Peptic-ulcer disease

C314T polymorphism in histamine N-methyltransferase gene and susceptibility to duodenal ulcer in Chinese population

BACKGROUND

Histamine is a regulator of gastric acid secretion, which is involved in the development of duodenal ulcer (DU). Histamine is metabolized by both histamine N-methyltransferase (HNMT) and diamine oxidase, and its local action is terminated primarily by methylation which is catalyzed by HNMT.

METHODS

Polymerase chain reaction-restriction fragment length polymorphism assay was used to identify the polymorphism of the point mutation C314T of HNMT gene of 498 Chinese patients with DU and 151 healthy individuals.

RESULTS

In normal controls, the allele frequency of HNMT T314 was 3.3%, which was significantly lower than American Caucasians. The HNMT T314 allele was detected in 3.5% of the DU patients. In cases and controls, the frequency of C/C genotypes were 93.0% and 93.4%, respectively. The HNMT T/T genotype was not found in this population. No significant differences were seen in both genotype frequencies and allele frequencies between DU groups and controls. After stratified by H. pylori infection, they also could not reach significant differences in our current study.

CONCLUSION

The HNMT T314 allele frequency is lower in Chinese population than in American Caucasians. No association can be found in the involvement of HNMT C314T polymorphism in the susceptibility to duodenal ulcer.

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005)

RACIONAL: A úlcera duodenal sempre representou uma doença muito prevalente entre as enfermidades digestivas, em qualquer parte do mundo. A prevalência média era de aproximadamente 10% da população mundial. A partir do início dos anos 90, a literatura, tanto européia como norte-americana, passou a demonstrar sua redução gradativa entre seus países. OBJETIVO: Demonstrar, através de análise retrospectiva, a prevalência anual da úlcera duodenal nos últimos 10 anos em um Serviço de Endoscopia Digestiva que é referência para o sistema público de saúde da cidade de Porto Alegre, municípios da Grande Porto Alegre e outras cidades vizinhas da mesma. Os dados analisados são de março de 1996 até dezembro de 2005. MÉTODOS: Estudo retrospectivo transversal, com análise documental de diagnósticos endoscópicos efetuados em endoscopia digestiva alta, no referido Serviço. Foi feita a análise retrospectiva de diagnósticos endoscópicos efetuados em 13.130 pacientes submetidos a endoscopia digestiva alta no período de março de 1996 a dezembro de 2005. A classificação de Sakita foi utilizada para o estádio do grau evolutivo da úlcera duodenal e foi considerado por ela acometido o paciente com a lesão no estágio A1, até o estágio S1, inclusive. Observou-se também a prevalência nos dois sexos, na raça, o percentual médio total nos 10 anos, além da prevalência anual. Para verificar se houve significância estatística dos resultados observados nos diferentes períodos, foi aplicado um teste de regressão linear ("linear regression model"). RESULTADOS: Observou-se decréscimo gradativo dos percentuais de prevalência da úlcera duodenal, ano após ano, iniciando-se em 1996 com 8,6% e se encerrando no final de 2005, com 3,3%. A exceção do período foi observada no ano de 2003 quando houve um acréscimo, comparando-se com o decréscimo gradativo dos 6 anos anteriores. Mas já, a partir do período seguinte (2004), a queda gradativa voltou a ser observada. O valor médio de queda anual, aplicando o teste de regressão linear, foi da ordem de 1,3% ao ano, no período analisado (10 anos). Este teste mostrou também significância estatística. A raça branca representou a maioria, com 78% dos pacientes, em relação a raça negra. O sexo masculino, em todos os períodos analisados, exceto em um (1997), foi o sexo mais acometido, com uma relação final masculino/feminino da ordem de 1.17/1.0. CONCLUSÕES: Observou-se então, neste estudo efetuado no Brasil, também uma redução da prevalência da úlcera duodenal, já apontada pela literatura em outros países. Estudos posteriores devem ser efetuados no sentido de apontar as razões desta importante observação.

Long-term risk of gastric cancer by subsite in operated and unoperated patients hospitalized for peptic ulcer

OBJECTIVE

We aimed to investigate whether the elevated risk of gastric cancer among patients with gastric ulcer (GU) and the enigmatic low risk among patients with duodenal ulcer (DU) pertain to both cardia and noncardia cancer. We also studied the risks among operated patients while taking the disparate baseline risks into consideration.

METHODS

Retrospective cohorts of 59,550 and 79,412 unoperated patients with DU and GU, respectively, plus 12,840 patients with partial gastric resection and 8,105 with vagotomy, recorded in the Swedish Inpatient Register since 1970, were followed from the first hospitalization (date of operation for the surgery cohort) until occurrence of any cancer, death, emigration, definitive surgery, or December 31, 2003. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) expressed relative risk (RR), compared to the age-, sex-, and calendar period-matched Swedish population. Cox regression produced adjusted RR estimates among operated patients, relative to unoperated ones with the same ulcer type.

RESULTS

While unoperated DU patients had a halved risk of noncardia cancer (SIR=0.5, 95% CI 0.4-0.7), their risk of cardia cancer was slightly above expectation (SIR=1.2, 95% CI 0.8-1.7). Unoperated GU patients had doubled risks for both cancers (SIR=2.1, 95% CI 2.0-2.4 and SIR=1.9, 95% CI 1.4-2.3, respectively). DU patients who underwent gastric resection had a 60% risk elevation (RR=1.6, 95% CI 1.0-2.5) compared to unoperated ones. Vagotomy was associated with a greater risk in the first 10 yr, but this excess disappeared with further follow-up. Resected GU patients had a 40% risk reduction relative to their unoperated peers (RR=0.6, 95% CI 0.5-0.8). This reduction persisted well beyond the first postoperative decade.

CONCLUSION

The DU-related protection against gastric cancer does not seem to pertain to cardia cancer. With gastric resection, risks are shifted toward normality, regardless of underlying ulcer type.

Helicobacter pylori and benign upper digestive disease

Acute infection with Helicobacter pylori causes hypochlorhydria and gastrointestinal upset. As the infection persists, patients develop chronic antral-predominant or pangastritis. Gastric and duodenal ulcers arise from chronic mucosal inflammation and disordered acid secretion in the stomach. With successful eradication of H. pylori, non-NSAID-related gastric and duodenal ulcers heal even without long-term acid suppression. More importantly, peptic ulcers and their complications rarely recur. Clearing H. pylori infection also reduces the risk of mucosal injury in NSAID and aspirin users; the protective effects are more pronounced in NSAID-naïve and aspirin users. H. pylori is unlikely to be the cause of gastro-oesophageal reflux disease. However, a patient's reflux symptoms may be more difficult to control after clearing the infection. Although there is little evidence to support a causal relationship between H. pylori and non-ulcer dyspepsia, treatment of the infection gives a modest improvement of symptoms.

Epidemiology and pathophysiology of Helicobacter pylori infection in children

Helicobacter pylori is one of the commonest bacterial pathogens in human. The organism is associated with development of peptic ulcer diseases, lymphoproliferative disorders and gastric cancer. Residence in a developing country, poor socio-economic conditions and genetic predisposition are regarded as risk factors. Prevalence of infection is higher in developing countries and re-infection is higher among under five children. It is transmitted mainly through feco-oral route in developing countries and gastro-oral route in developed nations. Transmission of 'close-contact infection' depends on the degree of mixing and age-distribution between susceptible and infected individuals. Host and bacterial factors with interaction of environment contribute pathogenicity. H. pylori cytotoxin-associated geneA (cagA), vacuolating toxinA (vacA) and adherence factors to gastric epithelium have been linked to enhanced pathogenicity of the bacterium. Host genetic polymorphism of cytokines, related legends, receptors and enzymes influence H. pylori infection.

Primer: managing NSAID-induced ulcer complications--balancing gastrointestinal and cardiovascular risks

Ulcer complications associated with the use of NSAIDs, in high-risk patients, are often caused by a failure to identify patients' risk factors, concomitant use of aspirin or multiple NSAIDs, and underutilization of gastroprotective agents. Current data suggest that cyclo-oxygenase 2 (COX2) inhibitors and some nonselective NSAIDs increase the risk of myocardial infarction. Physicians must, therefore, take into account both the gastrointestinal and the cardiovascular risks of individual patients when prescribing NSAIDs. In patients with a low cardiovascular risk, NSAIDs can be prescribed according to the level of gastrointestinal risk. Patients with a moderate gastrointestinal risk (one or two risk factors) should receive a COX2 inhibitor or an NSAID plus a PPI or misoprostol. Patients with more than two gastrointestinal risk factors or prior ulcer complications require the combination of a COX2 inhibitor and a PPI. Patients with a high cardiovascular risk (e.g. coronary heart disease or an estimated 10-year cardiovascular risk greater than 10%) should receive prophylactic aspirin and combination therapy with a PPI or misoprostol irrespective of the presence of gastrointestinal risk factors. Naproxen is the preferred NSAID because it is not associated with excess cardiovascular risk. Patients with a high cardiovascular risk and a very high gastrointestinal risk should avoid using NSAIDs or COX2 inhibitors.

H pylori infection among 1000 southern Iranian dyspeptic patients

AIM: To describe the frequency of H pylori infection among 1000 southern Iranian dyspeptic patients.

METHODS: A prospective study was performed in a referral hospital in south of Iran from 1999 to 2005. One thousand dyspeptic patients (518 males, mean ± SD age of 49.12 ± 12.82 years) consecutively underwent upper gastrointestinal endoscopy. Multiple gastric antral biopsy samples were taken from all patients for rapid urease test and histopathologic examination (96.9% satisfactory samples). Patients were considered H pylori-infected if one or both tests were positive.

RESULTS: Six hundred and seventy-one patients (67.1%, 95% confidence interval [CI]: 64.2%-70.0%) were H pylori-infected. H pylori positivity was significantly more frequent in patients with peptic ulcer disease (PUD) than in those with non-ulcer dyspepsia (P < 0.001). Male-to-female ratio for duodenal and gastric ulcers was 2.7:1 and 1.5:1, respectively. Moreover, the duodenal-to-gastric ulcer ratio was 1.95:1. The frequency of H pylori infection among those with endoscopic diagnosis of gastritis, duodenal ulcer, gastric ulcer, and normal mucosa was 70.1% (398/568), 86.2% (150/174), 71.9% (64/89), and 33.5% (54/161), respectively. H pylori infection, male sex, and older age were independently associated with PUD in multivariate analysis. H pylori positivity was associated with chronic gastritis, and chronic active gastritis with odds ratios of 34.21 (95% CI: 12.19%-96.03%) and 81.21 (95% CI: 28.85%-228.55%), respectively.

CONCLUSION: H pylori and PUD are highly frequent in dyspeptic patients from south of Iran. H pylori is a cardinal risk factor for chronic active or inactive gastritis.

Characterization of flgK gene and FlgK protein required for H pylori Colonization-from cloning to clinical relevance

AIM: To characterize the role of flgK and its protein product in H pylori colonization.

METHODS: The PCR cloning method identified the flgK gene. An isogenic flgK mutant was constructed by gene replacement and confirmed by Southern blot analysis and PCR analysis. The recombinant FlgK protein (r-FlgK) was purified. Electron microscopy (EM) was applied to demonstrate the flagella of H pylori. An in vitro motility test was assessed in semisolid medium. The densities of H pylori colonization with either the wild-type strain or its flgK mutant were compared among BALB/c mice with or without pre-immunization with r-FlgK. The serological responses to r-FlgK were analyzed for 70 clinical patients with different densities of H pylori colonization.

RESULTS: From a duodenal ulcer strain, the flgK gene was cloned and it contained 1821 bp, with a 95.7% identity to the published sequences. No flagella were observed under EM for the mutant strain, which had a loss of motility. H pylori density was lower in the BALB/c mice inoculated by the mutant or with pre-immunization with r-FlgK compared to unimmunized mice or mice inoculated by the wild-type strain (P < 0.05). In the H pylori-infected patients, the serological responses to r-FlgK were uniformly low in titer.

CONCLUSION: FlgK encoded by flgK is important for flagella formation and H pylori motility. Deficiency in FlgK or an enhanced serological response to r-FlgK can interfere with H pylori colonization. FlgK of H pylori could be a novel target for vaccination.

Intra-familial transmission of Helicobacter pylori infection in children of households with multiple generations in Vietnam

This community-based cross-sectional study in 533 participants from 135 households with multiple generations living in the same household aimed at investigating the relationship between Helicobacter pylori infection in children and the other household members. H. pylori infection in children was found significantly associated with the infection in mothers [OR (95% CI): 2.50 (1.19-5.26)], even after being adjusted for sex, age group and sibling number [adjusted OR (95% CI): 2.47 (1.12-5.47)]. It was also significantly associated with the infection in both parents [adjusted OR (95% CI): 4.14 (1.29-13.23)]. No significant association between H. pylori infection in the father, grandparent(s), uncle or aunt with that in their children was found. Results from the present study showed intra-familial transmission in a multi-generation population and supported the hypothesis of person-to-person transmission of H. pylori infection.

Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002: a population-based cohort study

Peptic ulcer epidemiology changes as the proportion of Helicobacter pylori infected people decreases, use of nonsteroidal anti-inflammatory drugs (NSAID) increases, and the proportion of elderly persons increases.

OBJECTIVES

To describe incidence and prognosis of uncomplicated and complicated peptic ulcer patients in Funen County 1993-2002.

METHODS

Data on endoscopies, gastric and duodenal operations, and related peptic ulcer diagnoses were extracted from four population-based databases covering a period from 1974 to 2002. All citizens of Funen County (population 470,000) who between 1993 and 2002 had a peptic ulcer diagnosed for the first time were identified.

RESULTS

Between 1993 and 2002 the incidence of uncomplicated duodenal ulcer decreased from 0.55/1,000 person-years (95% CI 0.49-0.62) to 0.37 (0.31-0.43), uncomplicated gastric ulcer decreased from 0.56 (0.49-0.63) to 0.40 (0.34-0.46), and perforated ulcer decreased from 0.14 (0.11-0.18) to 0.08 (0.06-0.11). The incidence of bleeding peptic ulcer was stable with 0.55 (0.49-0.62) in 1993 and 0.57 (0.51-0.64) in 2002. The proportion of possible NSAID-related incident peptic ulcers increased from 320/827 (39%) in 1993 to 363/686 (53%) in 2002 (p < 0.01). A total of 3,233 patients with incident complicated peptic ulcer (9,927 person-years) and 4,421 patients with incident uncomplicated peptic ulcer (17,773 person-years) was followed for up to 10 yr. The first month following newly diagnosed complicated ulcer the standardized mortality rate was 37.1 (33.4-41.1) during the next 11 months it was 5.1 (4.6-5.6), and in the following years it was 2.6 (2.4-2.8). The corresponding figures for incident uncomplicated peptic ulcer was 11.6 (9.6-13.9), 4.0 (3.6-4.4), and 2.5 (2.3-2.7).

CONCLUSION

During the period, incidence of peptic ulcers decreased and an increasing proportion was related to NSAID. Mortality is high.

Simultaneous determination of amoxicillin and ranitidine in rat plasma by high-performance liquid chromatography

A high-performance liquid chromatography method using ultraviolet detection at 230 nm for the simultaneous determination of amoxicillin and ranitidine in rat plasma has been validated. Plasma samples after pretreatment with acetonitrile to effect deproteinization were dried under N2 and reconstituted with water. The standard calibration curves for amoxicillin and ranitidine were linear (r2=0.9999) over the concentration range of 0.2-20 microg ml-1 and 0.03-6 microg ml-1 in rat plasma, respectively. The intra- and inter-day assay variability range for amoxicillin was 2.4-8.5% and 3.2-11.7%, and for ranitidine was 1.7-9.0% and 4.5-10.1%, respectively. This method has been successfully applied to a pharmacokinetic study after oral coadministration of amoxicillin and ranitidine to rats.

Qualea grandiflora, a Brazilian "Cerrado" medicinal plant presents an important antiulcer activity

Qualea grandiflora is one of the species widely used in folk medicine to treat gastric ulcers in Cerrado of the central region of Brazil. The hydroalcoholic extract of bark (HE) of Qualea grandiflora was investigated for their ability to prevent and heal lesions in the gastric mucosa. The oral administration of HE exhibited antiulcer activity decreasing the ulcerative index induced by HCl/ethanol solution, indomethacin/bethanechol and stress. In the Shay model, results showed that HE (p.o.) only reduced the severity of gastric lesions without effects on pH, gastric acidity or volume. When given by intraduodenal route, HE changed the pH, but did not modify the other parameters of the gastric juice. These data were in accordance with those obtained when HE was administered orally for 14 days after gastric ulcers were induced by acetic acid in rats. HE presented healing process in subacute gastric ulcer induced by acetic acid in rats. Moreover, histological examinations showed the simple columnar epithelium, lamina propria with simple branched tubular glandules with dilated lumen and large amounts of mucus secretion. Phytochemical investigation of HE led to the detection of terpenes, steroids, saponins, phenolic compounds and tannins in this extract, which may be involved in the observed activity.

Antiulcerogenic activity of Alchornea castaneaefolia: effects on somatostatin, gastrin and prostaglandin

The hydroethanolic extract of the leaves (HEL) and bark (HEB) obtained from Alchornea castaneaefolia (Euphorbiaceae) were investigated for their ability to prevent ulceration of the gastric mucosa in animal models. HEL (500 and 1000 mg/kg) and HEB (1000 mg/kg) significantly reduced the gastric injuries induced by the combination of HCl/ethanol and lowered the severity of gastric damage formation induced by indomethacin/bethanechol in mice. Further investigation showed that HEL also inhibited formation of ulcers in mice submitted to stress and pylorus ligature, but HEL did not modify gastric juice parameters in Shay mice. HEL was also effective in promoting the healing process in chronic gastric ulcer induced by acetic acid in rats. An enriched flavonoidic fraction (EFF at dose of 100mg/kg) obtained from HEL reduced gastric lesions induced by HCl/ethanol and indomethacin/bethanechol in mice. Although EFF did not modify the amount of free mucus production by gastric mucosa, it was able to increase prostaglandin production. When administered to rats submitted to ethanol-induced gastric lesions, EFF increased the somatostatin serum levels, while the gastrin serum levels were proportionally decreased. Phytochemical investigation on HEL and EFF led to the isolation of flavonoids glycosides as the main compounds, thus suggesting that these substances may be involved in the observed antiulcer activity.

[A case of postoperative pulmonary metastasis of breast cancer treated with docetaxel and cyclophosphamide therapy]

A 55-year-old woman underwent a partial breast resection in our hospital for breast cancer in May 2002. For adjuvant therapy, she received cyclophosphamide, pirarubicin and 5-FU infusion a total of 6 times, and anastrozole. Then, in May of 2004, an abnormal shadow was detected on her of chest X-ray. After CT scan we diagnosed multiple pulmonary metastasis of breast cancer. We used combination therapy of docetaxel 60 mg/m(2) and cyclophosphamide 500 mg/m(2). After 9 months, pulmonary metastasis disappeared on her CT scan. During chemotherapy, she showed no major side effect.

The effect of single-dose naproxen on eicosanoid formation in human gastroduodenal mucosa

BACKGROUND

In animal studies, aspirin and non-aspirin non-steroidal anti-inflammatory drugs contribute to gastroduodenal damage via cyclo-oxygenase inhibition and consecutive leucotriene formation (COX-LOX eicosanoid shunt).

AIM AND METHODS

Ten Helicobacter pylori-negative healthy volunteers received a single dose of 500 mg naproxen to address two questions: (i) is there a crosstalk between eicosanoids before medication in the human gastroduodenal mucosa and (ii) can we demonstrate a COX-LOX shunt following single-dose naproxen?

RESULTS

Significant correlations in the stomach mucosa before medication were obtained between leucotriene B4 (LTB4) and thromboxane B(2) (TxB(2); r = -0.38, P = 0.05), as well as LTB4 and prostaglandin E(2) (PGE(2); r = 0.71, P < 0.0001). In serum, a >90% inhibition of TxB(2) and PGE(2) occurred within 30 min of naproxen administration. In gastric mucosa, a significant decrease of TxB(2) occurred already at 15 min and preferably in the antrum. For LTB4 there was a non-significant trend towards a transient increase. Mucosal PGE(2) was unchanged in all regions; transcript levels of both cyclo-oxygenases/5-lipoxygenase were unaffected (except for a trend of increasing cyclo-oxygenase-2 in the corpus).

CONCLUSIONS

Baseline correlations between LTB4-TxB(2) and LTB4-PGE(2) reflect a crosstalk between these eicosanoids. A COX-LOX shunt; however, cannot be demonstrated following single-dose naproxen in a low-risk population.

An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit?

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection.

DESIGN

A prospective observational study followed by a case-control study.

SETTING

Seven ICUs in the Paris area, five of them located in teaching hospitals.

PATIENTS

All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04).

CONCLUSIONS

Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.

Should we eradicate Helicobacter pylori infection in patients receiving nonsteroidal anti-inflammatory drugs or low-dose aspirin?

Whether Helicobacter pylori infection alters the risk of ulcer disease in patients receiving nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin is one of the most controversial topics in peptic ulcer research. This is an important management issue, particularly in countries where peptic ulcer disease is common and the prevalence of H. pylori infection is high. Current evidence shows that H. pylori infection increases the ulcer risk associated with NSAIDs or low-dose aspirin. Eradication of H. pylori reduces the subsequent risk of endoscopic and complicated ulcers in patients who are about to start long-term NSAIDs. Among patients with H. pylori infection and a history of ulcer bleeding who continue to use low-dose aspirin, 1 week of eradication therapy prevents recurrent ulcer bleeding. Failure of eradication and concomitant use of NSAIDs, however, account for most cases of recurrent bleeding with low-dose aspirin. The apparent protective effect of H. pylori in long-term NSAIDs users reported in some studies was actually the weeding out of susceptible patients who were intolerant to NSAIDs. There is no convincing evidence that eradication of H. pylori has any clinically important adverse effect on the healing and prevention of ulcers in NSAIDs users.

Use of Antiplatelet Drugs in the Stroke Unit of a Hong Kong Hospital

OBJECTIVE

Antiplatelet drugs are widely used for secondary prevention of thrombotic cerebrovascular disease. The antiplatelet prescribing patterns has been evaluated in several studies but data about Hong Kong patients are lacking. This study is to investigate the prescribing patterns of antiplatelet agents in a Hong Kong hospital.

METHOD

All patients over 18 years, who attended the stroke unit between 1 October 2002 and 31 December 2002 and were on antiplatelet therapy were included in the study. Data were collected through retrospective chart review and recorded on a standardized data collection form. Continuous and categorical data were expressed as mean and counts respectively. Factors that determine frequency and pattern of antiplatelet therapy were assessed in multiple logistic regression models.

RESULTS

Three hundred and nineteen patients were included in the study. Aspirin and clopidogrel accounted for 82.1 and 16.3 of all prescriptions respectively and remaining patients were on aspirin/dipyridamole. Patients with no history of aspirin use were less likely to be treated with clopidogrel compared with those experienced aspirin intolerance (OR=0.004, 95 CI 0.000-0.051). Patients with history of gastrointestinal (GI) diseases were more likely to receive clopidogrel than those had no history of GI disorders (OR=154.86, 95 CI 33.76-710.38). Atrial fibrillation (AF) was positively associated with clopidogrel prescription (OR=11.83, 95 CI 1.21-115.85). In addition, patients with concomitant gastroprotective drugs received clopidogrel significantly less often than those without gastroprotective agents (OR=0.06, 95 CI 0.01-0.29).

CONCLUSION

Use of antiplatelet agents in patients receiving antiplatelet therapy of the stroke unit has complied with existing evidences. Several factors that determine choice between aspirin and clopidogrel were identified which included history of aspirin use and GI disorders, AF and co-prescribed gastroprotective drugs.

Diagnosing Helicobacter pylori in vivo by confocal laser endoscopy

BACKGROUND & AIMS

Confocal laser endomicroscopy enables subsurface microscopic imaging of living tissue during ongoing endoscopy. This case report describes the in vivo detection of Helicobacter pylori by endomicroscopy.

METHODS

Endomicroscopy (Pentax, Tokyo, EC-3870CIFK) was performed by using two different contrast stains: Topical Acriflavine in addition to intravenously applied fluorescein netted the surface and allowed identification of focal accumulation of Helicobacter pylori at the surface and in deeper layer of the gastric epithelium. Biopsies were performed at the antrum and corpus for urease testing and histology. In addition, biopsies were cultured for Helicobacter pylori. Cultured bacteria were re-assessed ex vivo using confocal microscopy with and without acriflavine staining.

RESULTS

Helicobacter pylori infection could be detected in a 70-year-old male by endomicroscopy. Accumulated, as well as single bacteria, could be observed and the distinct shape and flagella of Helicobacter pylori could be identified. Helicobacter pylori infection was proved by histology. Furthermore, ex vivo examination of cultures proved the presence of Helicobacter pylori and the active uptake of acriflavine into the bacteria.

CONCLUSIONS

Endomicroscopy is a new diagnostic approach, which enables the immediate diagnosis of Helicobacter pylori in vivo during standard video endoscopy.

Surgery for peptic ulcer disease in children in the post-histamine2-blocker era

BACKGROUND/PURPOSE

The aim of this study was to determine the presentation, treatment, and outcome of children requiring surgery for peptic ulcer disease (PUD) in the post-histamine 2 -blocker era.

METHODS

The charts of all children undergoing surgery for PUD in our institution since 1980 were retrospectively reviewed. Data were collected regarding clinical presentation, operative details, postoperative course, and outcome.

RESULTS

Twenty-nine children (7.2 +/- 7.5 years) required surgery for complications of PUD. Indications for operation were bleeding (n = 11), pneumoperitoneum (n = 13), peritonitis (n = 3), and gastric outlet obstruction refractory to medical therapy (n = 2). For those children with bleeding, 8 had simple oversew of the bleeding ulcer(s), 2 had oversew with vagotomy and pyloroplasty, and 1 required vagotomy and antrectomy. All patients with perforation (n = 16) were treated with simple closure with or without omental patch. One child with gastric outlet obstruction underwent vagotomy and antrectomy and 1 had vagotomy and pyloroplasty. Preoperative risk factors or comorbidities were present in 27 of 29 patients and included steroid or nonsteroidal antiinflammatory drug medications in 13 children (only 3 of whom were receiving antiulcer prophylaxis). Postoperative complications occurred in 11 of 29 patients. Three (10%) children required reoperation for persistent or recurrent ulcer disease and 4 children died.

CONCLUSIONS

PUD remains a highly morbid and mortal condition in children despite the availability of effective acid-reducing medications. Effective prophylaxis of children receiving steroids and nonsteroidal antiinflammatory drugs may play a role in decreasing the risk of PUD.

Comparison of Helicobacter pylori infection and gastric mucosal histological features of gastric ulcer patients with chronic gastritis patients

AIM: To compare Helicobacter pylori infection and gastric mucosal histological features of gastric ulcer patients with chronic gastritis patients in different age groups and from different biopsy sites.

METHODS: The biopsy specimens were taken from the antrum, corpus and upper angulus of gastric ulcer and chronic gastritis patients. Giemsa staining, improved Toluidine-blue staining and H pylori-specific antibody immune staining were performed as appropriate for the histological diagnosis of H pylori infection. Hematoxylin-eosin staining was used for the histological diagnosis of activity of H pylori infection, mucosal inflammation, glandular atrophy and intestinal metaplasia and scored into four grades according to the Updated Sydney System.

RESULTS: Total rate of H pylori infection, mucosal inflammation, activity of H pylori infection, glandular atrophy and intestinal metaplasia in 3839 gastric ulcer patients (78.5%, 97.4%, 82.1%, 61.1% and 64.2%, respectively) were significantly higher than those in 4102 chronic gastritis patients (55.0%, 90.3%, 56.2%, 36.8%, and 37.0%, respectively, P<0.05). The rate of H pylori colonization of chronic gastritis in <30 years, 31-40 years, 41-50 years, 51-60 years, 61-70 years and >70 years age groups in antrum was 33.3%, 41.7%, 53.6%, 57.3%, 50.7%, 43.5%, respectively; in corpus, it was 32.6%, 41.9%, 53.8%, 60.2%, 58.0%, 54.8%, respectively; in angulus, it was 32.4%, 42.1%, 51.6%, 54.5%, 49.7%, 43.5%, respectively. The rate of H pylori colonization of gastric ulcer in <30 years, 31-40 years, 41-50 years, 51-60 years, 61-70 years and >70 years age groups in antrum was 60.5%, 79.9%, 80.9%, 66.8%, 59.6%, 45.6%, respectively; in corpus, it was 59.7%, 79.6%, 83.6%, 80.1%, 70.6%, 59.1%, respectively; in angulus, it was 61.3%, 77.8%, 75.3%, 68.8%, 59.7%, 45.8%, respectively. The rate of H pylori colonization at antrum was similar to corpus and angulus in patients, below 50 years, with chronic gastritis and in patients, below 40 years, with gastric ulcer. In the other age- groups, the rate of H pylori colonization was highest in corpus, lower in antrum and lowest in angulus (all P<0.05). The rates of glandular atrophy and intestinal metaplasia were higher and earlier in H pylori-positive patients than those without H pylori infection (both P<0.01). In comparison of gastric ulcer patients with chronic gastritis patients, the rate of glandular atrophy and intestinal metaplasia was higher in H pylori-positive patients with gastric ulcer than in H pylori-positive patients with chronic gastritis (both P<0.01); the rate of glandular atrophy and intestinal metaplasia were also higher in H pylori-negative patients with gastric ulcer than in H pylori-negative patients with chronic gastritis (both P<0.01). Both glandular atrophy and intestinal metaplasia were much more commonly identified in the angulus than in the antrum, lowest in corpus (all P<0.01).

CONCLUSION: Rate of H pylori infection, glandular atrophy and intestinal metaplasia in gastric ulcer were higher than in chronic gastritis in all-different age -groups. Distribution of H pylori colonization is pangastric in the younger patients. It is highest in corpus, lower in antrum and lowest in angulus in the older age groups. Progression of glandular atrophy and intestinal metaplasia seem to have a key role in the distribution of H pylori colonization. H pylori appears to be the most important risk factor for the development of glandular atrophy and intestinal metaplasia, but it is not the only risk.

Epidemiology of peptic ulcer disease in Wuhan area of China from 1997 to 2002

AIM: To describe the epidemiological features of peptic ulcer disease in Wuhan area during 1997-2002, to analyze the sex, age and occupation characteristics, as well as the geographic distribution of peptic ulcer disease, and to determine the effective methods of preventing and controlling peptic ulcer disease.

METHODS: In the early 1980s, the peptic ulcer disease registry system was established to collect the data of peptic ulcer disease in Wuhan area. Here we performed a statistically detailed analysis of 4876 cases of peptic ulcer disease during 1997-2002.

RESULTS: The morbidity of peptic ulcer disease between males and females was significantly different (χ² = 337.9, P < 0.001). The majority of peptic ulcer diseases were found at the age of 20 to 50 years. Because of different occupations, the incidence of peptic ulcer disease was different in different areas.

CONCLUSION: The incidence of peptic ulcer disease is highly associated with sex, age, occupation and geographic environmental factors. By analyzing the epidemiological features of peptic ulcer disease, we can provide the scientific data for prevention and control of peptic ulcer disease.

Reducing major cause-specific hospitalization rates and shortening hospital stays after influenza vaccination

BACKGROUND

The impact of influenza vaccination on major cause-specific hospitalization and the duration of hospital stay is rarely reported. Our purpose was to study the effect of vaccine efficacy on major disease-specific hospitalization and the duration of hospital stays among elderly persons.

SUBJECTS AND METHODS

From 1 January through 30 June 2001, we prospectively observed 35,637 vaccinated elderly persons (age, >or=65 years) and 53,094 unvaccinated elderly persons in Kaohsiung County, Taiwan, by computerized linkage to the National Health Insurance database. Of these persons, 21,347 had been assigned a high-risk status by the Department of Health, Taiwan. Univariate and multivariate logistic regression were used for determining vaccine efficacy in hospitalization. Multiple linear regression analyses were performed for determining the length of hospital stays.

RESULTS

In both high-risk and low-risk groups, vaccination was associated with reducing the rates of hospitalization for all causes (20% vs. 23%), lung diseases, congestive heart failure (43% vs. 32%), renal disease, and liver disease (P<.05). It was also significant for stroke, hypertension, diabetes, neoplasm, and injury in low-risk patients (P<.05). Multivariate logistic regression showed that vaccination was significantly associated with reducing the rate of hospitalization (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.86-0.92), but those with high-risk status had an increased risk of hospitalization (OR, 3.69; 95% CI, 3.56-3.82). Multiple linear regression analysis showed that vaccination decreased the duration of all-cause hospital stays (coefficient, -2.4 days; 95% CI, -2.7 to -2.1 days) and of hospitalization due to lung disease (coefficient, -4.9 days; 95% CI, -6.0 to -3.8 days).

CONCLUSION

Influenza vaccination may reduce hospitalization rates and shorten hospital stays not only for lung diseases but also for other common diseases in high-risk and low-risk elderly populations.

The prevalence of peptic ulcer not related to Helicobacter pylori or non-steroidal anti-inflammatory drug use is negligible in southern Europe

BACKGROUND AND AIM

Helicobacter pylori is the major cause of peptic ulcer disease, but the proportion of H. pylori-negative peptic ulcers seems to be increasing in developed countries. We investigated the frequency of H. pylori-negative peptic ulcer without intake of nonsteroidal anti-inflammatory drugs (NSAIDs) in a Mediterranean European country.

MATERIALS AND METHODS

We prospectively collected consecutive patients with an endoscopically verified active peptic ulcer over 6 months from different areas of Spain. Helicobacter pylori infection was assessed by rapid urease test and histologic examination (corpus and antral biopsies). A (13)C-urea breath test was performed if H. pylori was not detected with the invasive test. Patients were considered H. pylori-negative if all three tests were negative. NSAID use was determined by structured data collection.

RESULTS

Of 754 consecutive peptic ulcer patients, 16 (2.1%) were H. pylori-negative and had not used NSAIDs before the diagnosis. Of the 472 patients who had duodenal ulcers, 95.7% (n = 452) were H. pylori-positive and only 1.69% (n = 8) were negative for both H. pylori infection and NSAID use; 193 patients had benign gastric ulcers and 87% (n = 168) of them were infected by H. pylori (p <.001 vs. duodenal ulcers). NSAID intake was more frequent in gastric ulcer patients (52.8%) than in duodenal ulcer patients (25.4%; p <.001). Consequently, the frequency of H. pylori-negative gastric ulcer in patients not using NSAID was 4.1% (n = 8).

CONCLUSION

Peptic ulcer disease is still highly associated with H. pylori infection in southern Europe, and only 1.6% of all duodenal ulcers and 4.1% of all gastric ulcers were not associated with either H. pylori infection or NSAID use.

Peptic ulcer disease and the risk of bladder cancer in a prospective study of male health professionals

Helicobacter pylori is a risk factor for gastric and duodenal ulcers, but gastric ulcers generally occur in individuals who have low acid production and diffuse gastritis, whereas duodenal ulcers are more likely to occur with high acid output and antrum-predominant gastritis. Low acid production, gastritis, and ulcer healing each contribute to poor antioxidant absorption, oxidative stress, and elevated nitrite levels in the stomach. N-Nitrosamines are known carcinogens, and nitrate ingestion has been related to bladder cancer risk. Consequently, we hypothesized that the gastric conditions associated with gastric ulcers may contribute to elevated bladder cancer risk. We thus examined the association between self-reported history of peptic ulcer disease and the risk of bladder cancer (414 cases) over 14 years of follow-up in the Health Professional Follow-Up Study. Cox proportional hazards models were performed to adjust for known risk factors of bladder cancer. Men who reported a gastric ulcer before 1986 had a significantly higher risk of bladder cancer compared with those with no history of gastric ulcer (relative risk = 1.55, 95% confidence interval = 1.03-2.33, controlling for smoking and other potential confounders). No association was observed for duodenal ulcers (multivariate relative risk = 0.97, 95% confidence interval = 0.68-1.38). The ulcers in this study were based solely on self-report and not medical records; consequently, misclassification of ulcers may have occurred. Although intriguing, these findings need to be replicated.

Have COX-2 inhibitors influenced the co-prescription of anti-ulcer drugs with NSAIDs?

AIMS

To quantify usage of COX-2 inhibitors compared with nonselective NSAIDs and to determine their impact (including financial) on the co-prescription of antipeptic ulcer (anti-PU) drugs.

METHODS

The Irish General Medical Services prescription database (covering 1.2 million people) was examined for NSAID prescriptions during December 1999-November 2001. NSAID users were excluded during the first 6 months. During the next 12 months (study period) patients on NSAIDs (>or= 3 prescriptions) were identified. The study period and final 6 months provided data on co-prescription of anti-PU drugs. Age, gender, number of concomitant prescriptions, co-prescribing of anti-PU drugs and monthly cost were evaluated for 8 NSAIDs (n= 4 non-selective NSAIDs and n= 4 COX-2 inhibitors) and odds ratios (OR) calculated using logistic regression.

RESULTS

COX-2 inhibitors were prescribed more frequently in older, female patients and those receiving multiple medications. After adjustment for age, gender and polypharmacy, anti-PU drugs were prescribed more frequently with COX-2 inhibitors (OR = 1.31 (1.23,1.40)). COX-2 inhibitors were up to 10-fold more expensive, median monthly costs (including anti-PU drugs) ranging from Euros 34.61 (COX-2 inhibitors) to Euros 3.26 (nonselective NSAIDs).

CONCLUSIONS

Since COX-2 inhibitors are associated with increased rates of co-prescription of anti-PU drugs and are more expensive than non-selective NSAIDs, these results suggest that the expected cost-savings with COX-2 inhibitors may not be occurring in practice.

Impact de l’infection à Helicobacter pylori sur le risque de complications gastro-duodénales des traitements anti-inflammatoires non stéroïdiens

The interaction of Helicobacter pylori (H. pylori) and non steroidal anti-inflammatory drugs (NSAIDs) on the development of gastro-duodenal ulcers and their complications is complex and controversial. From a clinical point of view, the question is whether or not H. pylori infection should be tested and eradicated in patients treated or about to be treated by NSAIDs or low-dose aspirin. Contradictory results have been reported in epidemiological studies. Recent data suggest that H. pylori-NSAID interaction may be different depending on the type of treatment, non aspirin NSAIDs or low-dose aspirin, the gastric or duodenal localization of ulcer and the strains of H. pylori. Controlled randomized studies suggest that eradication of H. pylori may be beneficial in NSAID-naïve patients but not in those already on long term NSAID therapy. Recommendations are proposed for different subgroups of patients. In NSAID users presenting with gastro-duodenal ulcer or complications, H. pylori screening and eradication are indicated. In patients treated or about to be treated by NSAIDs, the "test and treat" H. pylori strategy is recommended if there is a history of gastroduodenal ulcer or complications. Whether this strategy should be generalized preventively in patients without ulcer history is still controversial and deserves further studies.

Heterotopic gastric mucosa of the esophagus: literature-review and proposal of a clinicopathologic classification

The prevalence of heterotopic gastric mucosa (HGM) in the cervical esophagus is frequently underestimated. Tiny microscopic foci have to be distinguished from a macroscopically visible patch, also called "inlet patch." Symptoms as well as morphologic changes associated with HGM are regarded as a result of the damaging effect of acid, produced by parietal cells in the mostly fundic type of HGM. We herein review the literature and propose a new clinicopathologic classification of esophageal HGM: Most of the carriers of esophageal HGM are asymptomatic (HGM I). Some individuals with HGM in the esophagus complain of dysphagia, odynophagia, or "extraesophageal manifestations" (hoarseness and coughing), without further morphologic findings (HGM II). Still fewer patients are symptomatic due to morphologic changes, i.e., esophageal strictures, webs, or esophagotracheal fistula (HGM III). Malignant transformation via dysplasia (intraepithelial neoplasia, HGM IV) to cervical esophageal adenocarcinoma (HGM V) is exceedingly rare (only 24 reported cases). In contrast to Barrett's esophagus, HGM should not be regarded as a precancerous lesion. Symptoms are more likely to occur in patients with inlet patch, whereas malignant transformation and adenocarcinogenesis can also occur in microscopic HGM foci. Asymptomatic HGM requires neither specific therapy nor endoscopic surveillance. Only in symptomatic cases treatment, i.e., dilatation for (benign) strictures or acid suppression for reflux symptoms, can be recommended. Patients with low-grade dysplasia in HGM might be candidates for surveillance strategies, whereas in cases of high-grade dysplasia and invasive adenocarcinoma oncological treatment strategies must be employed.

Trends in peptic ulcer pharmacotherapy

Considering the diseases of the stomach and duodenum, peptic ulcer has been the one with a significant clinical impact. The pathophysiology of peptic ulcer has centred on an imbalance between aggressive and protective factors. The discovery of Helicobacter pylori as a cause of peptic ulcer has changed our approach greatly towards this disease. Despite the decreasing frequency of H. pylori-induced peptic ulcers, peptic ulcer remains a major clinical problem partly because nonsteroidal anti-inflammatory drug (NSAID)-related ulcers and hospital admissions for ulcer complications associated with NSAIDs have increased in frequency. The interaction between H. pylori and NSAIDs is one of the most controversial issues in peptic ulcer. In this article, current concepts of peptic ulcer etiopathogenesis and the management of peptic ulcer according to the etiology were reviewed.

Infection à Helicobacter pylori et résistance aux antibiotiques

PURPOSE

Seven days triple therapies combining a proton pump inhibitor (PPI) and 2 antimicrobial agents (clarithromycin [C], amoxicillin [A], metronidazole [M]), are recommended for the treatment of Helicobacter pylori infection. The eradication failures have increased these last years, particularly in France (about 30%). They are essentially related to the development of antimicrobial agents resistance, mainly concerning macrolides and nitro-imidazoles.

CURRENT KNOWLEDGE AND KEY POINTS

Primary resistance to clarithromycin is variable, but reaching now about 10% throughout the world and about 20% in France. It reduces the eradication success rate at 25%. The secondary resistance is very high, contra-indicating the use of clarithromycin in second line regimens. Primary resistance to amoxicillin has recently appeared, but remains very low until now, less than 2%, as the tetracyclin (T) resistance. Primary resistance to metronidazole is 3 times higher than macrolides resistance, but its determination is less accurate. Metronidazole resistance reduces eradication rate of about 25%, leading to the use of metronidazole in second line therapy, in increasing the triple therapy duration at 14 days (PPI-A-M), or in combination with quadruple therapy (Bismuth-PPI-T-M). Other rescue-treatments are efficacious, based on ranitidine bismuth citrate combined regimens or on rifabutine (R) based regimens (PPI-A-R).

FUTURE PROSPECTS AND PROJECTS

The recent knowledge of the mutations mainly responsible for H. pylori resistance to antimicrobial agents now allows the development of detection methods based on the study of bacterial DNA. These methods have been validated for clarithromycin and should favour in the near future the determination of resistance by the use of biopsy culture or directly on the gastric biopsy.

Pathogenesis of pre-neoplastic lesions of the stomach: targets for prevention

Gastric atrophy and intestinal metaplasia are generally considered to be precancerous lesions of the stomach. Chronic Helicobacter pylori infection is one the most important factors in the development of these pre-malignant gastric lesions. In addition to bacterial factors, polymorphisms in the cytokine genes of the host that modulate inflammatory responses are found to have a synergistic effect in the development of gastric cancer as well as pre-neoplastic lesions. Recently, inappropriate activation of the intestine-specific transcription factor like the homeobox gene complex CDX1 and CDX2 are found to be an important contributing factor in the induction of intestinal metaplasia in the stomach. Aberrant expression of cyclooxygenase-2 and epigenetic changes are also frequently detected in pre-neoplastic gastric lesions. One of the most important questions relating to these pre-neoplastic gastric lesions is that whether H. pylori eradication could reverse these changes. However, most controlled studies showed no or just modest improvement in intestinal metaplasia after H. pylori eradication. Further studies should evaluate the role of other chemopreventive agents, particularly cyclooxygenase-2 inhibitor, on regression of pre-neoplastic lesions.

Pharmacologic Treatment of Upper Gastrointestinal Bleeding

The first goal of therapy is to assess hemodynamic stability in a patient presenting with evidence of upper gastrointestinal bleeding and, second, to maintain hemodynamic stability using crystalloids or packed red blood cells. The diagnosis of the cause of upper gastrointestinal bleeding should be performed using endoscopic techniques, which should be performed early. Therapy directed at treating the cause of upper gastrointestinal bleeding should be initiated at the time of endoscopy. Pharmacologic management should be based on the prevention of ulcer rebleeding and should be initiated at the time of endoscopic diagnosis. Surgery should be considered only in cases when endoscopic and pharmacologic treatments are deemed a failure.

Review article: NSAIDs, gastroprotection and cyclo-oxygenase-II-selective inhibitors

In patients at high risk of NSAID-associated serious upper gastrointestinal complications, gastroprotection with misoprostol or a proton pump inhibitor should be considered. Only misoprostol, 800 micro g/day, has been shown to reduce serious upper gastrointestinal complications in a large clinical outcome trial. The benefit of Helicobacter pylori eradication in reducing NSAID-associated gastrointestinal toxicity is controversial, and routine testing for and eradication of H. pylori in NSAID users are not currently advised. The gastrointestinal safety of rofecoxib and celecoxib has been assessed in large clinical outcome trials which, on first analysis, show benefits over non-selective NSAIDs in the incidence of serious upper gastrointestinal complications. However, longer term gastrointestinal data from the celecoxib study (CLASS) and cardiovascular adverse event data from the rofecoxib study (VIGOR) have questioned the risk-benefit profile of these new drugs and, until they are better understood, it seems sensible not to use them routinely in large numbers of individuals. The gastrointestinal safety of meloxicam and etodolac has not been adequately assessed in such trials. Therefore, evidence for their use instead of non-selective NSAIDs, or instead of celecoxib or rofecoxib, is not robust.