Gastric secretion and peptic ulceration in cirrhosis

Active Breathing Coordinator reduces radiation dose to the stomach in patients with left breast cancer

BACKGROUND/PURPOSE

Gastric dose parameters comparison for deep inspiration breath-hold (DIBH) or free breathing (FB) mode during radiotherapy (RT) for left-sided breast cancer patients (LSBCPs) has not been investigated before. This study aimed to analyze the impact of Active Breath Coordinator (ABC)-DIBH technique on the dose received by the stomach during RT for LSBCPs and to provide organ-specific dosimetric parameters.

MATERIALS AND METHODS

The study included 73 LSBCPs. The dosimetric parameters of the stomach were compared between FB and DIBH mode. The correlation between the stomach volume and dosimetric parameters was analyzed.

RESULTS

Compared to FB mode, statistically significant reductions were observed in gastric dose parameters in ABC-DIBH mode, including Dmax (46.60 vs 17.25, p < 0.001), D1cc (38.42 vs 9.60, p < 0.001), Dmean (4.10 vs 0.80, p < 0.001), V40Gy (0.50 vs 0.00, p < 0.001), V30Gy (6.30 vs 0.00, p < 0.001), V20Gy (20.80 vs 0.00, p < 0.001), V10Gy (51.10 vs 0.77, p < 0.001), and V5Gy (93.20 vs 9.60, p < 0.001). ABC-DIBH increased the distance between the stomach and the breast PTV when compared to FB, from 1.3 cm to 2.8 cm (p < 0.001). Physiologic decrease in stomach volume was not found from FB to ABC-DIBH (415.54 cm3 vs 411.61 cm3, p = 0.260). The stomach volume showed a positive correlation with V40Gy (r2 = 0.289; p < 0.05), V30Gy (r2 = 0.287; p < 0.05), V20Gy (r2 = 0.343; p < 0.05), V10Gy (r2 = 0.039; p < 0.001), V5Gy (r2 = 0.439; p < 0.001), Dmax (r2 = 0.269; p < 0.05) and D1cc (r2 = 0.278; p < 0.05) in FB mode. While in ABC-DIBH mode, most stomach dosimetric parameters were not correlated with gastric volume.

CONCLUSIONS

The implementation of ABC-DIBH in LSBCPs radiotherapy resulted in lower irradiation of the stomach. Larger stomach volume was associated with statistically significantly higher dose irradiation in FB mode. To reduce radiotherapy related side effects in FB mode, patients should be fast for at least 2 hours before the CT simulation and treatment.

Clinical characteristics of reflux esophagitis among patients with liver cirrhosis: a case-control study

BACKGROUND

Reflux esophagitis (RE) can cause esophageal varices bleeding and largely reduce life quality of liver cirrhosis (LC) patients.

AIMS

To clarify the prevalence, severity and risk factors of RE among LC patients.

METHODS

A case-control study that enrolled 420 endoscopy-confirmed LC patients with RE as a case cohort and 409 LC patients without RE as a control group was conducted. Logistic regression was used to determine the risk factors for RE among LC patients.

RESULTS

The 10-year cumulative incidence rate of RE was 4.79% among the LC patients. The severity of RE among the LC patients was higher than that among the non-LC patients (p<.05). The LC patients with RE patients were older (56 years vs. 53 years) and had higher rates of male patients (77.14% vs. 65.77%), smoking (46.90% vs. 32.76%), alcohol intake (50.24% vs. 41.08%), past endoscopic variceal ligation (EVL) (9.05% vs. 4.65%), endoscopic injection sclerotherapy (EIS) (16.19% vs. 2.69%), hiatus hernia (7.14% vs. 0.13%) and portal vein thrombosis (PVT) (14.05% vs. 4.01%). Logistic regression demonstrated that hiatus hernia, past EIS, PVT, smoking, white blood cell count, age, spleen thickness and platelet (PLT) count were risk factors for RE among the LC patients.

CONCLUSIONS

Patients with LC tended to have severer RE than non-LC patients. The special risk factors of RE among LC patients included past EIS and PVT, which deserved extra attention for hepatologists as well as gastroenterologists to prevent.

Trends and outcomes of peptic ulcer disease in patients with cirrhosis

BACKGROUND

Peptic ulcer disease (PUD) is more prevalent in cirrhotic patients and it has been associated with poor outcomes. However, there are no population-based studies from the United States (U.S.) that have investigated this association. Our study aims to estimate the incidence trends, predictors, and outcomes PUD patients with underlying cirrhosis.

METHODS

We analyzed Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) data for years 2002-2014. Adult hospitalizations due to PUD were identified by previously validated ICD-9-CM codes as the primary diagnosis. Cirrhosis was also identified with presence of ICD-9-CM codes in secondary diagnosis fields. We analyzed trends and predictors of PUD in cirrhotic patients and utilized multivariate regression models to estimate the impact of cirrhosis on PUD outcomes.

RESULTS

Between the years 2002-2014, there were 1,433,270 adult hospitalizations with a primary diagnosis of PUD, out of which 70,007 (4.88%) had cirrhosis as a concurrent diagnosis. There was a significant increase in the proportion of hospitalizations with a concurrent diagnosis of cirrhosis, from 3.9% in 2002 to 6.6% in 2014 (p < 0.001). In an adjusted multivariable analysis, in-hospital mortality was significantly higher in hospitalizations of PUD with cirrhosis (odd ratio [OR] 1.78; 95% confidence interval [CI] 1.63-1.97; P < 0.001), however, there was no difference in the discharge to facility (OR 1.00; 95%CI 0.94 - 1.07; P = 0.81). Moreover, length of stay (LOS) was also higher (6 days vs. 4 days, P < 0.001) among PUD with cirrhosis. Increasing age and comorbidities were associated with higher odds of in-hospital mortality among PUD patients with cirrhosis.

CONCLUSION

Our study shows that there is an increased hospital burden as well as poor outcomes in terms of higher in-hospital mortality among hospitalized PUD patients with cirrhosis. Further studies are warranted for better risk stratification and improvement of outcomes.

Gut Dysbiosis Associated With Hepatitis C Virus Infection

Background

Little is known about the effect of hepatitis C virus (HCV) infection on gut microbiota and the relationship between alteration of gut microbiota and chronic hepatitis C (CHC) progression. We performed a comparative study of gut microbiota composition between CHC patients and healthy individuals.

Methods

Fecal samples from 166 CHC patients were compared with those from 23 healthy individuals; the gut microbiota community was analyzed using 16S ribosomal RNA gene sequencing. CHC patients were diagnosed with persistently normal serum alanine aminotransferase without evidence of liver cirrhosis (LC) (PNALT, n = 18), chronic hepatitis (CH, n = 84), LC (n = 40), and hepatocellular carcinoma in LC (n = 24).

Results

Compared with healthy individuals, bacterial diversity was lower in persons with HCV infection, with a decrease in the order Clostridiales and an increase in Streptococcus and Lactobacillus. Microbiota dysbiosis already appeared in the PNALT stage with the transient increase in Bacteroides and Enterobacteriaceae. Predicted metagenomics of microbial communities showed an increase in the urease gene mainly encoded by viridans streptococci during CHC progression, consistent with a significantly higher fecal pH in CH and LC patients than in healthy individuals or those in the PNALT stage.

Conclusions

HCV infection is associated with gut dysbiosis, even in patients with mild liver disease. Additionally, overgrowth of viridans streptococci can account for hyperammonemia in CH and LC. Further studies would help to propose a novel treatment strategy because the gut microbiome can be therapeutically altered, potentially reducing the complications of chronic liver disease.

The chronic use of beta-blockers and proton pump inhibitors may affect the rate of bacterial infections in cirrhosis

BACKGROUND & AIMS

Bacterial infections are among the most common and life-threatening complications in cirrhosis. Qualitative and quantitative modifications of the gut microbiota, dysfunction of the intestinal barrier and multiple immune defects are factors that contribute to a pathological 'bacterial translocation' (BT), leading to a higher susceptibility to infections in cirrhotic patients. Long-term therapies, commonly adopted in cirrhotic patients, may influence BT and modify the risk of infection in these patients. To investigate the influence of chronic therapies on the prevalence and microbiological characteristics of infections in cirrhosis.

METHODS

Consecutive cirrhotic patients hospitalised from 2008 to 2013 were enrolled. All previous treatments were carefully recorded. Infections were actively sought out, patients were actively monitored for infection, and possible risk factors were evaluated.

RESULTS

Four hundred cirrhotic patients were included. The most frequent therapies were proton pump inhibitors (PPIs) (67%), non-absorbable-disaccharides (44%), beta-blockers (BBs) (39%) and non-absorbable-antibiotics (10%). Child-Pugh C (P < 0.001; OR 5; 95%CI: 2.6-9.9) and PPI therapy (P = 0.008; OR 2; 95% CI: 1.2-3.2) were found to be independent predictors of infection, and the use of BBs was a protective factor (P = 0.001; OR 0.46; 95%CI: 0.3-0.7). Cirrhotic patients with bacterial infection showed lower morbidity and mortality when taking BBs.

CONCLUSIONS

Proton pump inhibitors increase the risk of infection in cirrhosis and should not be prescribed in these patients without specific indications. In contrast, the use of BBs is associated with a lower rate of infection and attenuates the consequences of infections in cirrhotic patients.

Helicobacter pylori is not the predominant etiology for liver cirrhosis patients with peptic ulcer disease

OBJECTIVES

Patients with liver cirrhosis (LC) often develop peptic ulcers. The differentiation of Helicobacter pylori etiology in LC patients from that of peptic ulcers in non-LC patients is critical. This study aimed to determine whether H. pylori plays a central role in LC patients with peptic ulcers.

METHODS

LC was defined by International Classifications of Diseases, Revision 9, and Clinical Modification (ICD-9-CM) codes 571.2, 571.5, and 571.6. To be defined as non-LC, we did not identify patients in an inpatient setting or by one or more ambulatory care claims containing the International Classifications of Diseases, Revision 9, and Clinical Modification codes 571.2, 571.5, and 571.6. The sample included 9465 H. pylori-positive patients and 3418 H. pylori-negative patients. A logistic regression model was used to calculate the odds ratio (OR) and a 95% confidence interval was used to determine whether LC was an independent factor of lower H. pylori infection rates in peptic ulcer patients.

RESULTS

This study included 102 decompensated LC patients with peptic ulcers, 39 H. pylori-positive and 63 H. pylori-negative. There were 360 compensated LC patients with peptic ulcers, 193 H. pylori-positive and 167 H. pylori-negative. Among the non-LC patients with peptic ulcers, 9233 were H. pylori-positive and 3188 were H. pylori-negative. On the basis of logistic regression analysis, decompensated LC patients (OR=0.23, P<0.001) and compensated LC patients (OR=0.48, P<0.001) had lower H. pylori infection rates.

CONCLUSION

H. pylori is not the predominant etiology for LC, especially the decompensated type, either with peptic ulcer disease or with recurrent ulcer disease.

Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review

BACKGROUND

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

AIM

To review NVGI bleeding in cirrhosis.

METHODS

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis."

RESULTS

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

CONCLUSIONS

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

Effects of pentoxifylline on intestinal bacterial overgrowth, bacterial translocation and spontaneous bacterial peritonitis in cirrhotic rats with ascites

BACKGROUND

Prophylaxis of spontaneous bacterial peritonitis with norfloxacin has been associated to development of antibiotic resistance. We investigated whether pentoxifylline compared to norfloxacin reduces bacterial translocation and spontaneous bacterial peritonitis in rats with CCl(4)-induced cirrhosis and ascites.

METHOD

After development of cirrhosis and ascites, animals were randomly allocated to receive pentoxifylline (16 mg/kg/d every 8h, oral route, n=13) or placebo (n=12) for 15 days. An additional group of 8 cirrhotic rats was given norfloxacin (5mg/kg/d for 15 days). Six healthy rats served as controls. Cecal flora and the prevalence of bacterial translocation and spontaneous bacterial peritonitis were analysed. Serum and ascitic fluid levels of TNF-alpha and cecal levels of malondialdehyde were also measured.

RESULTS

Pentoxifylline in comparison to placebo reduced intestinal bacterial overgrowth (21% vs. 67%, p=0.04), bacterial translocation to cecal lymph nodes (23% vs. 75%, p=0.03) and prevented spontaneous bacterial peritonitis (0% vs. 33%, p=0.04) by Enterobacteriaceae. Norfloxacin administration induced similar results. Pentoxifylline (0.18 ± 0.10 nmol/mg), but not norfloxacin (0.25 ± 0.13; p=0.02), significantly reduced cecal mucosal levels of malondialdehyde compared to placebo (0.33 ± 0.16; p=0.03).

CONCLUSION

In cirrhotic rats with ascites: (a) pentoxifylline as well as norfloxacin reduced intestinal bacterial overgrowth and bacterial translocation and prevented spontaneous bacterial peritonitis; (b) pentoxifylline, but not norfloxacin, reduced oxidative stress in cecal mucosal.

Gastroduodenal complications after concurrent chemoradiation therapy in patients with hepatocellular carcinoma: endoscopic findings and risk factors

PURPOSE

Concurrent chemoradiation therapy (CCRT) is useful in advanced hepatocellular carcinoma (HCC), but little is known about radiation-induced gastroduodenal complications following therapy. To determine risk factors, we investigated the prevalence and patterns of gastroduodenal complications following CCRT using endoscopy.

METHODS AND MATERIALS

Enrolled in the study were 123 patients treated with CCRT for unresectable HCC between January 1998 and December 2005. Radiation-induced gastroduodenal complications were defined as radiation gastritis/duodenitis, radiation gastric/duodenal ulcer, or other gastroduodenal toxicity associated with radiation, based on Common Terminology Criteria for Adverse Events (CTCAE 3.0). Serious gastroduodenal complications were defined as events occurring within 12 months from completion of CCRT, those requiring prompt therapeutic intervention, or symptoms equivalent to Grade 3 or 4 radiation-related gastroduodenal toxicity, including nausea or vomiting, based on CTCAE 3.0.

RESULTS

A month after completion of CCRT, 65 (52.8%) patients displayed endoscopic evidence of radiation-induced gastroduodenal complications. Radiation gastric and duodenal ulcers were found in 32 (26.0%) and 20 (16.3%) patients, respectively; radiation gastritis and duodenitis were found in 50 (40.7%) and 42 (34.1%) patients, respectively. Radiation-related bleeding was observed in 13 patients (10.6%). Serious gastroduodenal complications occurred in 18 patients (14.6%) and were significantly more frequent in patients with liver cirrhosis than in those without cirrhosis (p=0.043). There were no radiation-related deaths.

CONCLUSIONS

Endoscopically detectable radiation-induced gastroduodenal complications were common in HCC following CCRT. Although serious complications were uncommon, the frequency was higher in patients with liver cirrhosis; thus, these patients should be closely monitored when receiving CCRT.

Pathogenesis of portal hypertensive gastropathy: translating basic research into clinical practice

Portal hypertensive gastropathy (PHG) is often seen in patients with portal hypertension, and can lead to transfusion-dependent anemia as well as acute, life-threatening bleeding episodes. This Review focuses on the mechanisms that underlie the pathogenesis of PHG that provide reasonable grounds for the treatment of this condition, and ultimately enable translation of basic research into clinical practice. Increased portal pressure associated with cirrhosis and liver dysfunction is critical for the development of clinically significant PHG, and leads to impaired gastric mucosal defense mechanisms that render the stomach susceptible to mucosal injury. The use of pharmacological agents such as beta-blockers reduces the frequency of bleeding episodes in PHG. As a last resort, surgical decompression of the portal system, transjugular intrahepatic stent placement and liver transplantation can resolve this condition. Elimination of known risk factors for gastric injury such as alcohol, aspirin and traditional NSAIDs is critical. The role of Helicobacter pylori colonization of the gastric mucosa in PHG is not clear. Careful and critical interpretation of human and experimental data can be helpful to establish a rationale for the medical management of this important condition.

Proton pump inhibitors in cirrhosis: Tradition or evidence based practice?

Proton Pump Inhibitors (PPI) are very effective in inhibiting acid secretion and are extensively used in many acid related diseases. They are also often used in patients with cirrhosis sometimes in the absence of a specific acid related disease, with the aim of preventing peptic complications in patients with variceal or hypertensive gastropathic bleeding receiving multidrug treatment. Contradicting reports support their use in cirrhosis and evidence of their efficacy in this condition is poor. Moreover there are convincing papers suggesting that acid secretion is reduced in patients with liver cirrhosis. With regard to Helicobacter pylori (H pylori) infection, its prevalence in patients with cirrhosis is largely variable among different studies, and it seems that H pylori eradication does not prevent gastro-duodenal ulcer formation and bleeding. With regard to the prevention and treatment of oesophageal complications after banding or sclerotherapy of oesophageal varices, there is little evidence for a protective role of PPI. Moreover, due to liver metabolism of PPI, the dose of most available PPIs should be reduced in cirrhotics. In conclusion, the use of this class of drugs seems more habit related than evidence-based eventually leading to an increase in health costs.

Helicobacter pylori infection and peptic ulcer disease in patients with liver cirrhosis

BACKGROUND/AIMS

We investigated the prevalence and relationship of peptic ulcer disease and Helicobacter pylori infection to liver cirrhosis.

METHODS

We examined 288 patients with liver cirrhosis, 322 patients with non-ulcer dyspepsia, and 339 patients with peptic ulcer disease. Rapid urease test and Wright-Giemsa staining were used for diagnosis of H. pylori infection.

RESULTS

The prevalence of peptic ulcer disease in patients with cirrhosis was 24.3%. The prevalence of peptic ulcer disease in patients with cirrhosis divided into Child-Pugh classes A, B, and C was 22.3%, 21.0%, and 31.3%, respectively (p > 0.05). The prevalence of H. pylori infection in the patients with cirrhosis, non-ulcer dyspepsia, and peptic ulcer without chronic liver disease were 35.1%, 62.4%, and 73.7%, respectively (p < 0.001). The prevalence of H. pylori infection did not differ depending on whether there was peptic ulcer (35.6%) or not (34.9%) in patients with liver cirrhosis (p > 0.05). The prevalence of H. pylori infection in patients with hepatitis virus-related liver cirrhosis and in the patients with alcohol-related liver cirrhosis was 42.5% and 22.0%, respectively (p < 0.001). The prevalence of H. pylori infection in patients with Child-Pugh classes A, B, and C liver cirrhosis was 51.5%, 30.5%, and 20.0%, respectively (p < 0.001).

CONCLUSIONS

Factors other than H. pylori may be involved in the pathogenesis of peptic ulcer disease in the setting of liver cirrhosis.

Dose adjustment in patients with liver disease

Unfortunately, there is no endogenous marker for hepatic clearance that can be used as a guide for drug dosing. In order to predict the kinetic behaviour of drugs in cirrhotic patients, agents can be grouped according to their extent of hepatic extraction. For drugs with a high hepatic extraction (low bioavailability in healthy subjects), bioavailability increases and hepatic clearance decreases in cirrhotic patients. If such drugs are administered orally to cirrhotic patients, their initial dose has to be reduced according to hepatic extraction. Furthermore, their maintenance dose has to be adapted irrespective of the route of administration, if possible, according to kinetic studies in cirrhotic patients. For drugs with a low hepatic extraction, bioavailability is not affected by liver disease, but hepatic clearance may be affected. For such drugs, only the maintenance dose has to be reduced, according to the estimated decrease in hepatic drug metabolism. For drugs with an intermediate hepatic extraction, initial oral doses should be chosen in the low range of normal in cirrhotic patients and maintenance doses should be reduced as for high extraction drugs. In cholestatic patients, the clearance of drugs with predominant biliary elimination may be impaired. Guidelines for dose reduction in cholestasis exist for many antineoplastic drugs, but are mostly lacking for other drugs with biliary elimination. Dose adaptation of such drugs in cholestatic patients is, therefore, difficult and has to be performed according to pharmacological effect and/or toxicity. Importantly, the dose of drugs with predominant renal elimination may also have to be adapted in patients with liver disease. Cirrhotic patients often have impaired renal function, despite a normal serum creatinine level. In cirrhotic patients, creatinine clearance should, therefore, be measured or estimated to gain a guideline for the dosing of drugs with predominant renal elimination. Since the creatinine clearance tends to overestimate glomerular filtration in cirrhotic patients, the dose of a given drug may still be too high after adaptation to creatinine clearance. Therefore, the clinical monitoring of pharmacological effects and toxicity of such drugs is important. Besides the mentioned kinetic changes, the dynamics of some drugs is also altered in cirrhotic patients. Examples include opiates, benzodiazepines, NSAIDs and diuretics. Such drugs may exhibit unusual adverse effects that clinicians should be aware of for their safe use. However, it is important to realise that the recommendations for dose adaptation remain general and cannot replace accurate clinical monitoring of patients with liver disease treated with critical drugs.

The effects of eradication of Helicobacter pylori on the recurrence of duodenal ulcers in patients with cirrhosis

BACKGROUND

The role of Helicobacter pylori in patients with cirrhosis and increased prevalence of peptic ulcers is still poorly defined. The objective is to evaluate the effect of H pylori eradication on ulcer recurrence in patients with cirrhosis.

METHODS

The study was conducted at a single, tertiary, referral hospital with 1200 beds. Patients with cirrhosis and duodenal ulcers were tested for H pylori and were enrolled in the study. Patients with positive H pylori received eradication therapy. Patients with duodenal ulcers received antisecretory therapy and regular endoscopic examinations. Main outcome measurements were the recurrence of duodenal ulcers within 1 year.

RESULTS

A total of 104 patients with cirrhosis and duodenal ulcers were enrolled. Fifty-four patients (52%) were H pylori positive, and 50 patients (48%) were H pylori negative. Forty-four patients received antimicrobial treatment and 36 patients achieved eradication of H pylori. Recurrent duodenal ulcers within 1 year were noted in 21 of 36 patients (58%) who achieved H pylori eradication. Recurrent duodenal ulcers also were noted in 8 of the 18 patients (44%) who remained H pylori positive and in 24 of the patients (48%) who were H pylori negative since their enrollment in the study (p = 0.53). The limitation was a relatively small sample size.

CONCLUSIONS

The results of our study showed that the prevalence of H pylori in patients with cirrhosis and duodenal ulcers was only 52%. Eradication of H pylori in patients with cirrhosis and duodenal ulcers did not effectively reduce the recurrence of ulcers.

Helicobacter pylori density and cagA status in cirrhotic patients: a case-control study

BACKGROUND AND AIM

Despite a similar Helicobacter pylori prevalence, peptic ulcer is more frequent in cirrhotic patients than in controls. We evaluated whether cirrhotic patients had an increased bacterial density and/or a higher prevalence of H. pylori cagA-positive strains than controls.

METHODS

A total of 36 dyspeptic cirrhotic patients with H. pylori infection and 72 matched controls were enrolled. H. pylori infection was detected at histology on Giemsa staining, bacterial density was assessed using difference over baseline (DOB) values at 13C urea breath test, and cagA status was established at serology.

RESULTS

Overall, both DOB values and prevalence of cagA did not significantly differ between cirrhotic patients and controls. However, peptic ulcer controls showed significantly higher DOB value (27.9 +/- 17.4 vs 19.4 +/- 9.3, respectively; P = 0.009) and cagA positive rate (85%vs 48%; P = 0.01) than non-ulcer dyspepsia patients. Although not statistically significant, a similar trend was observed in cirrhotic patients with peptic ulcer for DOB values (26.5 +/- 16.3 vs 18.3/1000 +/- 9.2, respectively; P = 0.07), whereas the cagA-positive rate was similar between peptic ulcer and non-ulcer dyspepsia patients (60%vs 50%; P = 0.30).

CONCLUSIONS

The present data showed that both bacterial density and cagA prevalence did not differ between cirrhotic patients and controls.

Portal hypertension and duodenal ulcer in children

OBJECTIVES

The prevalence of duodenal ulcer (DU) in adult patients with portal hypertension is higher than in patients without portal hypertension. This study investigates the prevalence and characteristics of DU in children with portal hypertension.

PATIENTS AND METHODS

From January 1997 to December 2001, 80 children with portal hypertension who had undergone upper intestinal endoscopic examinations were enrolled. Possible factors contributing to the development of DU including severity of liver disease, portal hypertension, H. pylori, and serum gastrin level were studied. The control group consisted of 80 age-and sex-matched children with gastrointestinal symptoms but no liver disease and who underwent endoscopic examination during the same period.

RESULTS

The prevalence of DU was significantly higher in children with portal hypertension than in children with digestive symptoms only (22.5%v 8.8%; P =0.017). DU was more common and appeared earlier in children with a history of variceal bleeding. The presence of DU was independent of the severity of liver disease, H. pylori infection and serum gastrin level.

CONCLUSION

DU occurs commonly in children with portal hypertension, especially in those who have had variceal bleeding. It is mandatory to screen a patient with gastrointestinal bleeding for DU even in the presence of esophageal varices. Elevated portal pressure might be a factor contributing to the development of DU.

Helicobacter pylori diagnosis in patients with liver cirrhosis

BACKGROUND

In cirrhotics, Helicobacter pylori infection is the major cause of peptic lesions, which are an important cause of upper intestinal haemorrhage in these patients. However, some diagnostic methods are not accurate for H. pylori detection in cirrhotics.

AIMS

The study assessed the accuracy of different diagnostic methods for H. pylori detection in cirrhotics with and without gastroduodenal lesions.

METHODS

The study population comprised of 53 cirrhotics. All patients underwent upper endoscopy: three biopsies were taken in the antrum and three in the gastric body. Four biopsies were used for Giemsa staining, while two were used for a rapid urease test. A blood sample was obtained for serology using Western blotting, and a [13C]urea breath test was performed in all patients. Histological assessment was regarded as the gold standard for diagnosis of H. pylori infection.

RESULTS

H. pylori infection was detected at histological assessment in 28 (52.8%) patients. The [13C]urea breath test, rapid urease test, and serology were positive in 27 (51%) patients, 23 (43.4%) patients, and 34 (64.1%) patients, respectively. Sensitivity and specificity were 92.9 and 96% for the [13C]urea breath test, 78.6 and 96% for the rapid urease test, and 78.6 and 52% for serology.

CONCLUSIONS

The [13C]urea breath test is very accurate in cirrhotics, whilst both serology and the rapid urease test give disappointing results.

Gastroduodenal ulcer and erosions are related to portal hypertensive gastropathy and recent alcohol intake in cirrhotic patients

Gastroduodenal ulcers and gastroduodenal erosions are particularly frequent in cirrhotic patients, but their precise cause is unclear. The aim of this study was to identify pathogenic factors associated with ulcers and erosions in patients with cirrhosis. We studied 64 consecutive patients with cirrhosis referred for gastroscopy. The severity of portal hypertensive gastropathy was graded with an endoscopic score. H. pylori status was determined by histological examination of gastric biopsy samples or by the [13C] urea breath test. The daily alcohol intake within the preceding week was recorded. The Child-Pugh score was determined. Fifteen patients had gastroduodenal ulcer and 20 had gastroduodenal erosions. Cirrhosis was related to alcohol in 44 patients and hepatitis B or C virus in 14 patients. The portal hypertensive gastropathy was graded as severe in 12 patients and mild in 25 patients. H. pylori infection, found in 37 patients, was not related to the gastroduodenal lesions. Univariate and multivariate analysis showed the links between gastroduodenal erosions and hypertensive gastropathy and recent heavy drinking. Gastroduodenal ulcer was independently associated only with the severity of the gastropathy. In conclusion, in these patients with cirrhosis, the presence of gastroduodenal ulcer was significantly related to hypertensive gastropathy but not to H. pylori infection. Recent alcohol intake favored the occurrence of gastroduodenal erosions.

Helicobacter pylori infection in patients with liver cirrhosis: facts and fictions

Helicobacter pylori infection could play a role in different clinical alterations observed in cirrhosis, from gastroduodenal lesions to hepatic encephalopathy. Although its prevalence in cirrhotics is similar to that in controls, H. pylori infection is responsible for the increased prevalence of peptic ulcer observed in these patients. The ammonia production by H. pylori urease does not seem to increase blood ammonia levels during cirrhosis, indicating that its role in hepatic encephalopathy could be marginalized in clinical practice. Dual and triple therapies have been shown to be equally effective for H. pylori eradication in these patients.

Failure of Lactobacillus spp. to prevent bacterial translocation in a rat model of experimental cirrhosis

BACKGROUND/AIMS

Prophylaxis of spontaneous bacterial peritonitis in cirrhotic patients with norfloxacin is associated with emergence of quinolone-resistant Enterobacteriaceae. We investigated whether an alternative strategy with Lactobacillus prevents bacterial translocation and ascitic fluid infection in cirrhotic rats.

METHODS

CCl(4)-induced cirrhotic rats with ascites (n=34) were allocated to treatment with oral Lactobacillus strain GG at 1-2 x 10(9) cfu/day for 8-10 days (group LGG) or milk (group MILK). In addition, 20 cirrhotic rats were given a single dose of 15 mg norfloxacin orally and then allocated to Lactobacillus (group NOR-LGG) or milk (group NOR-MILK). Ten healthy rats served as control. After sacrifice the cecal flora were analyzed and the prevalence of bacterial translocation and ascitic fluid infection assessed.

RESULTS

Cecal colonization with Lactobacillus was achieved in 90% of treated rats. The prevalence of bacterial translocation to mesenteric lymph nodes was 10% in control rats and 93, 84, 70 and 100% in groups MILK, LGG, NOR-MILK and NOR-LGG, respectively (P>0.1 for comparison of treatment groups), the prevalence of ascitic fluid infection was 60, 32, 40 and 40% (P>0.1). Bacterial translocation of Lactobacillus was observed in 24% of rats treated.

CONCLUSION

Lactobacilli fail to prevent bacterial translocation and ascitic fluid infection in experimental cirrhosis in spite of successful intestinal colonization.

Role of Helicobacter pylori in cirrhotic patients with dyspepsia: a 13C-urea breath test study

The role of Helicobacter pylori in dyspeptic, cirrhotic patients remains unclear. This prospective outpatient study, conducted to assess the relationship of gastroduodenal disease and H. pylori as determined by the (13C) urea breath test, enrolled 109 consecutive cirrhotic patients with dyspepsia. All patients underwent upper-gastrointestinal endoscopy, which revealed respective prevalences of peptic ulcer, gastric ulcer, and duodenal ulcer of 41.3%, 23.9%, and 22.9%; H. pylori infection was found in 52.3%. The rate of peptic ulcer disease in the H. pylori-positive (45.6%) and -negative (36.5%) groups was not significantly different; neither was the prevalence of H. pylori in patients with or without portal hypertensive gastropathy and with or without esophageal varices. The relationship between peptic ulcer disease and H. pylori in dyspeptic patients with cirrhosis appears to be weak. Likewise, no significant relationship was evident between H. pylori and portal hypertensive gastropathy or esophageal varices. This organism may not be a major pathogenetic factor in gastroduodenal diseases in dyspeptic patients with cirrhosis.

Association of Helicobacter pylori infection with lifestyle, chronic disease, body-indices, and age at menarche in Danish adults

This study examines the association between lifestyle factors, chronic disease, body-indices, and the seroprevalence of Helicobacter pylori infection in Danish adults. The relationship between age at menarche and H. pylori infection is also assessed. A random sample of 3,608 Danish adults completed a questionnaire about lifestyle factors (smoking habits, alcohol consumption, and coffee and tea intake), doctor diagnosed chronic diseases (heart conditions, diabetes, chronic bronchitis, and hypertension), menarche, and socio-demographic factors. A total of 2,913 participants were eligible for the present study. Electrocardiographs were recorded and blood pressure and serum lipid levels (HDL cholesterol, triglyceride, and cholesterol) were measured. Height and weight were determined and body mass index (BMI) calculated. Sera were analysed with an enzyme-linked immunosorbent assay for the presence of H. pylori specific IgG antibodies. The seroprevalence of H. pylori infection was associated with weekly alcohol intake > or = 6 drinks (odds ratio 0.7, 95% confidence interval 0.6-0.9) due to a low rate of H. pylori infection among wine drinkers (odds ratio 0.6, 95% confidence interval 0.5-0.7). No associations were found with smoking habits or serum lipids. People with upper quartile BMI (> or = 26.8 kg/m2) were more likely to be seropositive for antibodies to H. pylori (odds ratio 1.6, 95% confidence interval 1.1-2.4). Chronic bronchitis (odds ratio 1.6, 95% confidence interval 1.1-2.5) and unspecified heart condition (odds ratio 2.0, 95% confidence interval 1.1-3.3) was more often seen in IgG seropositive women than in uninfected women. The likelihood of being seropositive for IgG antibodies to H. pylori increased with age at menarche (odds ratio per year 1.10, 95% confidence interval 1.02-1.19). Previously reported associations with age and socioeconomic status were confirmed. We conclude that wine drinking is associated with lower rates of H. pylori infection in Danish adults. The seroprevalence of H. pylori infection is increased in people with high BMI. H. pylori infection may relate to a history of late menarche and chronic bronchitis in Danish women.

Does quantitative serologic testing for Helicobacter pylori predict peptic ulcer disease in cirrhosis?

BACKGROUND

Helicobacter Pylori is strongly associated with peptic ulcer disease. A correlation between high IgG serum antibody concentrations and a clinical diagnosis has been reported. It has been recognized that peptic ulcer disease occurs with increased frequency in cirrhosis. In this study, we attempted to establish a relation between the magnitude of serum IgG antibody to H pylori and the endoscopic diagnoses in H pylori-infected cirrhotic patients.

METHODS

All cirrhotic patients who had undergone esophagogastroduodenoscopy with a positive H pylori IgG serology and who did not receive anti-H pylori treatment or take medications noxious to the gastroduodenal mucosa were included in the study. H pylori IgG serology was determined by an enzyme-linked immunosorbent assay with values of greater than 50 units/mL being seropositive. The functional reserve of cirrhosis was classified by modified Pugh-Child criteria.

RESULTS

One hundred four seropositive cirrhotic patients were recruited. The serum IgG titers ranged from 51 to 1200 units/mL with a peak frequency at 50 to 99 units/mL (35. 6%). Statistical analysis did not reveal any relation between the quantitative H pylori IgG values and the endoscopic diagnoses, which included gastric ulcers, duodenal ulcers, gastroduodenal erosions, and normal findings.

CONCLUSIONS

In cirrhosis, the magnitude of H pylori IgG serology cannot be used to predict the presence or absence of peptic ulcer disease.

Underlying mechanisms of portal hypertensive gastropathy

Gastric mucosal lesions are frequently observed in patients with liver cirrhosis and portal hypertension. Similar lesions can be observed in experimental portal hypertension. This review summarizes our current knowledge of the pathophysiology of portal hypertensive gastropathy, with a particular focus on the microcirculatory disturbances that characterize this condition. The stomach of cirrhotic patients exhibits an increased susceptibility to injury induced by several irritants. Similarly, the stomach of portal hypertensive animals is less resistant to injury. One of the most important factors contributing to the increased susceptibility to damage is an impaired hyperemic response when the epithelium is exposed to irritants. This appears to be related to a reduction in mucosal prostaglandin production and to altered microcirculatory responsiveness to nitric oxide. Nitric oxide overproduction in portal hypertension may have direct effects on gastric blood flow regulation. Elevated production of tumor necrosis factor-alpha by gastric mucosa in portal hypertensive rats has also been shown to contribute to mucosal injury. A better understanding of the pathogenesis of portal hypertensive gastropathy may lead to development of specific therapeutic interventions for this condition.

Evaluation of 24-hour gastric acidity in patients with hepatic cirrhosis

BACKGROUND/AIMS

Data from previous studies on gastric acid secretion in patients with hepatic cirrhosis are controversial, due, at least in part, to the possible interference of liver failure and altered gastric mucosal microcirculation on the pharmacological action of the substances used to stimulate the parietal cell. For this reason, we wished to investigate the circadian pattern of gastric acidity by means of continuous 24-hour pH monitoring, which permits measurement of pH fluctuations in a nearly physiological manner and does not require any pharmacological stimulus.

METHODS

Forty-nine patients with liver cirrhosis of different aetiology were recruited for this study. They underwent 24-hour gastric pH-metry with an electrode positioned in the gastric corpus, and their pattern of gastric acidity was compared with that of 49 healthy subjects, matched for age and sex. In a subgroup of 31 patients with cirrhosis, antral pH was recorded in addition to body pH in order to assess whether there are regional differences in gastric acidity.

RESULTS

The circadian, daytime and nocturnal gastric acidity in patients with cirrhosis was significantly lower (p < 0.05-0.001) than that of controls. In the 31 patients studied with two electrodes, antral pH was higher (p < 0.05) than body pH only during the night. The prevalence of Helicobacter pylori infection was rather low (42%) in our patients.

CONCLUSIONS

There is a marked hypoacidity over the circadian cycle in patients with cirrhosis compared to controls, and the greatest difference between them is visible during the nocturnal hours. Also, in patients with liver cirrhosis the pH in the antrum is higher than that in the body of the stomach during the night for reasons that need to be elucidated.

Helicobacter pylori in cirrhotic patients with peptic ulcer disease: a prospective, case controlled study

BACKGROUND

There is an increased prevalence of peptic ulcer disease in patients with liver cirrhosis, but the role of Helicobacter pylori is unclear.

METHODS

lgG antibodies against H. pylori were measured in 60 patients with compensated liver cirrhosis, in 60 sex- and age-matched patients with compensated liver cirrhosis, and in 60 normal controls. All patients received panendoscopic examinations to search for the evidence of esophageal varices, congestive gastropathy, and peptic ulcers.

RESULTS

Duodenal ulcers were more common in compensated and decompensated cirrhotic patients (16.7% and 13.3%, respectively) than in normal controls (3.3%, p < 0.05). Gastric ulcers were more frequent in decompensated (15.0%) than compensated cirrhotic patients and normal controls (3.3% and 1.7%, respectively, p < 0.05). The prevalence of H. pylori was not statistically different among the three groups (normal 60.0%, compensated 61.7%, and decompensated, 75.0%; p > 0.05). The prevalence of H. pylori also showed no statistical differences in respect to duodenal ulceration (100%, 80%, and 87.5%, respectively, p > 0.05). The prevalence of H. pylori did not differ significantly in relation to the presence or absence of esophageal varices (68.4% vs 100% if no varices, p = 0.04) and in the presence of congestive gastropathy (50.0 vs 94.7%, p = 0.03).

CONCLUSIONS

The prevalence of peptic ulcer was increased in cirrhotic patients, but the prevalence of H. pylori was similar in compensated cirrhotic patients, decompensated cirrhotic patients, and normal controls. The frequency of non-H. pylori-associated peptic ulcers in cirrhotic patients was increased in the presence of esophageal varices or congestive gastropathy.