Triple therapy with sucralfate, tetracycline, and metronidazole for Helicobacter pylori-associated duodenal ulcers

Triple therapy with bismuth, metronidazole, and tetracycline or amoxicillin is effective for the treatment of Helicobacter pylori, but side effects are common. Sucralfate inhibits H. pylori hemagglutinin, protease, and lipase and thus might affect colonization of the bacterium in the stomach.

OBJECTIVE

We compared the efficacy and side effects of triple therapy with sucralfate versus triple therapy with bismuth plus omeprazole in the treatment of H. pylori-associated duodenal ulcer (DU).

METHODS

One hundred and fifty DU patients were recruited in this study; 71 cases were randomized to receive bismuth 120 mg q.i.d., metronidazole 400 mg q.i.d., and tetracycline 500 mg q.i.d. (BMT) for 1 wk, and 79 cases were randomized to receive sucralfate 1 g q.i.d., metronidazole 400 mg q.i.d., and tetracycline 500 mg q.i.d. (SMT) for 1 wk. For the ulcer treatment, BMT patients were also given omeprazole 20 mg daily for 4 wk, and SMT patients received sucralfate for 4 wk from day of randomization.

RESULTS

Fifty-three patients in the BMT group and 60 in the SMT group finished the treatment and follow-up at 8 wk. H. pylori was eradicated in 49 out of 53 (92%) patients in the BMT group and in 45 out of 60 (75%) patients in the SMT group (p = 0.0057). Forty-nine (92%) patients who received omeprazole and BMT and 53 (88%) patients who received SMT had healed DU at 8 wk (p = 0.34). Side effects related to medication were reported in 38 (71.7%) patients in the BMT group and in 42 (70%) patients in the SMT group. On an intention-to-treat basis, there was no difference in ulcer healing between the BMT group (93.1%) and the SMT group (89.7%). H. pylori eradication was achieved in 84.4 and 66.2% in the BMT and SMT groups, respectively (p = 0.018).

CONCLUSION

Therapy of sucralfate, tetracycline, and metronidazole for 1 wk has a satisfactory but lower success rate in eradication of H. pylori when compared with the conventional triple therapy plus omeprazole. Side effects of this therapy are no fewer than the conventional triple therapy.

Laparoscopic left adrenalectomy: a new approach

Left adrenalectomy has been performed previously via anterior, posterior, loin or thoracoabdominal approaches. In the classical transabdominal approach the left adrenal gland is resected following either mobilization of the spleen with the tail of the pancreas or after entering the lesser sac, mobilizing the inferior border of the pancreas off the adrenal gland. This report describes laparoscopic left adrenalectomy, in a patient with Conn's syndrome, performed by a new approach via the root of the left transverse mesocolon.

Some new insights into bladder function in infancy

OBJECTIVES

To evaluate normal bladder function and micturition patterns in infants.

PATIENTS, SUBJECTS AND METHODS

Twenty-one infants (16 boys, five girls; mean age 5.9 months) with no lower urinary tract pathology underwent natural filling cystometry. Micturition patterns were also observed simultaneously with polysomnography in 26 healthy neonates (16 boys, 10 girls; mean age 7.4 days).

RESULTS

In infants, cystometry showed (95% CI) a capacity of 42-53 mL, a maximum rise in detrusor pressure during voiding of 95-120 cmH2O and a voiding efficiency (voided volume/capacity) of 0.86-0.91. On micturition, urinary flow was discoordinated from peak detrusor pressures in 10 infants. Detrusor instability occurred in one of 21 infants. Micturition was observed only during wakefulness or on arousal from sleep. In neonates, 17 of 61 recorded voids (28%) were during full wakefulness and 44 (72%) during arousal from sleep. Notably, none of the recorded voids occurred during quiet sleep.

CONCLUSIONS

The normal infant's bladder was stable and emptied almost completely. Voiding with incomplete co-ordination between detrusor contraction and urinary sphincter relaxation could be normal. Micturition never occurred during quiet sleep. There was cortical arousal in response to a full bladder even in new-born infants. This contradicts the traditional concept of a totally uninhibited bladder in infancy. There are potential implications for the management of children with nocturnal enuresis.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.

Intravenous ciprofloxacin as treatment for patients with acute suppurative cholangitis: a randomized, controlled clinical trial

One hundred consecutive patients with acute suppurative cholangitis were randomized in a prospective, controlled clinical trial to receive either ciprofloxacin (200 mg bd iv) or triple therapy comprising ceftazidime (1 g bd iv), ampicillin (500 mg qds iv) and metronidazole (500 mg tds iv); 46 and 44 patients in the ciprofloxacin and triple therapy groups respectively were suitable for inclusion in the analysis of efficacy. In two-thirds of the patients biliary obstruction was caused by ductal calculi and in one-third by malignant or benign strictures of the biliary tract. Bacteraemia was documented in 38% of patients in the ciprofloxacin group and in 34% of patients in the triple therapy group, while bile cultures were positive in 87% and 92% of patients in the ciprofloxacin and triple therapy groups respectively. Escherichia coli, Klebsiella spp. and Enterococcus spp. were the most common biliary isolates. Eighty-five per cent of evaluable patients in the ciprofloxacin group and 77% of those in the triple therapy group responded to therapy. The mean durations of fever, septicaemic shock and hospitalization were also similar in the two treatment groups. Six (13%) patients in the ciprofloxacin group and seven (16%) in the triple therapy group required urgent endoscopy or surgery for uncontrolled infection. Recurrence of fever after an initial response was documented in one (2%) patient receiving ciprofloxacin and in three (7%) patients receiving triple therapy. The incidences of mortality were 4% in the ciprofloxacin group and 2% in the triple therapy group. The results of this study suggest that ciprofloxacin alone is adequate empirical therapy for patients with cholangitis.

Effect of carbon dioxide pneumoperitoneum on bacteraemia and endotoxaemia in an animal model of peritonitis

Laparoscopy is increasingly used in conditions complicated by peritonitis. A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteraemia. This study examines the effect of carbon dioxide pneumoperitoneum on bacteraemia, endotoxaemia and physiological correlates of sepsis in an animal model of peritonitis. New Zealand white rabbits were assigned to three groups of six animals. Group 1 received an intraperitoneal inoculation of 10(9) colony-forming units of Escherichia coli followed by a 10-cm midline laparotomy. Group 2 received an identical bacterial inoculum followed by a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Group 3 received no bacteria but had a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Groups 1 and 2 had significantly higher levels of bacteraemia (P < 0.01) and endotoxaemia (P < 0.01) accompanied by significantly lower mean arterial pressures (P < 0.05) and higher heart rates (P < 0.05) compared with group 3. After 6 h groups 1 and 2 were significantly hypocarbic (P < 0.01), leucopenic (P < 0.01) and thrombocytopenic (P < 0.01). There was no difference between group 1 and group 2. A carbon dioxide pneumoperitoneum of 12 mmHg does not increase bacteraemia or endotoxaemia, nor does it adversely affect physiological or laboratory correlates of sepsis compared with laparotomy in this animal model of peritonitis.

Laparoscopic repair of perforated peptic ulcer

A total of 100 consecutive patients with perforated duodenal or juxtapyloric ulcers were treated by: laparotomy and omental patch repair (group 1, n = 44); laparoscopic suture patch repair (group 2, n = 35); and laparoscopic fibrin glue repair (group 3, n = 21). The three groups were comparable in Acute Physiology And Chronic Health Evaluation II score and in other known operative risk factors such as shock on admission, delayed presentation and associated underlying medical illness. Operative mortality and morbidity data were identical in all groups. The mean operating time was 52.1, 101.3 and 61.1 min respectively in the three groups (group 1 versus group 2, group 2 versus group 3, and group 1 versus groups 2 and 3 combined, P < 0.001). The median number of doses of analgesia required after operation was 4, 3 and 1 respectively (group 1 versus groups 2 and 3, P < 0.05). Conversion to laparotomy was necessary in six patients in group 2 and in one in group 3 (P not significant). The median hospital stay was 5 days in all three groups. Patients who underwent laparoscopic repair of perforated peptic ulcer required fewer postoperative doses of analgesia than those who had open repair. Laparoscopic glue repair has the additional advantage over laparoscopic suture of being technically simpler; it also takes less time to perform.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.

DNA ploidy as a predictor of cervical metastasis in advanced squamous carcinoma of the tongue

Flow cytometric analysis of nuclear DNA content was performed in 34 squamous cell carcinomas of oral cavity and base of tongue tumours using archived paraffin-embedded tissues. The DNA content was correlated with the presence of cervical metastasis. Ten and 24 patients were classified as early (I & II) and advanced (III & IV) clinical stages, respectively. The DNA index (DI) was grouped into diploid (DI 0.85-1.15) and non-diploid. Seven (70%) tumours were non-diploid in clinical stages I & II. Four out of 7 (57%) developed initial and late cervical lymph node metastasis (p > 0.05). There were 15 (62.5%) non-diploid tumours in clinical stages III & IV. Thirteen out of 15 (86.7%) had cervical lymph node metastases (p < 0.05). However, the survival period and the incidence of recurrent disease for the whole group did not show any association with DNA ploidy. Our results suggest that DNA content may be useful as a reliable predictor of regional metastasis in advanced stage carcinoma of the tongue.

Controlled duodenostomy for difficult duodenal stump

Three patients with bleeding duodenal ulcer underwent emergency Pólya's gastrectomy for haemostasis after failed endoscopic treatment. Intra-operatively, it was impossible to close the duodenal stump safely because of surrounding fibrosis and scarring. Controlled lateral wall duodenostomy was performed as an attempt to lower the intraluminal pressure of the afferent loop and good results had been observed in all three patients.

Resection of hepatocellular carcinoma with diaphragmatic invasion

Fourteen consecutive patients with hepatocellular carcinoma (HCC) and diaphragmatic invasion found during operation and confirmed histopathologically were studied. They were treated by resection of the liver tumour en bloc with part of the diaphragm. Eight of the 14 patients had a diaphragmatic hump on chest radiography. Preoperative ultrasonography, computed tomography and hepatic angiography were unable to diagnose diaphragmatic invasion in these patients. A control group of 14 closely matched patients were selected from 98 undergoing curative resection for HCC during the period of the study. No evidence of a diaphragmatic hump was found in the control patients (P < 0.001). There was no significant difference in survival, operative morbidity or mortality rates between the two groups. In patients with HCC situated in the dome of the liver, the presence of a diaphragmatic hump on chest radiography strongly suggests invasion of the diaphragm. There was no difference in outcome in patients with or without diaphragmatic invasion; the tumour should be resected if the patient is fit for operation.

Establishment and characterization of a human cell line from a squamous carcinoma of the tongue

A human squamous carcinoma cell line, PWH-S1, has been established from the metastatic lymph node of a Chinese patient with a squamous cell carcinoma of the tongue. The fibroblast-free culture has been propagated in DMEM supplemented with 10% fetal bovine serum for more than 100 passages. PWH-S1 cells showed anchorage-independent growth in 0.3% agar solution. PWH-S1 cell line exhibited a monolayer growth and loss of contact inhibition. The in vitro doubling time of the PWH-S1 cell line was approximately 28 h. PWH-S1 was tumourigenic after inoculation into nude mice. Karyotype analysis showed the chromosome abnormality with a modal number of 69. Electron microscopy demonstrated poorly differentiated neoplastic cells with some features of squamous cell differentiation. No human papillomavirus (type 6, 11, 16, 18, 31) was detected in the PWH-S1 cell line by the polymerase chain reaction.

Antibacterial treatment of gastric ulcers associated with Helicobacter pylori

BACKGROUND

There is a strong association between infection with Helicobacter pylori and gastric ulcers that are unrelated to the use of nonsteroidal antiinflammatory medications. We studied the efficacy of antibacterial therapy without medication to suppress gastric acid for the treatment of patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal agents.

METHODS

Patients with gastric ulcers seen on endoscopy and with H. pylori infection confirmed by smear or culture were randomly assigned to receive either a one-week course of antibacterial agents (120 mg of bismuth subcitrate, 500 mg of tetracycline, and 400 mg of metronidazole, each given orally four times a day) or a four-week course of omeprazole (20 mg orally per day). Follow-up endoscopies were performed after five and nine weeks. The patients and their physicians were aware of the treatment assignments, but the endoscopists were not.

RESULTS

A total of 100 patients were randomly assigned to treatment, and 85 completed the trial. At five weeks, H. pylori had been eradicated in 41 of the 45 patients in the antibacterial-treatment group (91.1 percent; 95 percent confidence interval, 82.9 to 99.3) and in 5 of the 40 in the omeprazole group (12.5 percent; 95 percent confidence interval, 2.3 to 22.7; P < 0.001). The gastric ulcers were healed in 38 of the patients treated with antibacterial drugs (84.4 percent; 95 percent confidence interval, 73.9 to 95.0) and in 29 of those treated with omeprazole (72.5 percent; 95 percent confidence interval, 58.6 to 86.4; P = 0.28). At nine weeks, ulcer healing was confirmed in 43 of the patients receiving antibacterial therapy and in 37 of those receiving omeprazole (P = 1.0). The mean (+/- SD) duration of pain during the first week of treatment was 1.9 +/- 2.6 days in the omeprazole group, as compared with 3.6 +/- 3.0 days in the antibacterial-treatment group (P = 0.004). One year after treatment, recurrent gastric ulcers were detected in 1 of 22 patients (4.5 percent) in the antibacterial-treatment group and in 12 of 23 (52.2 percent) in the omeprazole group (P = 0.001). H. pylori was detected in the 1 patient with a recurrent ulcer who had received antibacterial treatment and in 10 of the 12 patients with recurrent ulcers who had received omeprazole.

CONCLUSIONS

In patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal antiinflammatory drugs, one week of antibacterial therapy without acid suppression heals the ulcers as well as omeprazole and reduces the rate of their recurrence.

Pre-operative induction chemotherapy for small cell carcinoma of the oesophagus: a case report

Induction chemotherapy was prescribed to a patient who had locally advanced small cell carcinoma of the oesophagus which was considered to be irresectable on presentation. Significant tumour downstaging was observed and the patient remains recurrence free 16 months after a successful Ivor-Lewis oesophagectomy.

Mucosal pharmacokinetics and pilot study of short course of parenteral imipenem in the eradication of Helicobacter pylori

Eradication of Helicobacter pylori infection is known to reduce the incidence of duodenal ulcer recurrence. The most commonly used regimen for H. pylori infection is triple antimicrobial therapy for 1-2 weeks. This treatment is associated with frequent side effects and hence unsatisfactory compliance. As in vitro data showed that H. pylori is sensitive to imipenem, the pharmacokinetics of this drug in the gastric milieu, and the clinical efficacy of imipenem with omeprazole in eradicating H. pylori infection were studied. Imipenem/cilastatin levels in serum, gastric secretion and gastric mucosa were assayed in four patients after intravenous injection of a bolus dose of 500 mg. The serum and gastric secretion levels of imipenem achieved were more than 10 times the minimum inhibitory concentration of the drug for H. pylori. Gastric mucosal levels of imipenem vary considerably with time, which probably indicates rapid elimination of the drug into the gastric lumen. In the second part of this study, imipenem/cilastatin was given intravenously for the first 2 days after diagnosis of H. pylori infection in patients with endoscopically confirmed duodenal ulcers. The patients were also treated with 4 weeks of omeprazole. Clearance of H. pylori was initially achieved at the end of 2 days in 20 out of 22 (91%) patients. However, when the biopsies were repeated at 8 weeks, recurrence of H. pylori infection was evident in 19 cases (86.3%) indicating a failure of eradication. It was concluded that imipenem/cilastatin in combination with omeprazole failed to eradicate H. pylori infection.

Crohn's disease in the Chinese population. An experience from Hong Kong

PURPOSE

Crohn's disease was extremely rare among Chinese. We reviewed all cases diagnosed as having Crohn's disease during a five-year period.

METHODS

A diagnosis of Crohn's disease was made only if all of the following criteria were fulfilled: 1) clinical symptom(s) and sign(s) compatible with chronic inflammatory bowel disease; 2) exclusion of intestinal infection by repeated stool cultures; 3) macroscopic features of small and/or large intestinal inflammation with skip lesion, stricture, and fistula formation; 4) histologic features of Crohn's disease, i.e., focal lymphoid aggregate, focal cryptitis, and granuloma formation; 5) clinical response to conventional therapy for inflammatory bowel disease.

RESULTS

Fifteen ethnic Chinese patients were diagnosed as having Crohn's disease in this period. All patients had colitis, whereas small intestine inflammation was documented in only 47 percent of patients. Extraintestinal manifestations were uncommon except for arthropathy: ankylosing spondylitis (2), sacroiliitis (1), juvenile rheumatoid arthritis (1), and colitic arthritis (1). The majority of our patients responded to medical therapy. Surgery was undertaken in 33 percent of patients.

CONCLUSION

Although there is a general increased incidence of Crohn's disease in the Western world, we too are beginning to see more cases in the Far East. Nevertheless, gastrointestinal infection with bacteria and/or parasites should still be carefully excluded in these countries.

Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia

Over a 15-month period, 39 patients (37 men) of mean age 52 years underwent laparoscopic inguinal hernia repair. Seven patients had bilateral hernia. Forty-six hernias (33 indirect, five direct, eight both direct and indirect) were repaired. A piece of polypropylene mesh measuring 8 x 10 cm was used to cover the direct and indirect spaces with an endoscopic multifeed hernia stapler. The mean operating time for unilateral and bilateral repair was 49 and 63 min respectively (range 25-90 min). One-third of patients required no postoperative analgesia and only seven had more than one injection of pethidine. The median postoperative stay was 1 (range 1-3) days. The mean period to resumption of daily activities was 7 (range 4-21) days. Three patients complained of paraesthesia of the lateral aspect of the thigh and one developed a hydrocele. Two recurrences were noted on follow-up at 3 months.

Two-team synchronous oesophagectomy

Between 1984 and 1992, 131 patients underwent two-team synchronous oesophagectomy for carcinoma. Some 95 per cent of tumours were successfully resected by this technique. In 5 per cent of patients the tumour was found to be irresectable at operation and gastric bypass was performed. The overall operative mortality rate was 8 per cent and the pulmonary complication rate 10 per cent. The actuarial survival rate was 55 per cent at 1 year, 22 per cent at 3 years and 16 per cent at 5 years. When compared with the traditional two-stage Lewis approach, two-team synchronous oesophagectomy was significantly faster (mean 222 versus 282 min), but was not significantly different with respect to blood loss, transfusion requirement, pulmonary complications or operative mortality rate. Patients undergoing two-team oesophagectomy had a significantly shorter hospital stay than those receiving the two-stage procedure (mean 16 versus 24 days).

Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study

Eighteen patients with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial yttrium-90 microspheres. All these patients showed a lung shunting below 15% and a tumour-to-normal ratio higher than 2 as determined by diagnostic technetium-99m macroaggregated albumin (Tc-MAA) gamma scintigraphy. The treatment was given through an arterial port placed during laparotomy. The radiation doses to the liver and tumour were determined intraoperatively with a beta probe and liquid scintillation counting of multiple liver biopsies. The treatment was well tolerated without major complications. In all patients the tumour marker fell to a level which ranged from 41% to 0.2% of the pretreatment level. Tumour regression was found to be dose related. Progressive or static disease occurred in a higher proportion of patients whose tumours received < 120 Gy (P = 0.005). Survival was better in those whose tumours received > 120 Gy (median survival = 55.9 weeks) than those whose tumours received lower doses (median survival = 26.2 weeks). This difference is statistically significant with P = 0.005. We conclude that yttrium-90 microsphere therapy is safe and that tumour response is dose related. A tumour dose of > 120 Gy is recommended.