S3-guideline "helicobacter pylori and gastroduodenal ulcer disease" of the German society for digestive and metabolic diseases (DGVS) in cooperation with the German society for hygiene and microbiology, society for pediatric gastroenterology and nutrition e. V., German society for rheumatology, AWMF-registration-no. 021 / 001

This guideline updates a prior consensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Hygiene and Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE), and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based S 3 level consensus guideline and has also implemented grading criteria according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) process. Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics, and therapy were taken into account.

Host polymorphisms of immune regulatory genes as risk factors for gastric cancer

The infection of the stomach with the gram-negative bacterium Helicobacter pylori is the main risk factor for the development of gastric cancer (GC). This led to the classification of this germ as "definite carcinogen" by the World Health Organization in 1994. The current model of gastric carcinogenesis is based on the interaction of multiple risk factors including virulence factors of the bacterium (e.g. CagA, VacA), environmental factors (diet, smoking) and host factors (gene polymorphisms). The complex interplay among these factors determines the clinical outcome of the infection leading to at least one of three major diseases in 1 out of 7 infected persons, namely ulcer disease, GC and "mucosa-associated lymphoid tissue" lymphoma in 15 %, 1% and 0.1% of all persons infected with H. pylori, respectively. Recently, an increasing number of genomic polymorphisms, mostly single nucleotide polymorphisms have been identified as risk factors for gastric cancer. Among them are genes encoding for cytokines, pattern recognition receptors, cell cycle-regulators, proteases, HLA-molecules, and enzymes for detoxification. In the last years it has become clear that an uniform "genomic risk pattern" for all GC patients does not exist. Most of these host factors are restricted either to the histological type (intestinal vs. diffuse), ethnical background (particularly Caucasian vs. Asian) and tumor localization (non-cardia vs. cardia cancer). Here, we review the current knowledge about the role of host factors for the gastric carcinogenesis focusing on immune-regulatory genes, in particular on the cytokine interleukin-1beta.

A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding

Although the role of emergency esophagogastroduodenoscopy (EGD) and colonoscopy for upper and lower gastrointestinal bleeding (GIB) is well defined, there are no data on the concept of emergency double-balloon enteroscopy (DBE) for small-bowel bleeding. The aim of this study was to retrospectively evaluate the concept of emergency DBE in overt obscure GIB and assess its impact on patient management. A total of 17 emergency DBEs for overt obscure GIB were carried out in ten patients (six women, four men; mean age 68 years, range 35 - 83). The following diagnoses were made: actively bleeding Dieulafoy lesions of the small bowel, n = 2; bleeding tumors, n = 4 (carcinoids n = 2, adenocarcinoma n = 1, lipoma n = 1); bleeding angiodysplasias and/or large arteriovenous malformation (AVM), n = 2; multiple ulcers, n = 1; and no diagnosis, n = 1. Endoscopic therapies included argon plasma coagulation (n = 6), injection of epinephrine (n = 3), and use of fibrin glue (n = 1). It appears that emergency DBE is technically feasible, facilitates both diagnosis and therapy and enables management of patients with massive overt obscure GIB. This study is a first step in establishing the concept of emergency DBE for patients with suspected small-bowel bleeding.

Diagnosis and management of non-erosive reflux disease--the Vevey NERD Consensus Group

BACKGROUND/AIMS

Although considerable information exists regarding gastroesophageal reflux disease with erosions, much less is known of non-erosive reflux disease (NERD), the dominant form of reflux disease in the developed world.

METHODS

An expert international group using the modified Delphi technique examined the quality of evidence and established levels of agreement relating to different aspects of NERD. Discussion focused on clinical presentation, assessment of clinical outcome, pathobiological mechanisms, and clinical strategies for diagnosis and management.

RESULTS

Consensus was reached on 85 specific statements. NERD was defined as a condition with reflux symptoms in the absence of mucosal lesions or breaks detected by conventional endoscopy, and without prior effective acid-suppressive therapy. Evidence supporting this diagnosis included: responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic and histological findings. Functional heartburn was considered a separate entity not related to acid reflux. Proton pump inhibitors are the definitive therapy for NERD, with efficacy best evaluated by validated quality-of-life instruments. Adjunctive antacids or H(2) receptor antagonists are ineffective, surgery seldom indicated.

CONCLUSIONS

Little is known of the pathobiology of NERD. Further elucidation of the mechanisms of mucosal and visceral hypersensitivity is required to improve NERD management.

Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care--a 5-year follow-up

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be associated with laryngo-respiratory symptoms (LRS) such as chronic cough, asthma or laryngeal symptoms.

AIM

To analyse the long-term clinical course of LRS in a large population with GERD and LRS.

METHODS

ProGERD is a prospective multicentre cohort study of 6215 adult out-patients with GERD. At baseline, the prevalence of LRS was assessed. Initial standardized treatment was esomeprazole for up to 8 weeks. After 5 years of follow-up, patients were interviewed for LRS and a multivariate analysis was performed with resolved vs. persistent symptoms for chronic cough, asthma and laryngeal symptoms.

RESULTS

In all, 2886 patients (46.4%) were available for analysis at baseline and at 5 years. The prevalence of chronic cough and laryngeal disorders had decreased while the prevalence of asthma had increased. Resolution of LRS was independent of clinical reflux characteristics or PPI medication.

CONCLUSIONS

In a large population with GERD, only few patients reported persistent LRS over 5 years. Resolution of LRS was independent of the stage of GERD and PPI treatment. Accordingly, data on the direction of causality between GERD and LRS are lacking and the strength of the association between the two must remain controversial.

Tolerability of sorafenib in the treatment of hepatocellular carcinoma (HCC) in patients with Child A and B liver cirrhosis

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Background: Sorafenib (S) is the only drug that prolongs overall survival in patients (pts) with advanced HCC by nearly 3 months in pts with Child A liver cirrhosis (LC). This study aims to evaluate tolerability of S in pts with Child B LC. Methods: Pts with HCC not suitable for curative therapy were treated with S since it became available for clinical use. 50 of 139 consecutive patients diagnosed with HCC were treated with S (8 f, 42 m; median age 67 (18–86) yrs). Initial dose was 400 mg/day and increased in case of good tolerability stepwise up to 800mg/day. Pts were stratified according to the stage of LC and analyzed for treatment toxicity based on the National Cancer Institute Common Toxicity System. Results: 41 pts with HCC had LC, 17 in Child A and 24 in Child B stadium. Due to side effects a dose escalation to 800mg was possible in 9 pts (22.0%) only, 3 with Child A and 6 with Child B LC. Grade 1/2 toxicity was observed in 15 pts with initial Child A (88.2%) and in 11 pts with initial Child B LC (45.8%), grade 3/4 toxicity occurred in 2 pts with Child A (11.8%) and 3 pts with Child B LC (12.5%). After 12 weeks of follow-up, 12 pts with Child A (70.6%) and 10 pts with Child B LC (41.7%) at entry were still under treatment. A deterioration of liver function from Child A to Child B was observed in 5 of 17 pts (29.4%) and from Child B to Child C in 1 patient (4.2%). In 5 pts (29.4%) with Child A LC and 14 pts with Child B LC at entry treatment had been discontinued in advance. Survival in patients with LC Child A was better than in patients with LC Child B (median overall survival 327 (60–495) vs 138 (10–560) days resp., ns). Conclusions: Systemic therapy of advanced HCC with S appears to be a safe treatment option in pts with Child B LC. However, tolerability is an important limitation in the use of S independently of the stage of LC. Whether pts with advanced HCC benefit from a systemic treatment with smaller doses than 800mg/day needs to be addressed in further studies.

[Table: see text]

Eligibility of patients with hepatocellular carcinoma for systemic treatment with sorafenib

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Background: Sorafenib is the first systemic drug that effects prolonged overall survival in patients with advanced hepatocellular carcinoma (HCC) by almost three months with moderate toxicity. This study aims to evaluate how many patients diagnosed with HCC are candidates for systemic treatment and possibly benefit from it. Methods: All patients diagnosed with HCC in our hospital in between January 2006 and June 2008 were analysed regarding the presence and stage of liver cirrhosis, tumor stage and the treatment applied. Results: In a period of 30 months 182 patients were diagnosed with HCC (female n = 42, male n = 140, median age 66 (16–84)). 169 suffered from liver cirrhosis, 96 in Child A, 46 in Child B and 27 in Child C stage. 36 patients (19.8 %) were diagnosed with uninodular disease, in 17 patients (9.3%) 2 or 3 nodules were detected and 129 (70.9%) patients suffered from multinodular HCC. 79 patients received local ablative therapy or transarterial chemoembolisation, 15 underwent surgical resection, 29 patients were treated with best supportive care and 59 patients were candidates for systemic treatment. Out of these 25 either had no liver cirrhosis or were in stage Child A and 17 were in Child B stage and would therefore fit for therapy with sorafenib (23.1%). 17 pts with advanced disease and Child C cirrhosis did not fit for this treatment. Conclusions: Assuming that patients with advanced HCC and good or moderate liver function are candidates for systemic treatment with sorafenib every fifth patient is likely to benefit from the introduction of this treatment option.

[Table: see text]

Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series

The Fujinon intelligent color enhancement (FICE) system is a new, virtual chromoendoscopy technique that enhances mucosal visibility. The aim of this study was to assess the utility of double-balloon enteroscopy (DBE) with FICE technology (EPX-4400 processor, Japan) for the characterization of various small-bowel diseases. Overall, a total of 574 endoscopic pictures were obtained and analyzed. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias. Its use for the characterization of celiac and Crohn's disease appears to be limited. Overall, FICE may become a useful method that aids in characterization and provides new insights to small-bowel pathologies.

[Catheter-free pH-metry using the Bravo capsule versus standard pH-metry in patients with non-erosive reflux disease (NERD)]

BACKGROUND

pH-monitoring is considered the gold standard for the detection of acid reflux in patients with non-erosive reflux disease (NERD). Preliminary pH studies performed over periods longer than 24 hours have shown that in up to one-third of subjects abnormal pH exposure is detected only on the second day of monitoring. Therefore, pH-monitoring during 48 hours may yield more information about pathological acid reflux in patients being investigated for NERD.

AIM

The aim of this study was to compare conventional 24-hour pH-monitoring with the new wireless 48-hour Bravo pH-monitoring in patients with NERD.

PATIENTS AND METHODS

Patients with typical reflux symptoms, a positive reflux disease questionnaire and negative endoscopy (NERD) and without any form of acid suppressive therapy were included in this prospective study. The patients were divided into two groups: group A for conventional 24-hour pH-monitoring and group B for wireless 48-h Bravo pH-monitoring.

RESULTS

76 patients with a diagnosis of NERD based on a positive RDQ questionnaire and negative endoscopy were included. (47 woman, 29 men, median age: 49 years). 54 underwent conventional pH-monitoring and 22 underwent 48-h pH-monitoring with the new wireless BRAVO system. The overall incidence of acid reflux was 55 % in patients with NERD. Acid reflux was detected less frequently when using Bravo as compared to conventional pH-monitoring. In addition, the Bravo pH-metry showed a large day-to-day variability.

CONCLUSIONS

Prolonged pH-monitoring over a period longer than 24 hours did not improve the detection of acid reflux in patients with NERD. Thus, it appears that the Bravo pH-metry does not offer an advantage over standard pH-metry in the daily clinical practice.

The placebo response in functional dyspepsia--reanalysis of trial data

Clinical trial data rarely identify factors contributing to the placebo response. We reanalysed the data from the placebo arm (n = 157) of a functional dyspepsia (FD) trial to determine predictors of placebo response including total GIS score, change in GIS score during run-in, type of FD symptoms, duration of illness, age, gender, body mass index (BMI), family occurrence of FD-like symptoms, smoking and alcohol consumption. The same response criteria were applied to the drug arm (n = 158) of the study. Based on the initial 40% response criterion of the study, 35 (22.2%) were classified as placebo responders (PR), whilst 122 (78.8%) were placebo non-responders (PnR). Response rates for the drug arm were 41.1 and 56.9% respectively. PR had significantly lower GIS scores compared to PnR at visit 1 (10.6 +/- 0.6 and 12.3 +/- 0.4, respectively, P = 0.035), but not at visit 2 with study medication dispensing (10.9 +/- 0.5 and 11.3 +/- 0.4). Hence, PR symptoms increased during run-in by 4.2% whilst PnR symptoms decreased by 6.3% (P < 0.005). Gender, age and duration and type of FD symptoms were not different between PR and PnR. Smoking was less prevalent in PR (3%) compared to PnR (21%) (P < 0.025). Increasing the criteria for the placebo response resulted in higher BMI for PR than for PnR (P = 0.035). None of the predictors for placebo response were able to distinguish responders from non-responders to the drug. Variables predicting the PR point towards behavioural and biological mechanism of the PR, operating simultaneously and independently.

Health-related quality of life in patients with gastro-oesophageal reflux disease under routine care: 5-year follow-up results of the ProGERD study

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a common disorder associated with substantial reductions in health-related quality of life (HRQL).

AIM

To describe patterns of change in HRQL during 5 years of follow-up in a large population of GERD patients.

METHODS

In 2000, a total of 6215 GERD patients were enrolled in the Progression of GERD (ProGERD) study. During follow-up, patients received any medication considered necessary. HRQL was assessed yearly with the Short-Form 36 and the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. Associations between patient characteristics and changes in HRQL were analysed using multiple logistic regression models.

RESULTS

After 5 years, data on HRQL were available for 4597 (74%) patients. Both generic and disease-specific HRQL improved after baseline and remained well above baseline levels in the following years. A clinically relevant decrease in QOLRAD scores was reported by 3-5% of patients. According to our multivariate analysis, a decrease in HRQL was associated with a higher reflux symptom load and the presence of night-time heartburn.

CONCLUSIONS

Only a small minority of the ProGERD population reported a clinically relevant decrease in HRQL, which was associated most strongly with nocturnal heartburn.

Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding

BACKGROUND

Double-balloon enteroscopy (DBE) is a useful method for evaluation of obscure gastrointestinal bleeding (OGIB).

AIM

To determine the incidence of lesions within reach of conventional upper and lower endoscopes as the cause of OGIB in patients referred for DBE.

METHODS

All patients undergoing DBE for OGIB during a 3.5-year period at a university hospital were studied. OGIB was defined according to American Gastroenterological Association (AGA) guidelines.

RESULTS

One hundred and forty-three DBEs were performed in 107 patients for obscure overt (n=85) and obscure occult (n=22) GIB. Lesions outside the SB as possible sources of GIB were found in 51 patients (47.6%) and a definite source of bleeding outside the small bowel (SB) was detected in 26 patients (24.3%). Lesions considered to explain a definite source of GIB were: gastric ulcer (n=3), duodenal ulcer (n=3), Cameron's lesions (n=2), gastric antral vascular ectasias (n=4), radiation proctitis (n=1), radiation ileitis (n=2), duodenal angiodysplasias (n=1), haemorrhoids with stigmata of recent bleed (n=1), colon angiodysplasias (n=3), colon diverticulosis (n=3), colonic Crohn's disease (n=1), anastomotic ulcers (n=1).

CONCLUSIONS

The frequency of non-SB lesions definitely explaining the source of GIB in patients referred for DBE was 24.3%. Therefore, repeat esophago-gastroduodenoscopy (EGD) and ileocolonoscopy should be taken into consideration before DBE.

[S3-guideline "Helicobacter pylori and gastroduodenal ulcer disease"]

This guideline updates a prior concensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE) and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based consensus guideline of S 3 level and has also implemented grading criteria according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics and therapy were taken into account.

Small bowel polyps and tumours: endoscopic detection and treatment by double-balloon enteroscopy

BACKGROUND

Double-balloon enteroscopy has allowed us not only to inspect deeply the small bowel but also to carry out interventions for diseases of the small bowel.

AIM

To evaluate the utility of double-balloon enteroscopy for the diagnosis and therapy of these lesions.

METHODS

All patients undergoing double-balloon enteroscopy for evaluation of small bowel polyps and tumours during a 3.75-year period at a university referral hospital were studied. The types of polyps and tumours as well as endoscopic technique of removal, surgery and complications were documented.

RESULTS

The incidence of small bowel polyps and tumours in-patients undergoing DBE was 9.6%. A total of 40 double-balloon enteroscopy procedures were performed in 29 patients [13 female (44.8%), mean age 51 years, range 22-74]. The following lesions were found most frequently: adenomas in familial adenomatous polyposis syndrome, n = 8; hamartomas, n = 4 (Peutz-Jeghers and Cronkhite Canada syndromes), jejunal adenocarcinoma n = 5, neuroendocrine tumour n = 4 and others n = 6.

CONCLUSIONS

The incidence of small bowel tumours in those in-patients who were undergoing double-balloon enteroscopy was 10%. Double-balloon enteroscopy is useful for the diagnosis and treatment of small bowel polyps and tumours.

[Nutritional support in patients with acute pancreatitis]

A causal therapy for acute pancreatitis is not available, so treatment has to focus on best supportive care. As nutrition is a cornerstone in the treatment of the disease, recent clinical research has focused on this question. The concept of enteral nutrition is aiming at the maintenance of a normal mucosal barrriere function which has been discovered to be important in mild and severe acute pancreatitis. This review offers an overview about current concepts of nutritional support and gives recommendations for clinical care as well.

Distinct TPEF/HPP1 gene methylation patterns in gastric cancer indicate a field effect in gastric carcinogenesis

BACKGROUND

Aberrant methylation of the transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 gene was recently reported in hyperplastic colon polyps, colorectal adenomas and carcinomas. However, there are only limited data on significance of transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 gene methylation in gastric adenocarcinomas.

AIM

The aim of this study was to determine the prevalence of transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 promoter methylation in gastric adenocarcinomas.

PATIENTS

Study population consists of 48 patients with gastric cancer and 11 dyspeptic patients.

METHODS

Using the Methylight assay, transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 gene methylation was assessed in fresh frozen cancer tissue and matched tumoural-free area of patients with gastric cancer and in the gastric mucosa of dyspeptic patients.

RESULTS

Transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 promoter gene methylation was observed in 35 of 48 (73%) gastric adenocarcinomas, and in 27 of 48 (56%) matched tumoural-free area cases (p=0.087). In contrast, the occurrence of transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 methylation was much lower in gastric mucosa of dyspeptics (1 of 11; 9%) and the difference was significant in comparison with both tumoural tissue (p=0.0001) and tumoural-free area (p=0.0047) of cancer patients. Transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 gene expression was significantly reduced in adenocarcinomas in comparison with matched tumoural-free area (p=0.022).

CONCLUSION

Our data suggest that methylation of transmembrane protein containing epidermal growth factor and folistatin domains/hyperplastic polyposis 1 is present in the majority of gastric adenocarcinomas and in the surrounding tumoural-free area, indicating that this epigenetic change may point to a field effect in the gastric mucosa.

Low-dose aspirin reduces the gene expression of gastrokine-1 in the antral mucosa of healthy subjects

BACKGROUND

Gastrokine 1 (GKN1), one of the most abundant transcripts in normal stomach, is down-regulated by Helicobacter pylori infection. Aspirin (ASA), which is often used for secondary prevention of cardiovascular events, can damage gastric-duodenal mucosa within 1 or 2 h of ingestion.

AIM

To study the gastric mucosal expression of GKN1 during acute low-dose ASA consumption.

METHODS

Ten H. pylori-negative human volunteers took 100 mg ASA per day for 1 week, and underwent multiple upper GI endoscopies. GKN1 expression was analysed in antral and corpus mucosa by quantitative reverse-transcriptase polymerase chain reaction, western blot and immunohistochemistry (IHC). Gastric mucosal damage was detected endoscopically and histologically.

RESULTS

Gastrokine 1 was similarly expressed in both antral and corpus mucosa. The use of low-dose ASA led to a significant decrease (3.07 a.u. vs. 0.23 a.u., P < 0.001) in antrum at day 7, while GKN1 transcript levels in corpus mucosa were slightly elevated (twofold, P < 0.005). Western blot and IHC confirmed these changes at the protein level. Furthermore, IHC revealed a vesicular staining pattern in the cytoplasm for GKN1 that was confirmed by transfected human gastric adenocarcinoma cell line expressing GKN1.

CONCLUSION

Our data demonstrated that low-dose ASA downregulates GKN1 expression specifically in antral mucosa.