CBD into various sites of the upper digestive tract and discuss clinicopathological features of this condition.

DESIGN AND SETTING

Retrospective, observational study in a single tertiary care medical center.

PATIENTS

Consecutive patients undergoing ERCP who received a diagnosis of an ectopic opening of the CBD between September 2001 and August 2009 were reviewed.

INTERVENTIONS

Endoscopic and cholangiographic findings were reviewed.

MAIN OUTCOME MEASUREMENTS

The endoscopic and cholangiographic findings and clinical course of these patients were reviewed.

RESULTS

During the study period, 1040 patients underwent ERCP. A total of 11 patients (6 men and 5 women with a median age of 59.2 years) received a diagnosis of an ectopic opening of the CBD. The opening sites of the CBD were located as follow: 1 in the stomach, 4 in the duodenal bulb, 3 at a more lateral site of the second portion of the duodenum, and 3 in the third part of the duodenum. Seven patients had choledocholithiasis, 2 had acute pancreatitis, and 3 had severe cholangitis.

CONCLUSION

Although an ectopic opening of the CBD is rare, it may be associated with severe pancreaticobiliary disorders. Endoscopists should be aware of this anomaly and know what to do in case they encounter the condition.

An unusual cause of acute abdomen: mesenteric heterotopic pancreatitis causing confusion in clinical diagnosis

Heterotopic pancreas is defined as the presence of pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Frequent symptoms and signs are epigastric pain, abdominal fullness and tarry stools. The most frequent locations of heterotopic pancreas tissue are the stomach and jejunum; however, there are a few reported cases of heterotopic pancreas in the mesentery of the small intestine. Heterotopic pancreas may or may not cause complications related to the pathologic conditions of the pancreas itself. Here we present a case showing an unusual cause of acute abdomen, which caused confusion in the clinical diagnosis preoperatively. The definitive diagnosis was achieved only after histopathologic examination in the postoperative period. Final diagnosis of the patient was mesenteric heterotopic pancreatitis, which was a complication of heterotopic pancreas itself with a rarely seen location. In conclusion, mesenteric heterotopic pancreatitis is seen very rarely and may be an unusual cause of acute abdomen. If the pathologic condition develops in the heterotopic tissue, as in the case of heterotopic pancreas, signs and symptoms of the disease may cause confusion in the clinical diagnosis. We agree that preoperative diagnosis of heterotopic pancreas is still difficult, even in a symptomatic patient.

Alverine citrate plus simethicone reduces cecal intubation time in colonoscopy - a randomized study

BACKGROUND/AIMS

Successful colonoscopy depends on the insertion of the instrument to the cecum, a detailed examination, and minimal discomfort to the patient during the procedure. The aim of this study was to determine the effects of alverine citrate plus simethicone on the cecal intubation time, colonic spasm and bowel cleanliness.

METHODS

A prospective, randomized, controlled trial in a consecutive series of patients was conducted to compare alverine citrate as an antispasmodic agent for relaxation of spasm with elective colonoscopy. The drug used consisted of 60 mg alverine citrate plus 300 mg simethicone. Sodium phosphate soda and enema were recommended for bowel cleansing. During colonoscopy, spasticity, difficulty of the procedure, pain, and cleanliness of the colon were scored between 0-4. The time required to reach the cecum was recorded as minutes.

RESULTS

Of 165 total patients, 83 and 82 patients were randomized as the drug group (mean age: 51.85+/-13.47 years) and control group (mean age: 51.68+/-16.28 years), respectively. There was a statistically significant difference between the groups in the mean time to reach the cecum in favor of the drug group (7.48+/-3.45 minutes vs. 6.20+/-3.24 minutes; p=0.02). The time to reach the cecum prolonged with an increase in pain score and difficulty score (p=0.0001 and p=0.001, respectively).

CONCLUSIONS

Alverine citrate plus simethicone reduced the intubation time significantly by 19%, from 7.48 minutes to 6.20 minutes.

A case of Behçet's disease presenting with massive lower gastrointestinal bleeding

Behçet's disease, as initially described, is a triad of recurrent oral and genital ulcers and relapsing uveitis. Classified as a systemic vasculitis, it can involve both the arteries and veins of almost any organ. Intestinal Behçet's disease is characterized by deep ulcers, most commonly located in the ileoceal region, with tendency to bleeding and perforation at multiple sites. Here, we report a case of Behçet's disease presenting with lower gastrointestinal bleeding, mesenteric arterial thrombosis and duodenal perforation.

Detection of point mutations on 23S rRNA of Helicobacter pylori and resistance to clarithromycin with PCR-RFLP in gastric biopsy specimens in Mersin, Turkey

BACKGROUND/AIMS

Helicobacter pylori infection has a high prevalence and is considered an important health problem in Turkey. Unfortunately, an effective treatment has not yet been found for the eradication of Helicobacter pylori infection, at least in our country. Standard therapies recommended for the eradication of Helicobacter pylori have failed in the province of Mersin, Turkey. The rate of eradication with the standard triple treatment was only 45% in the province of Mersin. It may be that Helicobacter pylori has become resistant to antibiotics. Therefore, we aimed to determine the rate of resistance to clarithromycin in the province of Mersin.

METHODS

The study included 92 patients presenting with dyspepsia to the Gastroenterology Clinic of Mersin University Medical School and undergoing endoscopy. We obtained gastric biopsy specimens and investigated whether Helicobacter pylori was present and resistant to clarithromycin. We used polymerase chain reaction-restriction fragment length polymorphism to determine A2143G and A2144G mutations and resistance to clarithromycin.

RESULTS

Out of 92 specimens, 37 (40.2%) had Helicobacter pylori DNA. Out of 37 specimens with Helicobacter pylori DNA, 15 (40.5%) had point mutations. Eleven specimens (29.7%) had mutations on nucleotide 2144 and 4 specimens (10.8%) had mutations on 2143.

CONCLUSIONS

Taking account of the failure of the treatment regimens used to eradicate Helicobacter pylori infection in the province of Mersin, the high rate of point mutations determined in this study was not surprising and the rate of resistance to clarithromycin was an important indicator for the failure in the eradication of Helicobacter pylori infection.

Prevalence of celiac disease among dyspeptic patients: a community-based case-control study

BACKGROUND/AIMS

To determine the relation between undiagnosed celiac disease and dyspepsia in the community.

METHODS

Patients presenting to the gastroenterology outpatient clinic of Mersin University Hospital, aged between 18 and 70 years and with no malignancy, malabsorption, chronic diarrhea, inflammatory bowel disease, diabetes mellitus, heart failure or renal failure, were asked to complete a questionnaire for functional bowel disease (based on Rome II criteria for irritable bowel syndrome and dyspepsia). The patients diagnosed with dyspepsia based on Rome II criteria formed the dyspepsia group and those with gastrointestinal complaints other than dyspepsia and irritable bowel syndrome formed the control group. Serum tissue transglutaminase antibody (anti-tTG) was determined in all patients. The patients with anti-tTG levels of >20U/ml underwent endoscopic duodenal biopsy.

RESULTS

The study included a total of 137 patients, of whom 69 (50.4%) were assigned into the dyspepsia group and 68 (49.6%) into the control group. Of 137 patients, 24 (17.5%) had an anti-tTG level of > or =20U/ml: 14 in the dyspepsia group (20.3%) and 10 in the control group (14.7%), with no significant difference between the groups (p=0.39). Of the 24 patients positive for anti-tTG, 15 (64.5%) underwent endoscopy, and of these 15 patients, 8 (53.3%) had endoscopic duodenal biopsy. Biopsy revealed that of the 4 patients in the dyspepsia group, 3 (75%) had Marsh type 0 histology (IEL<40, normal crypt) and 1 (25%) had Marsh type 3a histology. Of the 4 patients in the control group, 3 (75%) had Marsh type 0 histology and 1 (25%) had Marsh type 3a histology. Histopathological examinations showed celiac disease in 2 out of the 8 patients (25%) positive for anti-tTG who underwent biopsy. Intention to treat analyses revealed that 1 of 69 patients in the dyspepsia group (1.44%) and 1 of 68 patients in the control group (1.47%) had celiac disease.

CONCLUSIONS

Celiac disease in this patient population had a high prevalence. Further studies with larger sample sizes are needed to confirm the relation between dyspepsia and celiac disease.

A pilot study evaluating sequential administration of a PPI-amoxicillin followed by a PPI-metronidazole-tetracycline in Turkey

BACKGROUND

There is no effective regimen for the eradication of Helicobacter pylori in our country. It may be due to the increasing prevalence of resistance to antibiotics used for the treatment of H. pylori. Recently, a study from Turkey has revealed that a new treatment scheme consisting of sequential administration of pantoprazole plus amoxicillin for 7 days followed by pantoprazole plus metronidazole, and tetracycline for the remaining 7 days was effective in the first-line treatment of H. pylori. Therefore, we aimed to confirm efficacy of a new therapy scheme in the first-line H. pylori eradication.

MATERIAL AND METHODS

This is a prospective, open label, single center, pilot study and included 32 patients infected with H. pylori diagnosed by both histologic examinations, rapid urease test and (13)C-urea breath test (UBT). The patients received a 14-day sequential regimen (pantoprazole 40 mg b.d. plus amoxicillin 1000 mg b.d. for 7 days and pantoprazole 40 mg b.d., metronidazole 500 mg b.d. and tetracycline 500 mg q.d. for the remaining 7 days). Eradication was assessed with (13)C-UBT 4 weeks after completion of the therapy. Intention-to-treat and per-protocol eradication rates were determined.

RESULTS

At intention-to-treat analysis, the eradication rate was 50% (16/32). For the per protocol analysis, the eradication rate was 57% (16/28). There were no significant adverse effects and treatment compliance was good.

CONCLUSION

A new therapy consisting of sequentially administered drugs for 14 days yielded unacceptably low eradication rates. This scheme was not efficient for H. pylori eradication in our region. Further investigations are needed to determine the effectiveness of this scheme in other regions of Turkey.

Watermelon colon: is there an association with alcohol?

BACKGROUND

Watermelon colon, or rectal vascular ectasia of the colon, is a very rare vascular lesion.

CASE REPORT

A 56-year-old male heavy drinker was admitted to hospital with hematochezia. Colonoscopy revealed linear, watermelon-like vascular stripes throughout the entire colon. Rectal biopsies confirmed the vascular nature of these lesions, showing dilated and trombosed capillaries in the lamina propria. He had neither cirrhosis nor portal hypertension. The watermelon-like lesions regressed spontaneously following the cessation of alcohol intake.

CONCLUSIONS

This observation suggests that this condition can be triggered by alcohol.

Low efficacy rate of moxifloxacin-containing Helicobacter pylori eradication treatment: in an observational study in a Turkish population

BACKGROUND

Standard triple therapy for Helicobacter pylori has an eradication rate of about 50% in Turkey. It may be due to an increased resistance of H. pylori to antibiotics. Therefore, we aimed to investigate the effectiveness of a new second-generation fluoroquinolone, moxifloxacin-containing triple therapy in H. pylori eradication.

MATERIAL AND METHODS

This is an open-label, prospective, single-center, pilot study. We studied 71 dyspeptic patients infected with H. pylori diagnosed by both histology and rapid urease test. Out of 71 dyspeptic patients, 64 had non-ulcer dyspepsia and seven had peptic ulcer. Patients received pantoprazole (40 mg b.i.d.) plus moxifloxacin (400 mg/day) and amoxicillin (1000 mg b.i.d.) for 14 days. Eradication was assessed 4 weeks after completing the therapy by histology and rapid urease test. Per-protocol and intention-to-treat eradication rates were determined.

RESULTS

The eradication rate was 42.2% for the intention-to-treat analysis and 47.6% for the per-protocol analysis. Of all patients included in the study, 29.5% had side-effects and only 2.8% of the patients discontinued the treatment because of side-effects. Most of the complications were mild and self-limiting.

CONCLUSION

Triple therapy with pantoprazole, moxifloxacin, and amoxicillin for 14 days yielded unacceptably low eradication rates. However, using tests of susceptibility to antibiotics, further studies with larger sample sizes are needed to judge these eradication rates of moxifloxacin containing eradication treatment.

Effects of seasonal variations on acute upper gastrointestinal bleeding and its etiology

BACKGROUND/AIMS

The aim of this study was to determine the causes and risk factors of acute upper gastrointestinal bleeding, a frequently encountered medical emergency, and to determine any relation in its frequency according to month or season.

METHODS

We evaluated the records of 336 patients who presented to our hospital with acute upper gastrointestinal bleeding between October 2001 and June 2005. Three hundred and sixteen patients had endoscopy within 12-24 hours of admission. Causes of bleeding, risk factors, drug usage and admission dates were documented, any relations with season or month of occurrence were determined and statistical analyses were made.

RESULTS

Two hundred and thirty-seven patients were male (70.5%) and 99 patients female (29.5%), with an average age of 57.7 years. The most frequent endoscopic findings were peptic ulcer (48.2%) and esophageal (or gastric) variceal bleeding (22%) in all seasons and months except September. Non-steroidal anti-inflammatory drugs (NSAIDs) were the most common risk factor (44.3%) and the risk of acute gastrointestinal bleedings was high in all seasons and months except October. March (14%) and spring (33.6%) were the month/season when bleeding was the most frequent. There was a gradual increase in the number of patients admitted with bleeding from autumn to spring. Furthermore, NSAID usage, which was the most frequent risk factor, showed a monthly fluctuation similar to the fluctuation in the total number of bleeding patients.

CONCLUSION

In the province of Mersin, Turkey, the most common cause of acute upper gastrointestinal bleeding is peptic ulcer, and NSAID usage is the most frequent etiological risk factor. Although statistically insignificant, there were seasonal and monthly fluctuations in upper gastrointestinal bleedings in Mersin, where the Mediterranean climate is predominant. Bleeding was the most frequent in March and spring and the least frequent in September and autumn. Bleedings showed a seasonal fluctuation similar to that of NSAID usage, which was the most frequent risk factor. Therefore, if unnecessary NSAID usage can be prevented, it may be possible to protect most people against this emergency condition, which can be lethal, in all months and seasons.

Helicobacter pylori-associated atrophic gastritis and carotid intima-media thickness: is there a link?

Chronic infections are associated with cardiovascular diseases. Helicobacter pylori-induced chronic active gastritis results in atrophic gastritis. In this study, we attempted to determine carotid intima-media thickness in patients with and individuals without H. pylori-induced atrophic gastritis. Oesophagogastroduodenoscopy was performed on 123 patients for various reasons. Helicobacter pylori were considered positive when histological examination and rapid urease test showed H. pylori. Helicobacter pylori-positive cases were divided into two groups, namely atrophic gastritis and non-atrophic gastritis. Of 123 patients, 92 patients had H. pylori-positive non-atrophic gastritis and 31 had H. pylori-positive atrophic gastritis. There was no significant difference in carotid intima-media thickness between the two groups. Carotid intima-media thickness is not associated with H. pylori-induced atrophic gastritis.

Bismuth-based therapies for the first step eradication of Helicobacter pylori

BACKGROUND/AIMS

Combination of a proton pump inhibitor, amoxicillin, and clarithromycin, which have been recommended as a primary treatment for Helicobacter pylori (H. pylori) infection, provides eradication in approximately 50% of cases of H. pylori infection in Turkey. There is no effective eradication regimen for H. pylori in our country. We aimed to compare bismuth- based triple and quadruple treatments for eradication of H. pylori.

METHODS

Eighty-two patients were enrolled into the study between October 2002 and August 2003. The patients were randomly assigned into two groups. One group received ranitidine bismuth citrate 2x400 mg, metronidazole 3x500 mg and tetracycline 2x1000 mg for 14 days (RMT group) and the other group pantoprazole 2x40 mg, bismuth subcitrate 4x300mg, amoxicillin 2x1000 mg and clarithromycin 2x500 mg for 14 days (PBAC group). The eradication was assessed four weeks after completion of the treatment, and the patients underwent endoscopy and were asked whether there were changes in their symptoms. When H. pylori was negative on both histological examination and urease test, the disease was considered eradicated.

RESULTS

H. pylori was eradicated in 26 of 42 patients in the RMT group (61.9%) and in 22 of 40 patients in the PBAC group (55%). In total, eradication was achieved in 48 out of 82 patients (58.5%). There was no significant difference in eradication between the groups.

CONCLUSION

Neither regimen (RMT or PBAC) was effective in eradicating H. pylori infection in our area. Further investigations are needed.

Acute upper gastrointestinal bleeding due to metastatic lung cancer: an unusual case

There have been several published reports on metastatic lesions in the stomach, but the number of cases have been limited due to the low frequency of the condition. Metastatic lesions in the stomach are usually asymptomatic. A 55-year-old man with known metastatic lung adenocancer exhibited epigastric pain, hematemesis, and melena. A bleeding, ulcerated gastric metastasis was found and treated with endoscopic therapy and omeprazole.

Lipid Profile in Chronic Allograft Nephropathy

Chronic allograft nephropathy (CAN) represents the cumulative and incremental damage to nephrons by time-dependent immunologic and nonimmunologic causes. Hyperlipidemia is one nonimmunologic mechanism that promotes injury and poor function in a renal transplant. The aim of our study was to determine the effect of lipid profiles on CAN among renal transplant recipients. We retrospectively evaluated 53 renal transplant recipients who were classified according to the presence of CAN: CAN+ = 28 (18 males, 10 females) constituted the study group, whereas those with stable graft function CAN- = 25 (14 males, 11 females) were the control group. Biochemical parameters included serum urea, creatinine, total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB), lipoprotein (a), homocysteine, and high-sensitive CRP (hs CRP). Angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB) use was significantly greater among the CAN+ group compared with the controls (P = .02, P = .04). Also, higher serum creatinine levels were observed in the CAN+ group (1.49 vs 1.22 mg/dL, P = .002), whereas serum levels of total cholesterol, triglyceride, hs CRP, and albumin were similar in both groups. The levels of ApoA1, ApoB, and lipoprotein (a) were similar, whereas the LDL/HDL cholesterol ratio and homocysteine levels were significantly higher in the CAN+ group (P = .04, P = .04). In conclusion, the LDL/HDL ratio may have a positive impact on CAN and may be used as a parameter during patient follow-up.

An unusual cause for massive upper gastrointestinal bleeding in children: Dieulafoy's lesion

Dieulafoy's lesion is a rare cause of severe upper gastrointestinal hemorrhage in children and predominantly occurs in the proximal stomach. We report a case of massive upper gastrointestinal bleeding in a 3-year-old boy that originated from a Dieulafoy's lesion and was treated by epinephrine injection.

Is there a relation between irritable Bowel syndrome and urinary stone disease?

Our aim was to investigate the role of renal colic, a clinical condition characterized by excruciating pain, in the etiopathogenesis of irritable bowel syndrome (IBS). Two groups of patients were enrolled in the study. Group I consisted of 59 patients (33 male and 26 female) with a median age of 41.9 (18 to 58) years. The patients in group I were admitted to our clinic with urinary stone disease and with a medical history of acute renal colic. Group II consisted of 55 patients (25 male and 30 female) with a median age of 40.1 (18 to 56) years, complaining of urologic abnormalities other than stone disease. IBS was diagnosed using Rome criteria. Metabolic analysis for stone disease was performed on patients in group I. The incidence of five metabolic abnormalities--low urine volume, hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia--in patients with and without irritable bowel disease was investigated. IBS was found in 16 of the 59 patients (27.1%) in group I and in 6 of the 55 patients (10.9%) in group II. The difference was statistically significant (P < 0.05). Relative risk of developing IBS was 2.48 times higher in patients with urinary stone disease than in those without stone disease. There was no statistically significant difference in the metabolic analysis of patients with and without IBS in group I. IBS causes great suffering. Urinary stone disease should be considered as an etiological factor during management of IBS patients. In the presence of gastrointestinal symptoms, a patient with a medical history of acute renal colic might be referred to a gastroenterologist.

Hepatic alveolar echinococcosis: clinical and radiologic features and endoscopic management

Hepatic alveolar echinococcosis is a rare but potentially life-threatening serious parasitic disease, developing as a result of intrahepatic growth of Echinococcus multilocularis larvae. It may present as an invasive mass causing biliary obstruction or portal hypertension due to invasion of the biliary and vascular structure of the liver. The only curative treatment of the disease is surgical resection; however, early diagnosis is the key point to achieve complete cure. In advanced disease, complications are common. We retrospectively analyzed 12 cases of hepatic alveolar echinococcosis and reviewed the relevant literature. A high index of suspicion and specific radiologic findings are very helpful in the diagnosis of the disease. While benzimidazole derivatives are used for the control of disease, endoscopic retrograde cholangiopancreatography is particularly effective in the biliary involvement, even in the late stage of disease.

Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation

OBJECTIVE

Some benign esophageal strictures are highly resistant to bougie dilation. The aim of this study was to determine whether intralesional steroid injection had additional benefit to Savary-Gilliard's bougie dilation therapy (SGBD).

METHODS

Twenty-one patients were treated with a bougie dilator. The patients were randomized into control and study groups. There were 11 patients in the control group (7 males, 4 females; mean age 45.09 +/- 24.64 years) and 10 patients in the study group (4 males, 6 females; mean age 49.40 +/- 16.49 years). The patients in the control group underwent only SGBD, but patients in the study group received an additional intralesional steroid injection (8 mg triamcinolone acetate into each quadrant). The number of dilations was divided by the follow-up period (in months) to determine the periodic dilatation index.

RESULTS

There was no difference in age, sex, etiology, localization and recurrence of lesions, treatment outcome, complications and the number of dilations between the study and control groups. In the study group, the mean periodic dilatation index was 0.712 (range 0.097-2.75) and 0.289 (range 0-1) before and after injections, respectively (P = 0.03). Additionally, the mean number of dilations was 5.3 (range 2-11) and 1.6 (range 0-5) before and after injections, respectively (P = 0.03). The mean symptom-free interval was 24 +/- 12.75 months in the study group and 5.18 +/- 5.06 months in the control group (P < 0.001). The total periodic dilatation index was 0.193 +/- 0.123 in the study group, while it was 0.597 +/- 0.583 in the control group (P < 0.05).

CONCLUSIONS

It can be concluded that intralesional steroid injections increase efficacy of bougie dilation and decrease the requirement for repetition of bougie dilatation.

Effects of terlipressin on systolic pulmonary artery pressure of patients with liver cirrhosis: An echocardiographic assessment

AIM: Portopulmonary hypertension is a serious complication of chronic liver disease. Our aim was to search into the effect of terlipressin on systolic pulmonary artery pressure among cirrhotic patients.

METHODS: Twelve patients (6 males and 6 females) with liver cirrhosis were recruited in the study. Arterial blood gas samples were obtained in sitting position at rest. Contrast enhanced echocardiography and measurements of systolic pulmonary artery pressure were performed before and after the intravenous injection of 2 mg terlipressin.

RESULTS: Of 12 patients studied, the contrast enhanced echocardiography was positive in 5, and the positive findings in contrast enhanced echocardiography were reversed to normal in two after terlipressin injection. The mean systolic pulmonary artery pressure was 25.5 ± 3.6 mmHg before terlipressin injection, and was 22.5 ± 2.5 mmHg after terlipressin (P = 0.003). The systolic pulmonary artery pressure was above 25 mmHg in seven of these 12 patients. After the terlipressin injection, systolic pulmonary artery pressure was < 25 mmHg in four of these cases (58.3% vs 25%, P = 0.04).

CONCLUSION: Terlipressin can decrease the systolic pulmonary artery pressure in patients with liver cirrhosis.

Comparison of ranitidine bismuth citrate, tetracycline and metronidazole with ranitidine bismuth citrate and azithromycin for the eradication of Helicobacter pylori in patients resistant to PPI based triple therapy

BACKGROUND/AIMS

Helicobacter pylori is the most common infectious disease all over the world. Ten to twenty percent of the patients remain infected despite treatment with proton pump inhibitors (PPIs), amoxicillin and clarithromycin. We compared PPI, bismuth, tetracycline and metronidazole with ranitidine bismuth citrate, tetracycline and metronidazole in cases resistant to PPIs-based triple therapies.

METHODS

The study included 52 patients who underwent a triple therapy with PPI, clarithromycin and amoxicillin for 14 days between September 2001 and December 2002, and were found to be resistant to the therapy. They were randomized to take ranitidine bismuth citrate (Rb) 400 mg twice a day, tetracycline (T) 1 g twice a day and metronidazole (M) 500 mg three times a day for 14 days (RbTM), or ranitidine bismuth citrate (Rb) 400 mg twice a day for 14 days and azithromycin (A) 500 mg once a day for 7 days (RbA). Four weeks after the treatment, endoscopies were repeated, and patients were assessed with respect to changes in symptoms. When H. pylori was negative on histological analysis and urease test, eradication was achieved.

RESULTS

A total of 52 patients, 32 females and 20 males with a mean age of 49+/-12 years, were included in the study. Eradication was achieved in 15 (28%) out of 52 patients in total. There was a significant difference between RbA and RbTM groups (p=0.01). In fact, H. pylori was eradicated in 3 (12%) out of 25 patients in the RbA group, whereas it was eradicated in 12 (44.4%) out of 27 patients in the RbTM group. Symptom scores significantly improved in both groups after the treatment, though there was not a significant difference between the groups (p=0.705).

CONCLUSIONS

Triple therapy including azithromycin does not seem to be a good choice in cases resistant to the first line therapies; however, a similarly lower rate of eradication was achieved with the quadruple therapy proposed. Therefore, different treatment schemes should be applied in resistant patients, and further studies are needed as well.

Maastricht II treatment scheme and efficacy of different proton pump inhibitors in eradicating Helicobacter pylori

AIM: The Maastricht II criteria suggest the use of amoxicillin and clarithromycin in addition to a proton pump inhibitor over 7-10 d as a first line therapy in the eradication of Helicobacter pylori (H pylori) . For each proton pump inhibitor, various rates of eradication have been reported. The present study was to compare the efficacy of different proton pump inhibitors like omeprazole, lansoprazole and pantoprazole in combination with amoxicillin and clarithromycin in the first line eradication of H pylori and to investigate the success of H pylori eradication in our district.

METHODS: A total of 139 patients were included having a Helicobacter pylori (+) gastroduodenal disorders diagnosed by means of histology and urease test. Besides amoxicillin (1000 mg twice a day) and clarithromycin (500 mg twice a day), they were randomized to take omeprazole (20 mg twice a day), or lansoprazole (30 mg twice a day), or pantoprozole (40 mg twice a day) for 14 d. Four weeks after the therapy, the eradication was assessed by means of histology and urease test. It was evaluated as eradicated if the H pylori was found negative in both. The complaints (pain in epigastrium, nocturnal pain, pyrosis and bloating) were graded in accordance with the Licert scale. The compliance of the patients was recorded.

RESULTS: The eradication was found to be 40.8% in the omeprazole group, 43.5% in the lansoprazole group and 47.4% in the pantoprazole group. Sixty-three out of 139 patients (45%) had eradication. No statistically significant difference was observed between the groups. Significant improvements were seen in terms of the impact on the symptom scores in each group.

CONCLUSION: There was no difference between omeprazole, lansoprazole and pantoprazole in H pylori eradication, and the rate of eradication was as low as 45%. Symptoms were improved independent of the eradication in each treatment group. The low eradication rates suggest that the antibiotic resistance or the genetic differences of the microorganism might be in effect. Further studies are required to verify these suggestions.