Endoscopic findings, Helicobacter pylori status, and dyspeptic complaints in vagotomized or medically treated peptic ulcer patients and healthy community controls

Helicobacter pylori-induced damage to the gastric mucosa is not modulated by previous vagotomy or medical treatment of peptic ulcer disease: a comparative study of vagotomized patients, medically treated peptic ulcer patients and community control subjects

BACKGROUND

An increase in the prevalence of precancerous lesions and atrophic changes in the gastric mucosa has been reported as long-term consequences of vagotomy-induced acid suppression. This study was designed to describe the long-term changes in the gastric mucosa caused by vagotomy and Helicobacter pylori infection.

METHODS

Seventy-nine patients with vagotomized peptic ulcers, 70 nonoperated patients with peptic ulcers, and 85 matched community control subjects were randomly selected to participate in an upper endoscopic study. Biopsy specimens were taken from predestined locations of the gastric mucosa.

RESULTS

Mean follow-up time for the vagotomized patients was 17.3 (range, 6-28) years and 12.7 (range, 10-17) years for the medically treated peptic ulcer patients. In H. pylori-positive subjects, severe atrophic changes in the distal gastric mucosa (prepylorus and angulus) was found in 30% (95% confidence interval (CI), 19-43) of the vagotomized patients and in 43% (95% CI, 29-58) of medically treated patients with peptic ulcers, and in 32% (95% CI, 20-46) of the community control subjects. Severe intestinal metaplasia was not found more frequently in vagotomized peptic ulcer patients compared with medically treated patients with peptic ulcers (p = 0.5). The histological picture of the age-matched community control subjects did not differ significantly from the patients with peptic ulcers when corrected for presence of H. pylori infection.

CONCLUSIONS

This study lends no support to theories of increased premalignant changes in the gastric mucosa of vagotomized patients. H. pylori infection rather than long-term acid suppression seems to be the explanation of the gastric mucosal changes seen after vagotomy.

Clostridium difficile infection: risk factors, medical and surgical management

BACKGROUND

Clostridium difficile has become recognized as a cause of nosocomial infection which may progress to a fulminant disease.

METHODS

Literature review using electronic literature research back to 1966 utilizing Medline and Current Contents. All publications on antibiotic-associated diarrhea, antibiotic-associated colitis, and pseudomembranous colitis as well as C. difficile infection were included. We addressed established and potential risk factors for C. difficile disease such as an impaired immune system and cost benefits of different diagnostic tests. An algorithm is outlined for diagnosis and both medical and surgical management of mild, moderate and severe C. difficile disease.

RESULTS

Diagnosis of C. difficile infection should be suspected in patients with diarrhea, who have received antibiotics within 2 months or whose symptoms started after hospitalization. A stool specimen should be tested for the presence of leukocytes and C. difficile toxins. If this is negative and symptoms persist, stool should be tested with 'rapid' enzyme immunoabsorbent and stool cytotoxin assays, which are the most cost-effective tests. Endoscopy and other imaging studies are reserved for severe and rapidly progressive courses. Oral metronidazole or vancomycin are the antibiotics of choice. Surgery is rarely required for selected patients refractory to medical treatment. The threshold for surgery in severe cases with risk factors including an impaired immune system should be low.

CONCLUSION

C. difficile infection has been recognized with increased frequency as a nosocomial infection. Early diagnosis with immunoassays of the stool and prompt medical therapy have a high cure rate. Metronidazole has supplanted oral vancomycin as the drug of first choice for treating C. difficile infections.

Pseudomembranous colitis: causes and cures

Clostridium difficile is the most common nosocomial pathogen of the gastrointestinal tract and has increased in frequency over time. Typical symptoms of C. difficile infection include diarrhea, which is usually nonbloody, or colitis associated with severe abdominal pain, fever and/or gross or occult blood in the stools. Pseudomembranous colitis (PMC), the severest form of this disease, occurs as a result of a severe inflammatory response to the C. difficile toxins. This review focuses on PMC, as this severe form is associated with the greatest medical concern. Diagnosis rests on detection of C. difficile in the stool, either by culture, tissue culture assay for cytotoxin B or detection of antigens in the stool by rapid enzyme immunoassays. Oral therapy with metronidazole 250 mg 4 times a day for 10 days is the recommended first-line therapy. Vancomycin is also effective, but its use must be limited to decrease the development of vancomycin-resistant organisms such as enterococci. Vancomycin (125-500 mg 4 times a day for 10 days) should be limited to those who cannot tolerate or have not responded to metronidazole, or when metronidazole use is contraindicated, as in the first trimester of pregnancy. A therapeutic response within a few days is usual. Recurrence of symptoms after antibiotics occurs in 20% of cases and is associated with persistence of C. difficile in the stools. Further recurrences then become more likely. Therapy with antibiotics in a pulsed or tapered regimen is often effective as are efforts to normalize the fecal flora. The yeast Saccharomyces boulardii has been proven in controlled trials to reduce recurrences when given as an adjunct to antibiotic therapy. Careful hand washing and environmental decontamination are necessary to prevent epidemics.