Serum gastrin and pepsinogens do not correlate with the different grades of severity of gastro-oesophageal reflux disease: a matched case-control study

BACKGROUND

Gastrin and pepsinogens reflect the functional state of the gastric mucosa.

AIM

To evaluate whether serum gastrin and pepsinogens correlate with the different grades of severity of gastro-oesophageal reflux disease (GERD).

METHODS

In all, 388 patients with heartburn not taking any form of acid suppressive therapy were matched-controlled for age and gender and sub-classified into four groups: group 1 non-erosive reflux disease (NERD); group 2, erosive reflux disease (ERD) Los Angeles (LA) A and B, group 3, ERD LA C and D; group 4 Barrett's oesophagus (BO). Fasting serum was analysed for gastrin 17, pepsinogen I, pepsinogen II und Helicobacter pylori using specific EIA tests (GastroPanel; Biohit, Plc).

STATISTICS

Kruskal-Wallis test and analysis of variance.

RESULTS

There was a significant difference among the four groups with respect for pepsinogen I, but not for pepsinogen II, the pepsinogen I pepsinogen II ratio, H. pylori serology and gastrin levels. Pepsinogen I was the lowest in NERD and the highest in BO (median 91.6, mean +/- standard deviation 106.2 +/- 51.6 vs. median 114.7, mean +/- standard deviation 130.4 +/- 70.6; P = 0.046). Pepsinogen I levels were higher in H. pylori positive subjects. After adjusting for H. pylori status, the differences in pepsinogen I across patient groups were no longer statistically significant (P = 0.298).

CONCLUSIONS

Serum gastrin and pepsinogen I and II do not correlate with the different grades of severity of GERD. The non-invasive GastroPanel is not useful for the differentiation of the various forms of GERD.

OLGA staging for gastritis: a tutorial

Atrophic gastritis (resulting mainly from long-standing Helicobacter pylori infection) is a major risk factor for (intestinal-type) gastric cancer development and the extent/topography of the atrophic changes significantly correlates with the degree of cancer risk. The current format for histology reporting in cases of gastritis fails to establish an immediate link between gastritis phenotype and risk of malignancy. The histology report consequently does not give clinical practitioners and gastroenterologists an explicit message of use in orienting an individual patient's clinical management. Building on current knowledge of the biology of gastritis and incorporating experience gained worldwide by applying the Sydney System for more than 15 years, an international group of pathologists (Operative Link for Gastritis Assessment) has proposed a system for reporting gastritis in terms of stage (the OLGA staging system). Gastritis staging arranges the histological phenotypes of gastritis along a scale of progressively increasing gastric cancer risk, from the lowest (stage 0) to the highest (stage IV). This tutorial aims to provide unequivocal information on how to consistently apply the OLGA staging system in routine diagnostic histology practice.

[Gastrointestinal neuroendocrine tumors]

Two thirds of all neuroendocrine tumors (NET) are located in the gastroentero-pancreatic system. Depending on its localisation, each tumor presents a different histological pattern as well as different clinical symptoms and prognosis. Symptoms are usually due to the mass effects of the local tumor or tumor-related fibrosis. The classical "carcinoid-syndrome" with flush and diarrhea is seen in fewer than 10 %. Tests like chromogranin A (serum) or 5-hydroxyindolacetic acid (24h urine-collection) are indicators for the initial diagnosis of NET. Somatostatin-receptor scintigraphy is the most valuable imaging modality. In addition CT/MRI can be used for further topographical definition. Endoscopic techniques like the use of capsule endoscopy are being evaluated for the diagnosis of small intestinal NETs. The only curative treatment of NET is still complete surgical resection. However, it can only be done in 20 %, depending on localization and local extension of the primary tumor. If the liver is involved local ablation techniques should be considered. The gold standard for medical treatment is the use of somatostatin analogs, although interferons show a comparable therapeutic potential. Traditional cytotoxic agents should only be used for poorly differentiated tumors refractory to other forms of treatment. New compounds that target different pathways at the intra- and intercellular level are under investigation. Supportive therapy should be considered for the control of symptoms.

[Barrett carcinoma--diagnosis, screening, surveillance, endoscopic treatment, prevention]

An adenocarcinoma of the distal esophagus may also be designated as Barrett's carcinoma as it evolves from Barrett's esophagus. Barrett's esophagus currently is defined as a columnar metaplasia of the distal esophagus, as identified by endoscopy, that, upon histopathology, is confirmed to contain intestinal metaplasia. A different histological entity of columnar metaplasia of the distal esophagus is cardia-type mucosa which probably precedes intestinal metaplasia, but lacks goblet cells typical for the latter. The conversion rate from Barrett's esophagus to Barrett's carcinoma amounts to 0.5 to 1 % per year. Patients with reflux symptoms should undergo early endoscopy in order to search for Barrett's esophagus (screening). In those cases where Barrett's esophagus is identified, regular endoscopic controls should be scheduled (surveillance). The intervals for this have been defined by recent consented guidelines. The aim is to detect neoplasia early. Neoplasia confined to the epithelium or mucosal layer can mostly be treated by endoscopic resection. The depth of infiltration, as determined by histopathology of the resected specimen, allows one to estimate the risk of lymph node metastasis, and therefore is crucial for the final judgment as to whether the endoscopic intervention may be considered curative. Individually, the risk of metastasis has to be weighed against the risk of morbidity and mortality conferred by the alternative surgical resection. The rapid increase of the incidence of Barrett's carcinoma in Western countries suggests that life style factors, in particular overweight, having a causal role. Data from interventional trials on prevention are, however, pending.

[Eosinophilic esophagitis--pathogenesis, clinical presentation and therapeutic management]

Eosinophilic esophagitis (EE) is a relatively new, chronic, TH 2-type allergic inflammation of the esophagus. EE occurs more frequently in men. Allergic diseases such as asthma or atopic dermatitis are present in 50-70 % of patients or their relatives. In adults, the most common presenting symptom of EE is dysphagia, with or without food bolus impaction. Endoscopic findings of EE include mucosal furrows, corrugated or concentric rings or ridges in the esophagus ("feline esophagus"), with or without tiny whitish exudates. The diagnosis is confirmed by the observation of high counts of eosinophils in the esophageal epithelium (at least 24 /HPF). The cornerstones of medical therapy are either topical or systemic corticosteroids. Additional therapies included leukotriene receptor antagonists (montelukast) and IL-5 blockers (Mepolizumab). Complications of EE such as esophageal strictures should be carefully dilated using either bougies or a balloon. Currently it is still not known whether the late complications of EE can be prevented by the use of anti-inflammatory agents and this can only be demonstrated through further long-term follow-up studies.

Incidence, clinical management and outcomes of esophageal perforations after endoscopic dilatation

BACKGROUND

Esophageal dilatation is performed for the treatment of anatomic and sometimes functional narrowing of the esophageal lumen caused by a variety of benign and malignant conditions. Esophageal perforation is the major complication associated with endoscopic dilatation.

AIM

The object of this study was to assess the incidence of perforation, management and outcomes after endoscopic esophageal dilatation.

METHODS

All patients who underwent endoscopic esophageal dilatation at our institution from June 2001 to December 2006 were identified. Data were obtained by searching our prospectively collected electronic database (MEDOS AG, Langenselbold, Germany), which includes all endoscopic reports as well as discharge summaries of patients who have undergone endoscopy in our department.

RESULTS

248 patients (148 male, 100 female, mean age 58 years, range 14-87 years) underwent 365 esophageal dilatations: 74 pneumatic balloon dilatations for achalasia, 79 balloon dilatations for other reasons such as tumors, peptic stenosis, or post-radiotherapy stenosis and 212 dilatations with Savary bougies. The overall incidence of perforation based on the number of procedures was 2.2% (8 perforations/365 procedures) and 3.2% (8/248 patients) based on the number of patients. The perforation rate was 1.9% for bougie dilatation, 0% for balloon dilatation and 5-4% for pneumatic balloon dilatation for achalasia. Five patients were treated surgically and 3 patients were managed conservatively. The mean hospital stay was 14 days (7-33 days). One patient in whom the perforation was recognized 16 days after the dilatation died.

CONCLUSIONS

Endoscopic esophageal dilatation is a safe procedure for the palliation of malignant strictures, for the management of benign strictures as well as for the therapy of achalasia. The perforation rate after these procedures is low. Early recognition of the perforation is associated with a good outcome. Small perforations can be treated conservatively.

New algorithm for the treatment of gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is associated with a variety of typical and atypical symptoms. Patients often present in the first instance to a pharmacist or primary care physician and are subsequently referred to secondary care if initial management fails. Guidelines usually do not provide a clear guidance for all healthcare professionals with whom the patient may consult.

AIM

To update a 2002-treatment algorithm for GERD, making it more applicable to pharmacists as well as doctors.

METHODS

A panel of international experts met to discuss the principles and practice of treating GERD.

RESULTS

The updated algorithm for the management of GERD can be followed by pharmacists, for over-the-counter medications, primary care physicians, or secondary care gastroenterologists. The algorithm emphasizes the importance of life style changes to help control the triggers for heartburn and adjuvant therapies for rapid and adequate symptom relief. Proton pump inhibitors will remain a prominent treatment for GERD; however, the use of antacids and alginate-antacids (either alone or in combination with acid suppressants) is likely to increase.

CONCLUSION

The newly developed algorithm takes into account latest clinical practice experience, offering healthcare professionals clear and effective treatment options for the management of GERD.

Characterization of yellow plaques found in the small bowel during double-balloon enteroscopy

BACKGROUND AND STUDY AIMS

The aim of this study was to characterize yellow (or whitish) plaques of the small bowel that were found during double-balloon enteroscopy (DBE) performed for small-bowel evaluation.

PATIENTS AND METHODS

Patients who were being evaluated for small-bowel pathology at our institution (for a variety of indications) were included in the study. In 16 patients, DBE revealed yellow or whitish submucosal plaques, defined as small, raised, submucosal lesions that were well circumscribed and covered by normal-appearing small-bowel mucosa. Biopsy tissue obtained during the procedures was stained with hematoxylin and eosin and with periodic acid-Schiff stain, and was subjected to immunochemical testing using endothelial markers (anti-CD31 and anti-CD34).

RESULTS

These 16 patients were identified out of a total of 150 DBE procedures performed in 120 patients (eight men, eight women; mean age 62, range 33 - 78). The lesions were mostly single (range 1 to > 5 lesions), ranging in size from 2 mm to 15 mm, and were slightly raised (from 1 mm to 2 mm). In four cases the plaques could not be biopsied because the patient had a coagulation disorder or because the DBE was being performed to investigate severe acute bleeding. In the other 12 patients, a characteristic white-yellow liquid exudated from the biopsy site in 80 % of lesions, and these 12 patients were shown to have lymphangiectasias. No association with an infiltrative disorder could be detected.

CONCLUSIONS

Yellow and white submucosal plaques are found in up to 13 % of patients undergoing DBE. They are most likely to be lymphangiectasias and are a normal anatomical variant. They do not require further work-up.

Palliative treatment of unresectable pancreatico-biliary cancer by either gemcitabine or octreotide/imatinib: Impact on biomarkers of angiogenesis

15101

Background: Gemcitabine represents standard Tx for unresectable cancers of the pancreas / distal biliary tract. Recent interest has focused on antiangiogenic properties in a mouse model of pancreatic cancer (JCI 2003); either VEGF or PDGF inhibition alone were less effective than the combination of both in terms of angiogenesis. In humans, imatinib (targeting PDGF) alone has been shown to be equivalent to gemcitabine in terms of survival (Cancer Lett. 2006;233:328–37), while most trials for octreotide (targeting IGF-1, VEGF) were disappointing. In HCC pts. we recently evaluated the impact of biomarkers on disease progression and survival (Cancer Res Clin Oncol 2006; 132:699–708). Methods: To investigate in a phase I/II trial the feasability of a combination (group I, n=11) of octreotide (30 mg im every 4 weeks, targeting VEGF-A) plus imatinib (400 mg po daily, targeting PDGF-B) vs gemcitable (group II, n=11, 1000mg/m2 weekly for 7/8 wks, then for 3/4 wks). Pts had either unresectable pancreatic cancer (n=18) or ampullary cancer (n=4). Primary outcome measure were changes in biomarkers (VEGF-A, PDGF-BB, soluble E-selectin, Ca19–9, CEA). Secondary outcome measures were TTP and OS. Results: 19/22 pts. had biomarker data available within the first 12 wks, changes over time are shwon in table . Median TTP was 109 vs 166 days (p<0.05) and median OS was 163 vs 325 days (p=NS) for group I vs II. Baseline Ca19–9 levels correlated with prognosis independent of Tx (p=0.05). In group I, high levels of PDGF-BB and VEGF-A levels at wk 12 but in group II, low levels of VEGF-A and s-E-selectin correlated with a better OS (p<0.05 each). TTP showed no correlations with biomarkers. Conclusions: The combination of octreotide plus imatinib is clinically less effective compared to gemcitabine. Although the absolute changes of angiogenesis markers are comparable between groups, chemotherapy compared to targeted therapy has a different impact on these in terms of survival.

[Table: see text]

No significant financial relationships to disclose.

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report

BACKGROUND

Guidelines on the management of Helicobacter pylori, which cover indications for management and treatment strategies, were produced in 2000.

AIMS

To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer.

RESULTS

Eradication of H pylori infection is recommended in (a) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; (b) patients with atrophic gastritis; (c) first degree relatives of patients with gastric cancer; (d) patients with unexplained iron deficiency anaemia; and (e) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a "test and treat" strategy if other causes are excluded. Eradication of H pylori infection (a) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and (b) may prevent peptic ulcer in patients who are naïve users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility.

CONCLUSION

The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report

BACKGROUND

Guidelines on the management of Helicobacter pylori, which cover indications for management and treatment strategies, were produced in 2000.

AIMS

To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer.

RESULTS

Eradication of H pylori infection is recommended in (a) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; (b) patients with atrophic gastritis; (c) first degree relatives of patients with gastric cancer; (d) patients with unexplained iron deficiency anaemia; and (e) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a "test and treat" strategy if other causes are excluded. Eradication of H pylori infection (a) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and (b) may prevent peptic ulcer in patients who are naïve users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility.

CONCLUSION

The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.

Octreotide Alone or in Combination with Rofecoxib as Palliative Treatment for Advanced Hepatocellular Cancer

BACKGROUND

Median survival for advanced hepatocellular carcinoma (HCC) is around 3 months. Previous octreotide-based treatment studies revealed conflicting results.

AIMS AND METHODS

To determine whether palliative treatment for HCC is beneficial in terms of survival and quality of life (primary outcome measures). Patients were prospectively randomised to receive open-label octreotide 30 mg monthly alone (n = 39) or in combination with rofecoxib (up to 50 mg bid daily, n = 32) for a minimum of six months, or until death occurred.

RESULTS

Median overall survival (154 days) and time to progression (94 days) were similar for both treatments and within the range of published trials for octreotide, while adding rofecoxib to octreotide did not alter overall survival (149 vs. 155 days, p = 0.849). Treatment-associated clinical benefit was seen in 16/71 patients (3 patients with partial remissions and 13 with stable disease). Delay in tumor progression was associated with prolonged median survival (p < 0.0001) and a better quality of life (p < 0.05). Moreover, survival outcome was associated with a CLIP score < 3, extent of portal vein infiltration, well-differentiated tumor histology, prothrombin time, alkaline phosphatase, bilirubin, serum ferritin, and gamma-glutamyltransferase (p < 0.01 each).

DISCUSSION

Rofecoxib added to octreotide treatment did not improve survival over octreotide treatment alone. Octreotide treatment, although without major side effects, cannot be recommended in general as monotherapy, unless the few patients responding can better be characterised. There may still be a role for combining octreotide with other emerging targeted therapies because of potentially synergistic modes of action.

Treatment of Helicobacter pylori

Triple therapy, consisting of two antibiotics, clarithomycin and amoxicillin or metronidazole in combination with a proton pump inhibitor (PPI) has become the first-line option for infection with Helicobacter pylori and has been recommended at several consensus conferences. In clinical practice, approximately 20% of patients will fail to obtain H. pylori eradication with the recommended treatment regimens. Major causes of treatment failure are insufficient patient compliance and antibiotic resistance. Because of antibiotic resistance, bismuth-based quadruple therapy has also become a first-line regimen in areas with exceedingly high rates of clarithromycin and metronidazole resistance, and is the preferred second-line option otherwise. Triple therapies based on levofloxacin and/or rifabutin mainly with combination of amoxicillin are options if multiple eradication failure occurs. However, following therapy failure beyond a second treatment attempt requires antibiotic resistance testing. New drugs and adjuvant agents have been reported but their efficacy needs further evaluation.