Helicobacter pylori infection in geriatrics

Main Disorders of Gastrointestinal Tract in Older People: An Overview

From a physiological standpoint, aging is a progressive reduction in each organ system’s capacity to maintain homeostasis in the face of illness or stressors. With advancing age, gastrointestinal (GI) symptoms and signs may increase, not only due to the aging processes but also to the superimposed effects of comorbidities, which can badly affect digestive functions (i.e., diabetes, malignancy, etc.) and environmental exposure. In general, gastrointestinal symptoms in older people more often underlie organic pathologies, while GI functional disorders are less frequently diagnosed in this age group. Moreover, gastrointestinal disease can also present in a nuanced and atypical manner, making the diagnostic hypothesis and, consequently, the correct diagnosis and therapy more challenging. In addition, with reference to this age group, the clinical implications of gastrointestinal pathologies can be more severe due to a decreased physiologic reserve, with a higher risk for malnutrition resulting in falls, depression, social isolation, and a deterioration of functional status. In this review, we focused on the most frequent GI tract disorders, highlighting the main age-related changes, their epidemiological, pathophysiological and clinical implications, and any differences with younger patients.

Cellular Senescence, Inflammation, and Cancer in the Gastrointestinal Tract

Due to modern medical advancements, greater proportions of the population will continue to age with longer life spans. Increased life span, however, does not always correlate with improved health span, and may result in an increase in aging-related diseases and disorders. These diseases are often attributed to cellular senescence, in which cells become disengaged from the cell cycle and inert to cell death. These cells are characterized by a proinflammatory secretome. The proinflammatory senescence-associated secretory phenotype, although part of a natural function intended to prevent further DNA damage, creates a microenvironment suited to tumor progression. This microenvironment is most evident in the gastrointestinal tract (GI), where a combination of bacterial infections, senescent cells, and inflammatory proteins can lead to oncogenesis. Thus, it is important to find potential senescence biomarkers as targets of novel therapies for GI diseases and disorders including cancers. However, finding therapeutic targets in the GI microenvironment to reduce the risk of GI tumor onset may also be of value. This review summarizes the effects of cellular senescence on GI aging, inflammation, and cancers, and aims to improve our understanding of these processes with a goal of enhancing future therapy.

Acute Helicobacter pylori Infection Prevalence Among Renal Failure Patients and Its Potential Roles with Other Chronic Diseases: A Retrospective Cohort Study

Background

Helicobacter pylori (H. pylori) infection is relevant to several chronic human diseases, from digestive diseases to renal, metabolic, and cancer diseases. H. pylori infections and chronic kidney diseases are in increasing, global records; if not well controlled in a specific population, these diseases might lead to more clinical complications.

Methods

In this retrospective study, we investigated the prevalence of acute H. pylori infections among 127 dialysis patients via subjecting their serums to the enzyme-linked immunosorbent assay (ELISA) to detect the human Immunoglobulin M (IgM) against H. pylori infections. Samples were from dialysis patients in a single hemodialysis center in Medina, Saudi Arabia, from January to August 2021.

Results

Our results indicated the significant prevalence of H. pylori acute infections among 33.1% of renal failure patients recruited in this study, chi-squared: 14.559, p-value: 0.0001. In addition, no significant occurrence of acute H. pylori infection among males and females, chi-squared: 1.823, p-value: 0.177. Furthermore, the prevalence of acute H. pylori infection was not significant in different age groups of renal failure patients. Chi-squared: 6.803, p-value: 0.147, despite H. pylori-infected cases predominantly represented in patients above 51 years. Moreover, we noticed that hypertension, followed by diabetes, was the most prevalent underlying medical condition among acute infected H. pylori and renal failure patients.

Conclusion

We documented the significant prevalence of acute H. pylori infection among renal failure patients. We also highlighted and discussed the possible potential roles of H. pylori in renal failure and other chronic diseases. Routine screening and treatment for acute H. pylori infection for chronic kidney diseases, hypertension, and diabetes patients would positively reduce the bacterium’s progressive effects on them. They might even improve the control of these diseases.

[Gastrointestinal Disease in the Population Aged 80 Years and above in Korea during Recent Decades: Multi-center Cross-sectional Study]

BACKGROUND/AIMS

Globally, the population aged 80 years or older is growing faster due to the rising life expectancy. Korea has already entered into an advanced aged society, and a post-aged society is expected in 2025. This study evaluated the patterns of gastrointestinal disease in the population aged 80 years or older during the recent decade in Korea.

METHOD

This study retrospectively reviewed the medical records of patients admitted to the gastrointestinal department of Suwon St. Vincent's hospital, Incheon St. Mary's hospital, and Uijeongbu St. Mary's Hospital - general hospitals of Seoul-Gyeonggi province in Korea. It was a repeated cross-sectional study in 2009 and 2019.

RESULTS

The number of admitted patients aged 80 years or older increased from 549 (9.0%) in 2009 to 1,073 (14.4%) in 2019 (p<0.01). As for the in-hospital mortality, there was no significant difference (p=0.25). On the other hand, the combined morbidities increased, and the duration of admission also increased (7.2±7.8 days vs. 8.1±8.2 days, p=0.03). The number of upper gastrointestinal hemorrhage and patients who are bleeding associated with drugs users increased (p<0.01). The proportion of lower gastrointestinal disease decreased (p<0.01) because of the decrease in procedure-related admissions (p<0.01). The number of those with pancreaticobiliary tract disease increased markedly (p<0.01), and the rate of cases that could not perform the procedure decreased (p=0.04).

CONCLUSION

The patterns of gastrointestinal disease in the population aged 80 years or older have changed in the recent decade in Korea. Hence, more preparation for this medical environment is needed.

Assessment of the diagnostic accuracy and relevance of a novel ELISA system developed for seroepidemiologic surveys of Helicobacter pylori infection in African settings

Beside diagnostic uncertainties due to the lack of a perfect gold standard test for Helicobacter pylori infection, the diagnosis and the prevalence estimation for this infection encounter particular challenges in Africa including limited diagnostic tools and specific genetic background. We developed and evaluated the accuracy of an enzyme-linked immunosorbent assay (ELISA) system tailored for H. pylori genetics in Africa (HpAfr-ELISA). Strains belonging to main genetic populations infecting Africans were exploited as sources for whole-cell antigens to establish in-house the ELISA system. A phase II unmatched case-control study explored the diagnostic accuracy of the HpAfr-ELISA using a training set of samples collected from dyspeptic patients from Kinshasa, the Democratic Republic of Congo (DRC) who had been tested with invasive standard tests (i.e., histology, culture, and rapid urease test) in 2017. Then the assay was cross-validated through a community-based survey assessing the prevalence of H. pylori and associated factors in 425 adults from Mbujimayi, DRC in 2018. Bayesian inferences were used to deal with statistical uncertainties of estimates (true prevalence, sensitivity, and specificity) in the study population. At its optimal cut-off-value 20.2 U/mL, the assay achieved an estimated sensitivity of 97.6% (95% credible interval [95%CrI]: 89.2; 99.9%) and specificity of 90.5% (95%CrI: 78.6; 98.5). Consistent outcomes obtained at repeated tests attested the robustness of the assay (negative and positive agreements always > 70%). The true prevalence of H. pylori was estimated 53.8% [95%CrI: 42.8; 62.7%]. Increasing age (adjusted odds ratio [aOR] > 1.0 [95% confidence interval (CI): > 1.0; 1.1]; p<0.001), overcrowding households (aOR = 3.2 [95%CI: 2.0; 5.1]; p<0.001), and non-optimal hand hygiene (aOR = 4.5 [95%CI: 2.0; 11.4]; p = 0.001) were independently associated with the H. pylori-seropositivity. The novel ELISA system has demonstrated good diagnostic accuracy and potential usefulness for management and mitigation strategies for H. pylori infection in African settings.

Vitamin D deficiency and risk of Helicobacter pylori infection in older adults: a cross-sectional study

BACKGROUND

Vitamin D deficiency is known to cause increased predisposition to various infectious diseases and the addition of vitamin D to antimicrobial treatment may improve treatment responses. However, the relationship between vitamin D and Helicobacter pylori (H. pylori) remains to be determined.

AIMS

To assess the association between vitamin D deficiency and H. pylori infection.

METHODS

This cross-sectional study included patients aged 65 and over, who underwent gastroscopy and had gastric biopsy performed between 2010 and 2017. Of the 441 patients, 254 had available 25-hydroxyvitamin D level results and were included in the analyses. Patients were categorized into H. pylori (+) and H. pylori (-) groups, according to histopathological examination results of gastric biopsies. Serum 25(OH) vitamin D levels less than 20 ng/mL were defined as vitamin D deficiency.

RESULTS

Of all patients, 43 were H. pylori (+) and 211 were H. pylori (-). More patients had vitamin D deficiency (< 20 ng/mL) in the H. pylori (+) group than the H. pylori (-) group (86% vs 67.3%, p = 0.014). The proportion of H. pylori (+) patients decreased across increasing quartiles of 25(OH) vitamin D levels (p for trend = 0.010). In multivariable logistic regression analysis, vitamin D deficiency was associated with increased odds of H. pylori infection after adjustment for age, gender, and Charlson Comorbidity Index (OR = 3.02, 95% CI 1.19-7.69, p = 0.020).

CONCLUSION

Vitamin D deficiency can be associated with increased risk of H. pylori infection. The potential protective effect of vitamin D against H. pylori infection and its possible role in the treatment of H. pylori should be evaluated in prospective trials.

Clinical and Socio- Demographic Risk Factors for Acquisition of Helicobacter pylori Infection in Nigeria

Background: The aim of the study was to assess clinical and socio-demographic characteristics as well as prior drug usage as risk factors for Helicobacter pylori (H. pylori) infection in Nigeria. Methods: A total of 347 respondents were surveyed by assessing their clinical and socio-demographic characteristics in comparison with the non-invasive gold standard for H. pylori diagnosis, the urea breath test (UBT). Chi-square test and odds ratio analyses were conducted in order to assess if variables such as socio-demographic factors, drug intake, and history of ulcer/gastritis/ gastric cancer within the family significantly predicted test results. Results: A total of 130 (37.5%) respondents were positive for H. pylori by the UBT. Living with more than three people in an apartment and a history of ulcer/gastritis within the family were significantly associated with H. pylori (p ≤0.05), as well as current antibiotic intake (p ≤0.05). Nationality, stay outside Nigeria, level of education, main occupation, smoking and drinking habits, sources of drinking water, number of children and history of gastric cancer had no significant association with H. pylori infection (p ≥ 0.05). Conclusion: The results of the questionnaire revealed that most socio-demographic characteristics of the respondents had no significant association with H. pylori. Overcrowding, having siblings/parents with history of ulcer/gastritis as well as prior antibiotic usage had a significant association.

Changes in gefitinib, erlotinib and osimertinib pharmacokinetics under various gastric pH levels following oral administration of omeprazole and vonoprazan in rats

1. Although drug interactions between epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) and gastric acid-suppressing medications (AS) are considered clinically significant, there is limited data regarding the influence of various gastric pH conditions on the pharmacokinetics of EGFR-TKIs. We aimed to clarify the changes in the pharmacokinetics of the EGFR-TKIs, gefitinib, erlotinib and osimertinib, due to the changes in gastric pH after administration of omeprazole or vonoprazan. 2. Omeprazole (10-100 mg/kg, p.o.) and vonoprazan (1-5 mg/kg, p.o.) led to a significant and dose-dependent increase in gastric pH. 3. AUC_0-3 of gefitinib and erlotinib (5 mg/kg, p.o.) started to decrease at gastric pH 3.3 and 5.6, respectively, reached a plateau at pH > 6, and then significantly decreased up to 47 and 59% of control levels, respectively. AUC_0-3 of osimertinib (5 mg/kg, p.o.) was not significantly changed by omeprazole and vonoprazan. 4. Although there are some issues regarding the extrapolation of the results of our rat study to humans, careful monitoring of patients treated with gefitinib and erlotinib is needed in cases in which the gastric pH increases from 3 to 5 and especially when the gastric pH is >5 in patients who are co-administered both the EGFR-TKIs and AS.

Abdominal Pain in the Geriatric Patient

Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.

Surgery of the Elderly Patient

The world population is becoming older. As many diseases that require surgery also increase with age, surgeons have to become familiar with special issues that are unique to elderly patients requiring surgery. This review highlights the perioperative care of the elderly patient.

Helicobacter pylori infection in older people

Since the discovery of Helicobacter pylori (H. pylori) infection as the major cause of gastroduodenal disorders three decades ago, H. pylori has been the focus of active research and debate in the scientific community. Its linkage to several diseases, such as peptic ulcer disease, gastritis and gastric malignancy is incontestable. In particular, it has been noticed that, as the aged population is increasing worldwide, older people are at increased risk of developing several gastroduodenal diseases and related complications. At the same time, gastric cancer is definitely more frequent in elderly than in adult and young people. In addition, it has been showed that peptic ulcer and related complications occur much more commonly in aged individuals than in young people, resulting in a significantly higher mortality. Although this infection plays a crucial role in gastrointestinal disorders affecting all age groups and in particular older people, only a few studies have been published regarding the latter. This article presents an overview of the epidemiology, diagnosis, clinical manifestations and therapy of H. pylori infection in elderly people.

[Aging and digestive diseases: at the view of the functional change of gastrointestinal tract]

Although it is difficult to define the term "aging" consensually, in medical fields, usually it means the progressive accumulation of irreversible degenerative changes leading to loss of homeostasis. It is supposable that there is also modest decline in the structure and function of several digestive organs. However, data about this subject are not enough. Main problem in studying aging digestive organ is that discrimination of primary senile change of the organ with secondary one from other senile diseases is not easy. That is, the prevalence of many non-digestive disorders which can badly affect the digestive functions is increasing by aging; for example, diabetes, malignancy, etc. To prove that some phenomenon is as result of pure senile change, it is necessary to exclude secondary one, but, the process is very complicated and difficult. In spite of this limitation, here, I will discuss the senile change of several digestive organs by aging, especially at the view of the gastrointestinal functions, with review of literatures.

Acute abdominal pain in the older adult

Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.

Regular arrangement of collecting venules: Does patient age affect its accuracy?

AIM

To address the diagnostic value of the regular arrangement of collecting venules (RAC) among old age patients.

METHODS

A total of 390 consecutive patients whose Helicobacter pylori (H. pylori) status was known and who received upper gastrointestinal endoscopy, were retrospectively studied for the presence or absence of RAC as well as gastric mucosal atrophy. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of RAC to detect normal gastric mucosa were assessed and were compared among two different age groups of patients.

RESULTS

The mean age ± standard deviation (SD) of included patients (n = 390), was 62.9 ± 13 years. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of RAC to detect normal gastric mucosa were 91.7%, 66.1%, 18.8%, 99% and 68.1% respectively. Although the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of RAC among patients < 60 years (n = 139) was 94.7%, 71.2%, 46.2%, 98.1%and 76.1%, respectively, it was 80%, 64.3%, 5.1%, 93% and 64.6%, respectively, among patients ≥ 60 years (n = 251). Younger Patients (< 60 years), have highly significant rates of RAC sensitivity, positive predictive value, and accuracy (P ≤ 0.001, ≤ 0.001 and ≤ 0.02, respectively). Older patients had highly significant rates of H. pylori infection and gastric mucosal atrophy (P ≤ 0.01).

CONCLUSION

Although RAC is a valuable sign for real-time identification of normal gastric mucosa, its accuracy seems to be affected by the patient's age.

Gastrointestinal and liver side effects of drugs in elderly patients

It is expected that the percentage of people >60 years of age will be 22% worldwide by the year 2050. Multi-morbidity and poly-pharmacy are common in individuals during old age, while adverse drug reactions are at least twice as common in the elderly compared to younger adults. Publications related to drug side effects are rather rare in this age group since most clinical trials exclude patients >75-80 years of age. Gastrointestinal adverse drug reactions studied in the elderly include non-steroidal anti-inflammatory drugs (NSAIDs) and anticoagulant-induced gastrointestinal tract mucosal injuries. Malabsorption, diarrhoea and constipation are common side effects of laxatives, antibiotics, anticholinergics and calcium channel blockers. Drug (amoxycilin/clavulanic acid, isoniazide, nitrofurantoin, diclifenac and methotrexate)-induced hepatotoxicity in the elderly is four times more common than in younger adults and may simulate almost all known liver disorders. Further clinical studies are needed to investigate gastrointestinal and hepatic side effects of drugs in elderly patients.

Infection in the elderly

Many functional, demographic, and immunologic changes associated with aging are responsible for increasing the incidence and severity of infectious diseases in the elderly. Management is complicated by age-related organ system changes. Because many of the elderly are on multiple medications for underlying illnesses, antimicrobial therapy needs to be chosen keeping drug interactions and adverse events in mind. Common infections seen in the elderly are infections of skin and soft tissue, urinary tract, respiratory tract, and gastrointestinal tract. Organized and well-funded programs to address infectious disease issues in the elderly are the only way to improve care.

Current management of Helicobacter pylori infections in the elderly

Helicobacter pylori infection is a chronic gastric gram-negative infection that increases with age worldwide. However, the percentage age of H. pylori-positive elderly patients who are tested and treated for their infection remains very low. It is now demonstrated that H. pylori infection induces a whole cascade of events leading to gastric pathologies, such as peptic ulcer diseases, gastric precancerous lesions and gastric cancer. Recent data also demonstrated that H. pylori chronic infection can play a role in gastric aging, appetite regulation and extradigestive diseases, such as Alzheimer's disease, in the elderly. The diagnosis of H. pylori infection remains difficult to realize in the very old population, and the urea breath test obtains the best performance in this population. 1-week proton pump inhibitor-based triple therapy regimens are highly effective and well tolerated in elderly patients, and antibiotic resistance remains very low. Low compliance is the main factor related to treatment failure in this population.

Comparison of four proton pump inhibitors for the short-term treatment of esophagitis in elderly patients

AIM: To compare efficacy and tolerability of four proton pump inhibitors (PPIs) commonly used in the short-term therapy of esophagitis in elderly patients.

METHODS: A total of 320 patients over 65 years with endoscopically diagnosed esophagitis were randomly assigned to one of the following treatments for 8 wk: (1) omeprazole 20 mg/d; (2) lansoprazole 30 mg/d; (3) pantoprazole 40 mg/d, or (4) rabeprazole 20 mg/d. Major symptoms, compliance, and adverse events were recorded. After 8 wk, endoscopy and clinical evaluation were repeated.

RESULTS: Per protocol and intention to treat healing rates of esophagitis were: omeprazole = 81.0% and 75.0%, lansoprazole = 90.7% (P = 0.143 vs omeprazole) and 85.0%, pantoprazole = 93.5% (P = 0.04 vs omeprazole) and 90.0% (P = 0.02 vs omeprazole), rabeprazole = 94.6% (P = 0.02 vs omeprazole) and 88.8% (P = 0.04 vs omeprazole). Dividing patients according to the grades of esophagitis, omeprazole was significantly less effective than the three other PPIs in healing grade 1 esophagitis (healing rates: 81.8% vs 100%, 100% and 100%, respectively, P = 0.012). Pantoprazole and rabeprazole (100%) were more effective vs omeprazole (89.6%, P = 0.0001) and lansoprazole (82.4%, P = 0.0001) in decreasing heartburn. Pantoprazole and rabeprazole (92.2% and 90.1%, respectively) were also more effective vs lansoprazole (75.0%, P < 0.05) in decreasing acid regurgitation. Finally, pantoprazole and rabeprazole (95.2% and 100%) were also more effective vs lansoprazole (82.6%, P < 0.05) in decreasing epigastric pain.

CONCLUSION: In elderly patients, pantoprazole and rabeprazole were significantly more effective than omeprazole in healing esophagitis and than omeprazole or lansoprazole in improving symptoms. H pylori infection did not influence the healing rates of esophagitis after a short-term treatment with PPI.

Detection of Helicobacter pylori infection in symptomatic Bulgarian adults

This study assessed the prevalence of Helicobacter pylori in symptomatic Bulgarian adults by means of culture, Gram's stain and an in-house rapid urease test (RUT), and also assessed the H. pylori density by culture. In total, 1441 non-treated and 270 treated patients were evaluated. Most non-treated patients with ulcers (87.7%), gastric malignancy (79.2%) and other gastroduodenal diseases (73.4%) were H. pylori-positive. Among non-treated and treated patients, 75.3% and 54.8%, respectively, of elderly patients, and 78.3% and 56.1%, respectively, of other adults were H. pylori-positive. Two (0.1%) non-treated adults were Helicobacter heilmannii-positive. The accuracy of direct Gram's stain and the in-house RUT were 74.8% and 64.2% in non-treated patients, and 73.7% and 63.0% in treated patients, respectively. Culture was highly accurate (>95%) in both groups. Older age decreased the sensitivity of the RUT in non-treated patients by 10.7% and that of all tests in treated patients by 6.9-8.1%. Incubation for 11 days was required for the growth of 2% and 4% of the strains from treated patients on selective and non-selective medium, respectively. There were no differences in isolation rates between positive fresh (74.2%) and frozen (75.2%) specimens. In non-treated adults, a high H. pylori density (growth in all quadrants of the plates) was more common (43.1%) in ulcer patients than in other patients (25.4%). In conclusion, H. pylori infection was common in Bulgarian patients, and at a high density in >40% of ulcer patients, while H. heilmannii infection was uncommon. Culture provided a highly accurate diagnostic approach. Stomach biopsies from non-treated patients can be frozen for several days. The benefit of reporting H. pylori density, as determined by culture, requires further evaluation.

Correlation of Helicobacter pylori virulence genotypes vacA and cagA with histological parameters of gastritis and patient's age

The histological parameters of Helicobacter pylori (H. pylori) gastritis are dependent on the virulence factor profile of the microbe, which includes the cytotoxins vacA (vacuolating cytotoxin A) and cagA (cytotoxin-associated gene A) as well as the duration of infection. The virulence factor genotypes vacA and cagA were assessed by the line probe reverse hybridization assay INNO-LiPA and correlated with the histological parameters of H. pylori infection, in particular intestinal metaplasia (IM) as well as with the patient's age. A total of 120 patients were analyzed; 47 patients with IM in the antrum and 73 control patients without this alteration. The vacA s1 cagA+ genotype (high virulence) correlated with the presence of antral IM, a more intense acute inflammation in both antrum and corpus and the formation of ulcer. The vacA m1 genotype (high virulence) correlated with a more intense acute inflammation in only the corpus as well as more prominent Russell bodies in the antrum. H. pylori strains with the vacA s2 m2 cagA- genotype (low virulence) were rarely found in these conditions (all P <0.05). No correlation with the virulence status was found for the type and extent of IM, the intensity of chronic inflammation, the formation of lymphoid follicles and the microbial density. Furthermore, patients with IM were 7 years older than their counterparts without (P<0.05). Finally, there was a trend for more virulent vacA s1 m1 cagA+ strains to be found in younger individuals (P>0.05). The virulence genotype of the microbe is an important determinant for the severity of the gastritis and the formation of antral IM. Age is an additional factor for the development of IM.

Infection à Helicobacter pylori chez la personne âgée

PURPOSES

Helicobacter pylori (H. pylori) infection is a chronic gastric Gram-negative infection that increases with age. Acquired in childhood, H. pylori infection may induce a whole cascade of events leading to gastric pathologies such as peptic ulcer diseases, gastric precancerous lesions, and gastric lymphomas (MALT). The characteristics of the diagnosis and the treatment of this infection in geriatrics are thus particularly important to take into account.

MAIN POINTS

1) The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations. Clinical signs such as anorexia and malnutrition are proven to be excellent indications for endoscopic explorations in the elderly. NSAID-use and H. pylori infection were shown to be independent and unrelated risk factors for peptic ulcer and gastroduodenal bleeding in elderly subjects; 2) H. pylori infection diagnosis is difficult to realize in the very old population, and the urea breath test is the test which obtain the best performances in this population.

PERSPECTIVES

Recent work showed the part played by H. pylori chronic infection in gastric aging and in appetite regulation in the elderly. Research tasks should be continued in this field in order to better understand the part played by this chronic infection in gastric aging and in other pathologies (i.e. neurological or cardiovascular diseases) in this population.

Clinical features of reflux esophagitis in older people: a study of 840 consecutive patients

OBJECTIVES

To compare symptoms and other clinical characteristics of reflux esophagitis in patients of different ages.

DESIGN

Observational cross-sectional study of consecutive patients.

SETTING

Geriatric Unit, Casa Sollievo della Sofferenza Hospital, Istituto di Ricovero e Cura a Carattere Scientifico.

PARTICIPANTS

Eight hundred forty patients with endoscopically diagnosed erosive esophagitis divided into four groups according to age (young (<50, mean 36.7, n=114), adult (50-69, mean 59.1, n=126), elderly (70-84, mean 77.3, n=425), and very elderly (>or=85, mean 88.4, n=175)).

MEASUREMENTS

Gastrointestinal symptoms were evaluated using the Gastrointestinal Symptom Rating Scale questionnaire. Other symptoms were recorded when present as an indication for endoscopy. Severity of esophagitis, presence of Helicobacter pylori infection, presence and size of hiatus hernia, Barrett's esophagus, antrum or corpus gastric atrophy, and nonsteroidal antiinflammatory drug (NSAID) use were also evaluated.

RESULTS

Elderly and very elderly patients had a significantly lower prevalence of typical gastroesophageal reflux disease symptoms (heartburn or acid regurgitation (P<.001) and epigastric pain (P<.001)) than young and adult patients. Conversely, the prevalence of other symptoms (anorexia (P<.001), weight loss (P<.007), anemia (P<.001), vomiting (P<.001), and dysphagia (P<.001)) significantly increased with age. The prevalence of severe esophagitis (P<.001), hiatus hernia (P<.005), the size of hiatus hernia (P<.001), antrum and corpus gastric atrophy (P<.05) and NSAID use (P<.005) also significantly increased with age. Multivariate analysis demonstrated that older age (65-84, odds ratio (OR)=2.66, 95% confidence interval (CI)=1.38-5.12; >or=85, OR=4.57, 95% CI=2.15-9.71), hiatus hernia larger than 3 cm in diameter (OR=2.38, 95% CI=1.41-4.01), and male sex (OR=2.83, 95% CI=1.72-4.64) are independent risk factors for severe esophagitis, whereas H. pylori infection, gastric atrophy, NSAID use, and the presence of hiatus hernia were not.

CONCLUSION

Elderly patients with reflux esophagitis had less-typical and more-nonspecific symptoms than young or adult patients. Old age, male sex, and hiatus hernia size greater than 3 cm are significantly associated with severe esophagitis. Clinicians caring for older patients should be aware of the nonspecific presentation and potential severity of reflux esophagitis in this population.

Comparison of a monoclonal antigen stool test (Hp StAR) with the 13C-urea breath test (UBT) in monitoring Helicobacter pylori eradication therapy

AIM: To evaluate the agreement between a mAb-based stool test (HP StAR) and the urea breath test (UBT) in monitoring (H pylori) infection after eradication therapy.

METHODS: Patients with discordant results on UBT and Hp StAR underwent endoscopy with biopsies for rapid urease test, culture, and histology to confirm H pylori status.

RESULTS: Among 250 patients (50±14 years), 240 (96.0%) had concordant UBT and Hp StAR tests with a significant correlation between DOB and A values (R = 0.87; P<0.0001). The remaining 10 (4.0%) patients had discordant tests (positive Hp StAR and negative UBT) with the Hp StAR inaccurate in five cases (false positive) and UBT inaccurate in the other five cases (false negative). The “maximal expected” sensitivity, specificity, +PV, -PV, +LR, and -LR were 91%, 100%, 100%, 97.4%, , and 8.2 respectively, for the UBT, and 100%, 97.4%, 91%, 100%, 38.8, and 0, respectively, for the Hp StAR. Overall accuracy for both tests was 98%.

CONCLUSION: Both the UBT and the Hp StAR are equally accurate in monitoring H pylori infection. Nowadays, the choice of the “best” non-invasive H pylori test in the post-treatment setting should be done not only in terms of diagnostic accuracy but also in view of cost and local facilities.

Influence of 1-week Helicobacter pylori eradication therapy with rabeprazole, clarithromycin, and metronidazole on 13C-aminopyrine breath test

Helicobacter pylori eradication therapy is commonly prescribed in the general population. Treatment consists of drugs that are mainly metabolized by the liver cytochrome P-450 (CYP) enzymatic pool. Most H. pylori-infected patients often take drugs for comorbid illnesses, therefore increasing the potential for drug-drug interactions. We aimed to evaluate the interactions of rabeprazole, clarithromycin, and metronidazole 1-week H. pylori eradication therapy with CYP-dependent liver metabolic function in clinical practice. Ten patients referred to our unit for H. pylori infection underwent 1-week eradication therapy with rabeprazole (20 mg, b.i.d.), clarithromycin (500 mg, b.i.d.), and metronidazole (500 mg, b.i.d.). We chose the 13C-aminopyrine breath test (13C-ABT) to evaluate CYP-dependent liver function since it is noninvasive and nonharmful. All patients underwent 13C-ABT at three time points: before therapy (to), at the end of therapy (t8), and after 1 month of follow-up (t38). Mean 13C-ABT dose/hr (t0 = 14.0 +/- 5.4, t8 = 13.5 +/- 4.0, t38 = 16.1 +/- 5.6) as well as 13C-ABT cumulative dose (t0 = 2.4 +/- 1.1, t8 = 2.4 +/- 0.8, t38 = 2.6 +/- 1.0) were not statistically different at the three time points of the study. These results did not seem to be influenced by drugs being administered concomitantly. In everyday clinical practice rabeprazole-based H. pylori eradication therapy does not seem to display any significant interactions with CYP-dependent liver function, even in patients on multiple drugs.

High rate of Helicobacter pylori eradication with sequential therapy in elderly patients with peptic ulcer: a prospective controlled study

BACKGROUND

Helicobacter pylori eradication rates with triple therapies are decreasing, and few data in elderly patients are available. A 10-day sequential regimen succeeded in curing such H. pylori infection in unselected patients.

AIM

To compare this sequential regimen and the standard triple therapy for H. pylori eradication in geriatric patients with peptic ulcer.

METHODS

Overall, 179 H. pylori-infected patients with peptic ulcer were enrolled (mean age: 69.5 years; range: 65-83). Patients were randomized to 10-day sequential therapy (rabeprazole 20 mg b.d. plus amoxicillin 1 g b.d. for the first 5 days, followed by rabeprazole 20 mg, clarithromycin 500 mg and tinidazole 500 mg, all b.d., for the remaining 5 days) or standard 7-day triple regimen (rabeprazole 20 mg, clarithromycin 500 mg and amoxicillin 1 g, all b.d.). Helicobacter pylori status was assessed by histology and rapid urease test at baseline and 4-6 weeks after completion of treatment.

RESULTS

The sequential regimen achieved eradication rates significantly higher in comparison with the standard regimen at both intention-to-treat (94% vs. 80%; P = 0.008) and per-protocol (97% vs. 83%; P = 0.006) analyses. In both treatment groups, compliance to the therapy was high (> 95%), and the rate of mild side-effects was similarly low (< 12%). At repeated upper endoscopy, peptic ulcer lesions were healed in 97% patients, without a statistically significant difference between the sequential regimen and the standard triple therapy.

CONCLUSIONS

In elderly patients with peptic ulcer disease, the 10-day sequential treatment regimen achieved significantly higher eradication rates in comparison with standard triple therapy.

13C-urea breath test for diagnosis of Helicobacter pylori infection in the elderly

Helicobacter pylori infection has a high prevalence in the elderly, but its characteristics and treatment in the geriatric population are not well defined. The aims of the study were to characterize geriatric patients according to referral patterns and results of the 13C-urea breath test (13C-UBT) and to investigate the results of treatment combinations for H. pylori eradiction. The 13C-UBT was performed with 75 mg urea labeled with 13C. Physicians who ordered the test completed a questionnaire covering demographic data, indication for the test, chronic use of a proton pump inhibitor, or nonsteroidal anti-inflammatory drug, and type of eradiction therapy. The study sample consisted of 2128 patients, aged 70-102 years, 958 (45%) men, referred for 13C-UBT. The test was positive on 697 (33%). History of peptic disease was the main indication for referral, following by validation of successful eradication, Israeli origin screening for gastric cancer, treatment with regimen containing metronidazole, history of peptic disease, and recurrence of symptoms were predictive factors for a positive 13C-UBT. Multivariate logistic regression analysis revealed a significant influence of eradication therapy on negative results. History of peptic disease and validation of successful eradication are the main indications for referral of the elderly for 13C-UBT. Our results are in accordance with the increase in metronidazole resistance of H. pylori stains and the cohort effect of H. pylori infection on the elderly Israeli-born population.