[The scintigraphy of somatostatin receptors in the carcinoid tumor]

This study aimed to evaluate the diagnostic utility of 111In-DTPA-D-Phe1-octreotide scintigraphy in the different situations that can be present when an examination is requested during the clinical course of the carcinoid tumor (CT).

MATERIALS AND METHODS

We have performed 41 scintigraphies with 111In-octreotide (145-185 MBq) in 35 patients (19 females and 16 males) with clinically suspected or confirmed CT. The patients were classified into five groups: Group A: Indolent symptoms of CT (n=9); B: CT staging located in lung (n=4), stomach (n=2), cecum (n=1), thymus (n=1) and pancreas (n=1); C: Carcinoid syndrome (n=1); D: CT staging after surgery located in pancreas (n=1), ovary (n=1), cecum (n=1), stomach (n=1), appendix (n=1) and ileum (n=1); and E: Post-treatment follow-up (n=13), with CT located in bronchial tree (n=5), small intestine (n=3), appendix (n=2), thymus (n=1), ovary (n=1) and unknown primary tumor (n=1). Three patients of this group had one scintigraphic study before the treatment. Head and neck, thorax and abdomen images were obtained at 4 and 24 h in all of the patients and SPECT images of the abdomen (n=14), thorax (n=10), and brain (n=1) were obtained at 24 h in 25 patients.

RESULTS

Group A: In the 3 patients with a positive scintigraphy, the definitive diagnosis was meningioma, Hurtle cell's carcinoma and lung adenocarcinoma. The clinical follow-up in the six other patients, at least during one year, did not show any evidence of CT. Group B: Six of the 9 CT were detected with the scintigraphy. In 2 cases of bronchial CT, the scan showed sarcoidotic regional lymph node involvement and CT hepatic and bone metastases, respectively. Group C: The scintigraphy detected hepatic metastases from an unknown primary tumor. Group D: The scintigraphy was positive in 3 cases (hepatic or/and abdominal metastases) and was normal in the other 3. The scintigraphy was negative in one patient with peritoneal metastases. Group E: The scintigraphy was normal in 7 patients in concordance with the clinical follow-up. In 3 patients with a scintigraphy performed prior to treatment, the scintigraphy detected recurrence (thymic CT), progression of the metastatic disease (ovarian CT) and partial regression of the hepatic metastases (carcinoid syndrome). In the three other patients, the scintigraphy showed metastases located in liver in one patient and hepatic and extra-hepatic metastases in the two other patients. The sensitivity and specificity of 111In-Octreotide in the detection of the primary tumor and metastases were 72% and 84% respectively.

CONCLUSIONS

The 111In-Octreotide scintigraphy has a low diagnostic utility in patients with indolent symptoms of CT. However, it is the first line of diagnosis for the staging of the CT and to evaluate the follow up after therapy.

[Budesonide in inflammatory bowel disease: a meta-analysis]

BACKGROUND

Budesonide is a synthetic glucocorticoid used in the Crohns's disease (CD) and ulcerative colitis (UC). The aim of the study was to evaluate its efficacy in inducing and maintaining remission of CD in oral administration and in inducing endoscopic and histologic remission in distal UC when was given as enema.

MATERIAL AND METHOD

Systematic review of controlled clinical trials was made and meta-analysis were performed using the Peto method. Eight studies provided data regarding CD (4 in induction of remission and 4 in maintenance therapy) and 4 regarding UC.

RESULTS

CD-inducing remission: in total 560 patients were involved; 280 received 9 mg/d of budesonide and 280 received 40-46 mg/d of prednisolone. Clinical remission was similar in both groups [0.76 (0.54-1.06)] [0R (CI 95%)] and adverse events were more frequent in patients treated with prednisolone [0.42 (0.30-0.58)]. Plasma cortisol was evaluated in 292 patients (146 each group); values were significantly lower in prednisolone group [0.32 (0.20-0.50)]. CD-maintaining remission: in total 449 patients were enrolled; 174 and 90 received 3 mg/d or 6 mg/d of budesonide respectively and 185 received placebo. There were not significant differences between placebo and budesonide 3 mg/d [1.04 (0.56-1.92)]. Budesonide 6 mg/d was also similar to placebo group [0.91 (0.59-1.39)]. UC: 325 patients were included, 156 received budesonide and 169 were given conventional glucocorticoids. No significant differences were found between both groups in endoscopic remission rates [1.15 (0.71-1.88)].

CONCLUSIONS

Budesonide is as useful as prednisolone in treatment of active CD and it has a lower impact in serum cortisol levels. Nevertheless, at evaluated dose, it is not useful for maintenance therapy. In UC is as effective as conventional glucocorticoids.

[High eradication rates in Helicobacter pylori infection in patients with duodenal ulcer who failed previous eradication therapy]

BACKGROUND

To analyze the effectiveness of a second-line treatment of Helicobacter pylori infection in patients with duodenal ulcer based on previous antibiotic regimen.

PATIENTS AND METHODS

Open, prospective, uncontrolled study, but guided by protocol including 30 consecutive patients with endoscopic diagnosis of active duodenal ulcer and failure of a first-line H. pylori eradication treatment diagnosed by urea breath test or a new endoscopy with histology and positive urease test. Treatment consisted in 10 days with omeprazole (20 mg/12 h), bismuth subcitrate (120 mg/6 h), tetracycline (500 mg/6 h) and metronidazole (500 mg/8 h) (OBTM) if previous regimen was with clarithromycin; or 10 days with omeprazole (20 mg/12 h), clarithromycin (500 mg/12 h) and amoxycillin (1g/12 h) (OCA) if previous regimen did not include clarithromycin; using metronidazole (500 mg/8 h) instead of amoxycillin (OCM) in case of allergy. Eradication was defined as a negative 13C-urea breath test 2 months after the end of therapy.

RESULTS

One patient had to stop treatment due to the side effects and in 2 patients urea breath test was not performed (3 patients due to the OBTM group). Per protocol eradication was achieved in 25 out of 27 patients (92.6%) and by intention-to-treat eradication was attained in 25 out of 30 cases (83.3%). When both groups analyzed separately, the OCA combination was successful in 5 from 6 patients (83.3%; 95% CI 35.9-99.6); while the OBTM combination was successful in 20 from 21 valuable patients (95. 2%; 95% CI 76.2-99.9). In this second case we make an intention to treat analysis and eradication was achieved in 20 from 24 (83.3%; 95% CI 62.6-95.3).

CONCLUSION

The eradicative treatment for H. pylori based in different antibiotics used in subsequent attempts get high eradication rates in patients with duodenal ulcer.

Factors affecting the variation in antibiotic resistance of Helicobacter pylori over a 3-year period

Strains of Helicobacter pylori, isolated from 300 patients between 1996 and 2000 were tested for their sensitivity to clarithromycin, metronidazole and amoxycillin. Primary resistances (95% CI) were 9. 7% for clarithromycin and 21.7% for metronidazole. No strains were resistant to amoxycillin. There was no significant difference between the number of resistant strains in the male and female groups. Clarithromycin resistance was more common in older patients (P<0.01) and metronidazole resistance was more common in patients with peptic ulcer compared with patients with chronic gastritis (P<0. 05). Logistic regression analysis confirmed these results.

Third line treatment for Helicobacter pylori: a prospective, culture-guided study in peptic ulcer patients

BACKGROUND

A third line treatment is needed in roughly 5% of patients infected with Helicobacter pylori. Few data have been reported on efficacy of treatment regimens in these patients.

METHODS

A prospective trial was designed to study the effectiveness of third line treatment of H. pylori infection in ulcer patients. Two-week quadruple, culture-guided, combinations were used in 31 consecutive patients. Susceptibility to metronidazole and clarithromycin were studied by E-test, and thereafter a predetermined treatment regimen was used. Compliance was evaluated by pill count, and eradication defined by negative urea breath test at 6 weeks.

RESULTS

Two main quadruple regimens were used in 29 patients. In spite of good compliance, the combination of omeprazole, tetracycline, bismuth and clarithromycin (OTBC) showed an eradication rate (per protocol analysis) of 36% (five out of 14; CI: 12.8-64.9), and if amoxycillin was used (OTBA) the rate was 67% (eight out of 12; CI: 34.9-90.1). The difference was not significant. No clinical factor was found to be associated with failure to eradicate.

CONCLUSIONS

Third line treatment often fails to eradicate H. pylori infection. New strategies need to be developed and tested for this common clinical situation.

[Cost-effectiveness analysis of 2 strategies of Helicobacter pylori eradication: results of a prospective and randomized study in primary care]

BACKGROUND

To analyze cost-effectiveness of two different strategies to treat H. pylori infection in peptic ulcer in the primary care setting.

PATIENTS AND METHODS

Consecutive patients with endoscopic diagnosis of peptic ulcer were randomized to one of two strategies: a) treatment during 7 days with omeprazole, tetracycline, metronidazole and bismuth subcitrate ("quadruple" therapy) and if failure second-line treatment with omeprazole, amoxycillin and clarithromycin during 7 days (OCA7), and b) initial treatment with OCA7 and if failure treatment with "quadruple therapy". End point was eradication 8 weeks after last treatment dose. Direct and indirect costs were estimated (euros, 1997) and a cost-effectiveness analysis using a decision-tree model was undertaken after real clinical data. 95% confidence intervals are given.

RESULTS

After screening 255 patients, 97 were finally included. 48 patients were given strategy a and 49 strategy b. Eradication was obtained (intention-to-treat) in 72.9% (CI 95%: 58.2-84.7) in group a versus 91.8% (CI 95%: 80.4-97.7) (p < 0.05) in group b. Mean cost per case treated was lower in group a (237 versus 268 euros) but cost per case eradicated was lower in group b (320 versus 296 euros). The cost was primarily determined by efficacy.

CONCLUSIONS

Treatment with OCA7 followed by rescue with "quadruple" therapy if failure is more efficient in our area that the inverse strategy. Efficiency is mostly determined by efficacy.

[Does eliminating Helicobacter pylori mean the healing of the duodenal ulcer? The results of a prospective study in Spain]

AIM

To evaluate the predictive value of Helicobacter pylori eradication in the healing of duodenal ulcer.

METHODS

A prospective study of 92 duodenal ulcer patients (diagnosed by endoscopy) with H. pylori infection demonstrated by rapid urease test, positive histology and culture. They were treated with a 7-day regimen of lansoprazole, clarithromycin and amoxicillin. Healing was evaluated in a follow-up gastroscopy performed one month after treatment had finished. Eradication was defined as negative urease test, histology and culture at 30 days and negative urea breath test at 60 days.

RESULTS

Duodenal ulcer healing was observed in 85 patients (92.4%, CI 85-96.9). Eradication of H. pylori infection was the only variable independently associated with ulcer healing. Healing was observed in 97.2% of patients with H. pylori eradication versus 75% of those with persistent infection (p < 0.01; OR = 11.6; CI 95% = 2.06-65.9).

CONCLUSION

Eliminating H. pylori infection favors duodenal ulcer healing and, from a clinical point of view, confirmation of H. pylori eradication almost always means healing of duodenal ulcer.

Is 1-week treatment for peptic ulcer healing sufficient and safe?

OBJECTIVE

To confirm whether 1-week anti-Helicobacter therapy to achieve ulcer healing is sufficient and safe.

METHODS

We retrospectively analyzed patients with peptic ulcer who were infected with Helicobacter pylori and treated with 3 different 7-day regimens, according to predefined protocols in 3 different centers in the same geographical area (Aragón, Spain). Three combinations commonly described in the literature were used: a) omeprazole (40 mg/24 h), tetracycline hydrochloride (2 g/24 h), colloidal bismuth subcitrate (480 mg/24 h) and metronidazole (750 mg/24 h) (OBTM, n = 105); b) omeprazole (40 mg/24 h), clarithromycin (1.5 g/24 h) and amoxicillin (3 g/24 h) (O40C1.5A3, n = 13); and c) omeprazole (40 mg/24 h), clarithromycin (1 g/24 h) and amoxicillin (2 g/24 h) (O40C1A2, n = 4). In all patients the diagnosis of peptic ulcer disease was confirmed endoscopically, and H. pylori infection was verified with urease testing and histological analysis. After treatment ended, no other antacids were allowed until after endoscopic examination to check eradication and ulcer healing.

RESULTS

122 patients were included (107 with duodenal ulcer, 12 with gastric ulcer and 3 with both). Compliance was good and side effects infrequent and mild. Eradication rates were 88.5% (93/105) in the OBTM group, 100% (13/13) with O40C1.5A3, and 75% (3/4) with O40C1A2. Healing was achieved in 98.16% (107/109) of the patients in whom the bacterial infection was eradicated, and in 23.07% (3/13) of those in whom it was not (p < 0.0001). No patient had any complications during the period without treatment.

CONCLUSIONS

1-week eradication therapy with previously described combinations commonly used in clinical practice achieves high ulcer healing rates with no complications in the period without antacid treatment. We consider that it is not necessary, at least in most patients, to prolong antacid therapy.

Quadruple therapy is effective for eradicating Helicobacter pylori after failure of triple proton-pump inhibitor-based therapy: a detailed, prospective analysis of 21 consecutive cases

BACKGROUND

Data regarding the effectiveness of second-line treatment of Helicobacter pylori infection are limited, especially if microbiological studies are considered.

METHODS AND PATIENTS

We conducted a prospective, uncontrolled study of a consecutive series of 21 peptic ulcer patients with failure of 1-week lansoprazole, amoxicillin, and clarithromycin. H. pylori status was evaluated by urease test, histology, culture, and urea breath test. Susceptibility to amoxicillin, clarithromycin, and metronidazole was studied by E-test. Cure of infection was defined as negative results from endoscopy-based tests 1 month after treatment and negative results from a urea breath test at 2 months. Treatment consisted of a 1-week combination of lansoprazole (30 mg bid), tetracycline (500 mg qid), metronidazole (500 mg tid), and bismuth subcitrate (120 mg qid).

RESULTS

H. pylori was resistant to metronidazole in three cases, to clarithromycin in three cases, and to both clarithromycin and metroinidazole in an additional three patients. No resistance to amoxicillin was found. Eradication was obtained in 20 cases (95.2% confidence interval [CI], 76.2-99.9). The only patient in whom infection was not eradicated harbored a metronidazole-resistant (minimum inhibitory concentration > 32 micrograms/ml) strain. No significant side effects were reported.

CONCLUSION

Quadruple therapy obtains a high eradication rate even in patients with clarithromycin- and metronidazole-resistant strains. Further randomized and controlled studies are warranted and are urgently needed.

[Multidrug-resistant Salmonella a significant clinical problem?]

The incidence of infections caused by Salmonella strains resistant to antibiotics, including ampicillin, chloramphenicol, streptomycin, sulfonamides, tetracycline and even amoxicyllin-clavulanate, is increasing. We present two cases that illustrate the potential severity of infections caused by multidrug-resistant Salmonella and also the difficulty of reaching a differential diagnosis with inflammatory bowel disease.

Impact of clarithromycin resistance on the effectiveness of a regimen for Helicobacter pylori: a prospective study of 1-week lansoprazole, amoxycillin and clarithromycin in active peptic ulcer

BACKGROUND

Clarithromycin is a key antimicrobial in the combinations used to cure Helicobacter pylori infections, so there is a need to define the impact of in vitro resistance on in vivo results.

METHODS

A prospective trial was designed to study the effectiveness of the 1-week combination of lansoprazole, clarithromycin and amoxycillin in 102 consecutive patients with active peptic ulcer. The pre-treatment and post-treatment sensitivity to amoxycillin, metronidazole and clarithromycin were studied by E-test, and H. pylori status was defined by histology, culture and urease test at diagnosis and one month after treatment, and by urea-breath test 2 months after treatment.

RESULTS

The eradication rate (intention-to-treat analysis) was 77% (95% CI: 69-86). No clinical factor was found to be different between eradicated and non-eradicated patients. Clarithromycin-resistant strains were found in 10 (10%; CI: 5-17) patients. The eradication rate was 20% (CI: 3-56) in these patients vs. 83% (CI: 75-91) in patients harbouring clarithromycin-sensitive strains (P < 0.001). A logistic-regression analysis confirmed clarithromycin resistance as the only factor associated with treatment failure.

CONCLUSIONS

Clarithromycin resistance significatively impairs the effectiveness of the combination of lansoprazole, amoxycillin, and clarithromycin. The 80% efficacy goal will be difficult to reach in areas with high (>10%) primary clarithromyicin resistance, if currently recommended proton pump inhibitor-triple therapies are used.

Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Spanish Group for the Study of Crohn's Disease and Ulcerative Colitis (GETECCU)

OBJECTIVE

Butyrate enemas may be effective in the treatment of active distal ulcerative colitis. Because colonic fermentation of Plantago ovata seeds (dietary fiber) yields butyrate, the aim of this study was to assess the efficacy and safety of Plantago ovata seeds as compared with mesalamine in maintaining remission in ulcerative colitis.

METHODS

An open label, parallel-group, multicenter, randomized clinical trial was conducted. A total of 105 patients with ulcerative colitis who were in remission were randomized into groups to receive oral treatment with Plantago ovata seeds (10 g b.i.d.), mesalamine (500 mg t.i.d.), and Plantago ovata seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months.

RESULTS

Of the 105 patients, 102 were included in the final analysis. After 12 months, treatment failure rate was 40% (14 of 35 patients) in the Plantago ovata seed group, 35% (13 of 37) in the mesalamine group, and 30% (nine of 30) in the Plantago ovata plus mesalamine group. Probability of continued remission was similar (Mantel-Cox test, p = 0.67; intent-to-treat analysis). Therapy effects remained unchanged after adjusting for potential confounding variables with a Cox's proportional hazards survival analysis. Three patients were withdrawn because of the development of adverse events consisting of constipation and/or flatulence (Plantago ovata seed group = 1 and Plantago ovata seed plus mesalamine group = 2). A significant increase in fecal butyrate levels (p = 0.018) was observed after Plantago ovata seed administration.

CONCLUSIONS

Plantago ovata seeds (dietary fiber) might be as effective as mesalamine to maintain remission in ulcerative colitis.

[Effectiveness of the eradication of Helicobacter pylori by treatment with omeprazol, amoxicillin, and clarithromycin according to dosage and administration schedule]

BACKGROUND

There are many reports that evaluate the efficacy of the combination of omeprazole, amoxicillin and clarithromycin in the eradication of Helicobacter pylori, but data about effectivity in clinical practice are sparse. The goal of our study is to evaluate the effectivity in the clinical setting of this combination with diverse durations and doses.

METHODS

This is a retrospective analysis of 187 patients (128 male and 59 female), with an endoscopic diagnosis of duodenal ulcer (156), gastric ulcer (25) and both (6) with Helicobacter pylori infection as defined by both: a positive ureasa test and histology. After diagnosis the patient were treated with one of three combinations: a) omeprazole: 20 mg/12 h + amoxicillin: 1 g/12 h + clarithromycin: 500 mg/12 h, during 6 days (n = 60); b) omeprazole: 20 mg/12 h + amoxicillin: 1 g/12 h + clarithromycin: 500 mg/12 h, during 7 days (n = 74), and c) omeprazole: 20 mg/12 h + amoxicillin: 1 g/8 h + clarithromycin: 500 mg/8 h, during 7 days (n = 53). After the 6 or 7 day treatment period the patients did not receive any further treatment until a follow-up control unit. Eradication was evaluated with one of two tests: endoscopy (with ureasa test and at least 4 histologic samples) (n = 90) or urea breath test according to european protocol (n = 97).

RESULTS

No patient dropped out because of side effects and compliance was above 80% in all cases. The global eradication rate was 87.2% (CI 95%: 82.4-92%). According to treatment the rate were respectively 80% (CI 95%: 67.7-89.2%) with scheme A; 89.2% (CI 95%: 79.8-95.2%) with scheme B, and 92.5% (CI 95%: 81.8-97.9%) with scheme C, with no statistically significant differences among groups. Difference between schemes and C, however, was almost reached (p = 0.053).

CONCLUSIONS

The combination of omeprazole, amoxicillin and clarithromycin at standard doses (scheme B) is effective in clinical practice. Higher dose of amoxicillin and clarithromycin does not improve the results, and shorter duration of therapy associated with lower, although not significant rate of eradication.

The ideal therapy must be defined in each geographical area: experience with a quadruple therapy in Spain

BACKGROUND

Multiple therapeutic combinations have been tested to determine the optimal regimen(s) for Helicobacter pylori eradication, leading to very different results depending on the geographical area. Our goal was to evaluate the efficacy of a "quadruple" therapy with omeprazole, tetracycline, bismuth and metronidazole in our area.

MATERIALS AND METHODS

We investigate 106 consecutive patients with active peptic ulcer disease (duodenal, gastric or both) and Helicobacter pylori infection. One-week therapy with omeprazole 20 mg b.i.d., tetracycline hydrochloride 500 mg q.i.d., colloidal bismuth subcitrate 120 mg q.i.d., and metronidazole 250 mg t.i.d was prescribed. Between the days 30 and 40 after treatment ended follow-up endoscopy was performed. Eradication was defined as both negative urease test and histology. Between days 90 and 360 a 13C urea breath test was performed in 100 patients.

RESULTS

Of the 106 patients in the study, 91 had duodenal ulcer, 12 had gastric ulcer, and 3 had both. Side effects were observed in 25% of the cases. Eradication was achieved in 87.7% (93/106; CI 79.9-93.3). Healing was obtained in 95.2% (100/105; CI 89.2-98.4); 97.8% (CI 92.4-99.7) in those eradicated and 75% (CI 42.8-94.5) in non-eradicated (p < .01).

CONCLUSIONS

Quadruple therapy with omeprazole, tetracycline, bismuth subcitrate and metronidazole achieves healing rates up to 95-100%. The 87.7% eradication rate obtained suggests that the regimen we used is a reasonable therapeutic alternative in our area.

Eradication of helicobacter pylori among patients from a primary care practice

BACKGROUND

The eradication of Helicobacter pylori is becoming the therapy of choice for peptic ulcers, if the infection is present. Published data from primary care settings are, however, limited.

METHODS

An open-ended, prospective study was undertaken that included 31 patients with active peptic ulcer demonstrated by endoscopy and H pylori infection confirmed by urease and histologic tests. After a 14-day period of treatment with omeprazole, bismuth, tetracycline, and metronidazole, healing and H pylori status were evaluated by repeat endoscopy done at least 28 days after the last treatment dose. Eradication is defined as absence of H pylori in at least four (two from the fundus and two from the antrum) samples taken from the gastric mucosa and a negative urease test. Drug side effects and patient compliance were monitored in all cases.

RESULTS

Twenty-eight patients completed the protocol. Healing was obtained in all cases, and eradication was accomplished in 25 (89%). Side effects were common (69%) but mild. Compliance was good. After a mean follow-up of 300 days (range, 180 to 400), one ulcer recurrence was observed in an H pylori-positive patient and none in H pylori-negative patients.

CONCLUSIONS

The treatment of H pylori infection is an effective way of healing peptic ulcers, and can be applied in primary care settings. Further studies with more patients and with shorter and easier therapies should be undertaken to confirm our findings.

[The value of symptoms in the diagnosis of peptic ulcer: an approximation to the primary care medium]

GOAL

To evaluate which clinical data are useful to select those patients with peptic ulcers in primary care most likely to benefit from complementary studies.

METHODS

This is a prospective study done on 101 patients evaluated in a period of a year in a Primary Care Center. In all patients an endoscopy was done when a peptic ulcer was considered a possibility. In all cases a standardized questionnaire was completed before endoscopy and the patient evaluated by his primary care physician. The final diagnosis was defined according to endoscopy, done by expert endoscopists within seven days of the clinical evaluation. Statistical analysis was undertaken with SPSS software.

RESULTS

An active peptic ulcer was found in 45 (44.5%) cases. A high-grade MALT lymphoma was diagnosed in one case. Male sex, smoking status, number of cigarettes, smoking-index, and a previous history of ulcer complications were significantly associated with the diagnosis, as well as severe diurnal or nocturnal pain. Mean age was lower in ulcer patients. However no clinical data in individual or combined form did show any predictive value.

CONCLUSIONS

Clinical data do not permit to obviate endoscopy as the key initial procedure to diagnosis, even in primary care.