Congestive gastropathy and Helicobacter pylori: an endoscopic and morphometric study

Molecular mechanism of portal hypertensive gastropathy: An update

Portal hypertensive gastropathy (PHG) is a serious complication and the most common gastric mucosal injury amongst patients afflicted with cirrhotic or non-cirrhotic portal hypertension (PHT). The pathogenesis of PHG is not completely understood and is likely to be complex. The roles of portal hypertension pressure, parenchymal liver disease, Child-Pugh classification, variceal pressure and Helicobacter pylori infection in the development of PHG are controversial. Splanchnic blood flow, the distribution of mucosal blood, vascular ectasia, local disturbances, inflammatory cell infiltration and increased cytokine production have also been examined to elucidate the underlying mechanisms of PHG. Moreover, various other elements, including prostaglandin E2 (PGE2), endothelin-1 (ET-1), tumour necrosis factor-α (TNF-α), Fas ligand (FasL)/Fas, nitric oxide (NO), oxygen free radicals and vascular endothelial growth factor (VEGF), have also been revealed to participate in the pathogenesis of PHG. This review provides an overview of the risk factors, classification and potential molecular processes involved in PHG, followed by a concise summary of our and other studies. This review aims to integrate information to deepen our understanding of the interplay between different signalling pathways involved the pathogenesis of PHG and provides insights into how these signalling pathways are regulated to control the development of PHG.

Helicobacter pylori infection is not associated with portal hypertension-related gastrointestinal complications: A meta-analysis

Despite the importance of Helicobacter pylori infection and portal hypertension (PH)-associated gastrointestinal (GI) diseases, such as esophageal varices and portal hypertensive gastropathy (PHG), the impact of H. pylori infection on PH-related GI complications has not yet been elucidated. This meta-analysis investigated the association between H. pylori infection and the risk of PH-related GI complications. An electronic search for original articles published before May 2020 was performed using PubMed, EMBASE, and the Cochrane Library. Independent reviewers conducted the article screening and data extraction. We used the generic inverse variance method for the meta-analysis, and Begg's rank correlation test and Egger's regression test to assess publication bias. A total of 1,148 cases of H. pylori infection and 1,231 uninfected controls were included from 13 studies. H. pylori infection had no significant association with esophageal varices [relative risk (RR) = 0.96, 95% confidence interval (CI) = 0.87-1.06 for all selected studies; RR = 0.95, 95% CI = 0.84-1.07 for cohort studies; odds ratio (OR) = 0.96, 95% CI = 0.60-1.54 for case-control studies]. Although H. pylori infection was significantly associated with PHG in case-control studies [OR = 1.86, 95% CI = 1.17-2.96], no significant differences were found in the cohort studies [RR = 0.98, 95% CI = 0.91-1.05] or all studies combined [RR = 1.18, 95% CI = 0.93-1.52]. In conclusion, H. pylori infection was not associated with the risk of PH-related GI complications. Clinicians should carefully treat cirrhotic patients with PH-related GI complications, regardless of H. pylori infection.

Portal Hypertensive Gastropathy in Liver Cirrhosis: Prevalence, Natural History, and Risk Factors

Objective Portal hypertensive gastropathy (PHG) is a common finding in patients with liver cirrhosis (LC) and may cause both acute and chronic bleeding. A number of risk factors for PHG have been identified. The present study explored the characteristics of Japanese patients with LC who develop PHG. Methods Clinical findings (age, sex, etiology, the presence of esophageal varices, splenomegaly and severity of LC), laboratory data, and whether or not atrophic gastritis was found on endoscopy were retrospectively reviewed in patients with LC who had undergone esophagogastroduodenoscopy. PHG was endoscopically graded as absent, mild, or severe. Results Of 262 patients with LC (mean age, 69 years old; 145 men), 158 had no PHG, 41 had mild PHG, and 63 had severe PHG. In a univariate analysis, a younger age, male sex, non-viral etiology, absence of atrophic gastritis, presence of esophageal varices, splenomegaly, severe LC, low platelet count, and low hemoglobin concentration were associated with PHG. A multivariate analysis showed a significant association of PHG with the absence of atrophic gastritis (p<0.048), presence of esophageal varices (p<0.001), non-viral etiology (p<0.033), splenomegaly (p<0.048), and severe LC (p<0.005). There were no cases of massive bleeding from PHG during follow-up. Conclusion Esophageal varices, splenomegaly, severe liver cirrhosis, the absence of atrophic gastritis, and etiology were found to be risk factors for PHG in Japanese patients.

Portal hypertensive vasculopathy - An entity worth remembering with non-neoplastic gastrointestinal lesions

Portal hypertensive vasculopathy (PHV) represents an increase in the pressure in the portal circulation. This increased pressure leads to changes in the mucosa that can be appreciated endoscopically as well as histopathologically. Lesions can be observed in the entire gastrointestinal tract (GIT) including stomach, duodenum, jejunum and colon. The histological changes are appreciated mainly in the mucosal and submucosal blood vessels. A knowledge of these lesions as well as the changes helps in separating them from other close differentials with specific treatment to be instituted. The pathogenesis of the hemodynamic changes is not well-understood. The underlying factor is increased portal pressure. Studies indicate, that besides increased portal pressure other factors in combination led to the observed changes. Portal hypertensive gastropathy (PHG) is seen in the gastric body and fundus, while varices are noted in the cardia and fundus. Changes may be seen in the small intestine and throughout the colon with anorectal varices. Histopathological changes include dilated, congested and ectatic capillaries and edema in the lamina propria besides a large spectrum of other histopathological changes. Mucosal capillaries with thick irregular wall show absence of red blood cells in the lumen. Thickening of the vessel wall serves as a better marker than the vascular diameter when portal hypertension (PHT) is considered. Long standing cases may show fibrosis in lamina propria. At times, these changes may lead to occult gastrointestinal bleeding. Important differentials need to be ruled out in all the cases as the treatment and the outcome of all differs. Endoscopically or histopathologically if the mucosal changes are observed they should not be overlooked and a detailed work-up must be carried out.

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.

Efficacy of argon plasma coagulation in the management of portal hypertensive gastropathy

Objectives: Evaluation of the outcome and experience in 2 years of management of portal hypertensive gastropathy (PHG) by argon plasma coagulation (APC) in a cohort of Egyptian cirrhotic patients. Methods: This study was conducted over a 2-year period from January 2011 to February 2013. Upper gastrointestinal endoscopy was performed to evaluate the degree and site of PHG. APC was applied to areas with mucosal vascular lesions. Results: In total, 200 cirrhotic patients were enrolled; 12 patients were excluded due to death (n = 6) caused by hepatic encephalopathy (n = 3), hepatorenal syndrome (n = 2), or chronic lymphatic leukemia (n = 1), or did not complete the treatment sessions (n = 6), so 188 patients completed the study. PHG was mainly fundic in 73 patients (38.8 %), corporeal in 66 patients (35.1 %), and pangastric in 49 patients (26.1 %) (P = 0.026). Patients were exposed to APC and received proton pump inhibitors together with propranolol at a dose sufficient to reduce the heart rate by 25 % or down to 55 beats/min. The mean (± standard deviation) number of sessions was 1.65 ± 0.8; six patients needed four sessions (3.2 %), 19 patients needed three sessions (10.1 %), 74 patients needed two sessions (39.4 %), and 89 patients needed one session (47.3 %). Patients with fundic and corporeal PHG required the lowest number of sessions (P = 0.000). Patients were followed up every 2 months for up to 1 year; the end point was a complete response with improved anemia and blood transfusion requirement which was achieved after one session in 89 patients (75.4 %), two sessions in 24 patients (20.3 %) and three sessions in five patients (4.3 %). A complete response was more prevalent in patients with corporeal and fundic PHG (P = 0.04). Conclusions: After 2 years' experience in managing PHG, we found that a combination of APC and non-selective beta blockers was highly efficacious and safe in controlling bleeding from PHG. In addition, APC alone is rapid, and effective in the control of PHG induced bleeding, especially when beta blockers are contraindicated.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Probe-based confocal laser endomicroscopy quantitative morphometric markers associated with portal hypertension in duodenal mucosa

BACKGROUND & AIMS

Early detection of portal hypertension (PH) may help to prevent the morbidity of late-stage cirrhosis by stratifying disease severity and enabling disease-modifying interventions in potentially reversible conditions like non-alcoholic fatty liver disease and alcoholic hepatitis. This study seeks to correlate morphometric features by confocal endomicroscopy with established surrogate clinical markers of PH.

METHODS

Patients with and without PH scheduled for upper endoscopy at VA Boston participated in this IRB-approved study. Real-time probe-based confocal endomicroscopy (pCLE) was performed in the duodenum. Vascular and epithelial morphometry was performed off-line, in a blinded manner, using image-processing software.

RESULTS

Morphometric analysis of pCLE images from 16 patients with PH and 15 control patients was performed. Statistically significant differences were observed among control and PH patients for average vessel diameter (AVD: 11.7 μm vs. 17.1 μm), average vessel branching (AVB: 0.11 vs. 0.31 bifurcations per image frame), and average columnar cell height (ACCH: 40.0 μm vs. 52.0 μm). Spearman correlations comparing AVD, AVB and ACCH to portal gastropathy scores (0.86, 0.44 and 0.70) and to grade of oesophageal varices (0.88, 0.41 and 0.66) were statistically significant. Similarly, Pearson correlations of AVD and ACCH to spleen size (0.72 and 0.57), platelet count (-0.69 and -0.40) and the platelet count/spleen size ratio (-0.69 and -0.41) were also found to be statistically significant.

CONCLUSIONS

Duodenal pCLE reveals microvascular dilatation and altered epithelial cell volume/morphology in PH. These morphometric pCLE markers correlate with surrogate markers of PH. Additional studies will define the correlation between microscopic vascular patterns, epithelial cell volume and the hepatic venous pressure gradient.

Effect of Helicobacter pylori infection on esophagogastric variceal bleeding in patients with liver cirrhosis and portal hypertension

BACKGROUND AND AIMS

Bleeding from esophageal and gastric varices is a fatal event in patients with liver cirrhosis and portal hypertension. However, the effects of Helicobacter pylori (H. pylori) infection on esophagogastric variceal bleeding are not known. The present study was aimed to elucidate the role of H. pylori infection in esophagogastric variceal bleeding.

METHODS

The subjects were 196 cirrhotic patients who were admitted to the Kurume University Hospital to treat their esophagogastric varices consisted of 95 with acute bleeding and 101 with nonbleeding but high risk of bleeding. For the diagnosis of H. pylori infection, a (13) C-urea breath test was used, and serum pepsinogen (PG) I and II levels and the PG I/II ratio were also measured.

RESULTS

Esophagogastric variceal bleeding was seen in 34.9% (n = 30) of the H. pylori-infected patients (n = 86) and in 59.1% (n = 65) of the noninfected patients (n = 110) (P < 0.0007). There was no significant difference in the infection rate between the bleeding sites of the esophagus and the stomach. The serum PG I and II levels and the PG I/II ratio were 65.6 ng/dL, 14.7 ng/dL, and 4.4, respectively, for the bleeding patients (n = 95), and 43.7 ng/dL, 17.7 ng/dL, and 3.1 for the nonbleeding patients (n = 101). Thus, the nonbleeding patients had significantly higher rate of H. pylori infection and lower acid secretion than bleeding patients (0.001). In addition, multivariate logistic regression analysis showed a significant negative association between H. pylori infection and esophagogastric variceal bleeding.

CONCLUSIONS

These results suggest that H. pylori infection has a protective effect against esophagogastric variceal bleeding through the induction of gastric mucosal atrophy and concomitant hypoacidity.

Portal gastropathy and duodenopathy in children with extrahepatic and intrahepatic portal hypertension: endoscopic diagnosis and histologic scoring

OBJECTIVES

The aim of the study was to determine the frequency of portal gastropathy (PG) and duodenopathy (PD) in children, to document the correlation of various clinical and laboratory parameters associated with portal hypertensive gastroduodenal lesions, to compare the endoscopic portal hypertensive lesions with different histologic findings, and to evaluate the use of a possible histologic scoring system.

METHODS

All children undergoing endoscopic investigation for portal hypertension (PH) between January 2006 and November 2007 were analysed retrospectively. Clinical and demographical data and endoscopic and histologic findings were recorded. Histologic findings suggestive of PG and PD (capillary dilation, increased numbers of capillaries, histologic bleeding, and edema) were scored.

RESULTS

Of 51 consecutive children (29 boys, mean age 10.1 ± 3.6 years [range 2.5-15.8 years]), 28 were cirrhotic. PG was diagnosed in 58.8% endoscopically. Children with cirrhotic PH had the highest rate of PG (64.3%), whereas those with extrahepatic or intrahepatic noncirrhotic PH were alike (50% and 54.5%, respectively). Baveno PG scores were higher in children with cirrhosis with higher Child-Pugh scores. Capillary dilation was the only histologic finding showing significant association with the endoscopic diagnosis. Only 9% had PD on endoscopy. None of the histologic findings correlated with endoscopic diagnosis of PD.

CONCLUSIONS

PG and PD are seen in children with extrahepatic and intrahepatic PH at rates similar to those reported in adult studies. Baveno PG scores increased in parallel with Child-Pugh class in children with cirrhosis. Capillary dilation was the only histologic finding showing significant association with the endoscopic diagnosis of PG in this study.

[Association between Helicobacter pylori infection and gastroduodenal lesions in patients with chronic liver disease]

CONTEXT

The relationship between Helicobacter pylori infection and gastroduodenal lesions in chronic liver disease remains controversial.

OBJECTIVE

Evaluate the evidence of the role of H. pylori infection in gastroduodenal lesions in patients with chronic liver disease.

METHODS

Forty-six patients with chronic liver disease were matched with 27 dyspeptic persons for age and sex. The gastroduodenal lesions were portal hypertension gastropathy, erosion and peptic ulcer. All patients underwent upper endoscopy: two biopsies were taken in the antrum and in the gastric body. The biopsies were used for Giemsa staining.

RESULTS

A gastroduodenal lesions were found in 38 (82.6%) patients with liver disease and was significantly more frequent than among controls (P = 0.002). H. pylori infection was detected at histological assessment in 13 (28.2%) patients with chronic liver disease and in 17 (62.9%) controls. The odds ratio (OR) showed an interaction statistically significant between gastroduodenal lesions and chronic liver disease (P = 0.04; OR = 5.1; 95% CI = 1.6-17.3). When adjusted for the presence of H. pylori OR was significantly with H. pylori negative (OR 13.0 IC 95%, 1.4-327.9).

CONCLUSION

Patients with chronic liver disease showed higher risk of developing gastroduodenal lesions regardless of the presence of the H. pylori infection.

Effect of early propranolol administration on portal hypertensive gastropathy in cirrhotic rats

AIM

To investigate any protective effect of early propranolol administration in the development of portal hypertensive gastropathy in cirrhotic rats.

METHODS

For the development of liver cirrhosis and portal hypertensive gastropathy, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. After two weeks of CCl(4) administration, the rats were randomly separated into two groups. In group A, propranolol was continuously administered intragastrically throughout the study, whereas in group B normal saline (placebo) was administered instead. Hemodynamic studies and vascular morphometric analysis of gastric sections were performed after complete induction of cirrhosis.

RESULTS

Vascular morphometric studies showed higher numbers of vessels in all mucosal layers in the control group. Statistical analysis revealed a significantly higher total vascular surface in the control group compared to the propranolol group, but with no statistically significant difference between the mean vascular surfaces between the groups. Our study clearly shows that the increased mucosal blood flow is manifested by a marked increase of vessel count.

CONCLUSION

Early propranolol's administration in portal hypertensive cirrhotic rats seems to prevent intense gastric vascular congestion that characterizes portal hypertensive gastropathy.

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.

Diagnosis of portal hypertensive gastropathy

Portal hypertensive gastropathy is a relatively recently described entity that is an important cause of bleeding in portal hypertension. This article focuses on the endoscopic diagnosis of portal hypertensive gastropathy, including a review of different proposed scoring systems, and briefly examines the epidemiology, pathogenesis, and treatment of portal hypertensive gastropathy.

Role of acute elevation of portal venous pressure by exogenous glucagon on gastric mucosal injury in rats with portal hypertension

Time-course studies revealed the increased susceptibility of the gastric mucosa to noxious injury in portal hypertension correlates with the level of elevated portal venous pressure and hyperglucagonemia. Whether acute elevation of portal venous pressure by exogenous glucagon aggravates such injury is not known. We tested the hypothesis that glucagon in a dose sufficient to acutely elevate portal venous pressure aggravates noxious injury of the gastric mucosa in rats with portal hypertension. Infusion of a portal hypotensive dose of somatostatin should reverse these changes. In anesthetized rats with portal vein ligation, glucagon, somatostatin or the combination was administered intravenously in a randomized, coded fashion. Acidified ethanol-induced gastric mucosal injury was determined. Portal venous pressure and gastric mucosal perfusion and oxygenation (reflectance spectrophotometry) were monitored to confirm the effects of the respective intravenous treatments. Exogenous glucagon exacerbated acidified ethanol-induced gastric mucosal injury. The exacerbation was attenuated by somatostatin. These changes paralleled the portal hypertensive and hypotensive effects of glucagon and somatostatin, respectively. Our data suggest that a unique mechanism is triggered with the onset of portal hypertension. In an antagonistic manner, glucagon and somatostatin modulate this novel mechanism that controls portal venous pressure and susceptibility of the gastric mucosa to noxious injury.

Helicobacter pylori infection is associated with greater impairment of cytochrome P-450 liver metabolic activity in anti-HCV positive cirrhotic patients

Helicobacter pylori gastric infection has been associated with various digestive and extradigestive diseases. In liver disease bacterial infections have been associated with impairment of cytochrome P-450 liver metabolic activity. Moreover, infection by Helicobacter spp. seems to be linked with the development of hepatocellular carcinoma (HCC) in mice. Our aims were to evaluate the influence of H. pylori infection on cytochrome P-450 liver metabolic activity as assessed by means of monoethylglycinexylidide (MEGX) test and to assess the prevalence of H. pylori infection in patients with HCC. Ninety-six hepatitis C virus (HCV) -positive cirrhotic patients, 36 of whom had HCC, were tested for H. pylori infection by means of anti-H. pylori IgG. Patients underwent the MEGX test. Characteristics of the patients were then analyzed on the basis of the presence of H. pylori infection. Seroprevalence of H. pylori infection was similar between cirrhotic patients without (68%) or with (63.8%) HCC. Mean MEGX values were significantly (P < 0.0001) lower in H. pylori infected patients (18.2 +/- 13.9 ng/ml) as compared to the noninfected ones (46.9 +/- 17.1 ng/ml), independently of Child-Pugh's classification. These differences persisted even after subdividing patients according to the presence of HCC. In conclusion, in anti-HCV positive cirrhotic patients H. pylori infection is associated to an impairment of cytochrome P-450 liver metabolic activity. Seroprevalence of H. pylori infection in HCC patients is similar to that observed in tumor-free cirrhotics.

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.

No additive effect between Helicobacter pylori infection and portal hypertensive gastropathy on inducible nitric oxide synthase expression in gastric mucosa of cirrhotic patients

Increased expression of inducible nitric oxide synthase (iNOS) has been reported in gastric mucosa of patients with Helicobacter pylori infection or portal hypertensive gastropathy (PHG) but whether there is an additive or synergistic impact between H. pylori and PHG on iNOS expression was unknown. Sixty cirrhotic patients and 21 age-matched control subjects without liver disease were included. Biopsies from the gastric antrum and body were obtained for quantitative histological assessment and immunohistochemical staining for iNOS. iNOS staining was detected in endothelial cells and macrophages. In the absence of PHG, H. pylori significantly induced iNOS expression in cirrhotic patients. PHG also significantly induced iNOS expression in H. pylori-negative patients. However, there was no synergistic or additive effect between H. pylori and PHG on this expression. Furthermore, expression of iNOS was significantly higher in patients with severe PHG than in those with mild PHG and without PHG.

Helicobacter pylori is a risk factor for peptic ulcer disease in cirrhotic patients. A meta-analysis

BACKGROUND

Peptic ulcer disease is highly prevalent in cirrhosis, and ulcer complications are a major cause of morbidity in these patients. Helicobacter pylori infection is considered the chief aetiological factor of ulcer disease. However, in cirrhotic patients the role of H. pylori in the pathogenesis of peptic ulcer remains uncertain.

AIM

To evaluate the evidence of the pathogenic role of H. pylori infection in peptic ulcer disease in patients with cirrhosis.

MATERIALS AND METHODS

An extensive MEDLINE search of the literature was performed. Studies reporting the prevalence of H. pylori infection in cirrhotic patients with and without ulcers were selected. Meta-analysis was conducted using RevMan 4.0.3. Pooled odds ratios were calculated for each comparison, using a fixed model analysis.

RESULTS

The search identified seven studies with a total of 976 patients with cirrhosis (275 cases with ulcer disease and 701 controls). The prevalence of H. pylori infection in patients with peptic ulcer disease was higher than in those without. The pooled odds ratio was 2.70 (95% CI, 1.91-3.82). H. pylori infection was associated more or less equally with duodenal and gastric ulcers.

CONCLUSION

H. pylori infection increases the risk of peptic ulcer disease in patients with cirrhosis.

Impairment of cytochrome P-450-dependent liver activity in cirrhotic patients with Helicobacter pylori infection

BACKGROUND

Helicobacter pylori gastric infection has been associated with various digestive and extra-digestive diseases. The systemic influence of gastric H. pylori infection seems to be mediated by the release of various cytokines. In liver disease, bacterial infections have been associated with the impairment of liver metabolic function.

AIMS

To evaluate the influence of H. pylori infection on liver function as assessed by means of the monoethylglycinexylidide test, which depends upon liver blood flow and cytochrome P-450 activity, and the 13C-galactose breath test, which depends on cytosolic enzymatic activity and is correlated with hepatic functional mass. Moreover, to evaluate whether H. pylori-associated modifications of liver function may be related to tumour necrosis factor-alpha serum levels.

PATIENTS AND METHODS

Thirty-five patients with liver cirrhosis of various aetiologies, who underwent monoethylglycinexylidide and 13C-galactose breath tests, were retrospectively evaluated for H. pylori infection by means of anti-H. pylori immunoglobulin G. The main clinical, biochemical and functional characteristics of the patients as well as their tumour necrosis factor-alpha serum levels were then analysed on the basis of the presence of H. pylori infection.

RESULTS

Twenty-one patients tested positive for H. pylori infection (60%), and 11 tested negative (31.4%). No clinical or biochemical differences were observed between H. pylori-infected and non-infected patients. H. pylori infection showed no difference in distribution according to Child-Pugh classes (A, 55%; B and C, 67%). The monoethylglycinexylidide test results were significantly lower at each sampling time in H. pylori-positive patients compared to H. pylori-negative patients (MEGX15, P=0.027; MEGX30, P=0.014; MEGX60, P=0.028), while 13C-galactose breath test showed no significant differences considering both cumulative percentage dose and percentage dose/h. The median tumour necrosis factor-alpha serum levels were no different between H. pylori-positive (16.1 pg/mL, 95% confidence interval, 8.7-28.7) and H. pylori-negative (12.3 pg/mL, 95% confidence interval, 8.7-23.4) patients.

CONCLUSIONS

In cirrhotic patients, H. pylori infection seems to selectively affect cytochrome P-450 liver activity, while hepatic functional mass does not seem to be impaired. Tumour necrosis factor-alpha does not seem to be the mediator of this impairment. Further studies are needed to evaluate the impact of H. pylori eradication on parameters of liver function.

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.

Gastric epithelial cell proliferation in patients with liver cirrhosis

An increased risk for gastric cancer in patients with liver cirrhosis has recently been reported. This study was performed in order to determine gastric epithelial cell proliferation in cirrhotic patients and to evaluate the role of congestive gastropathy (CG) and Helicobacter pylori infection in this process. Thirty-six cirrhotic patients and 18 controls were enrolled in the study. All patients underwent endoscopy and three biopsies were performed in the antrum and three in the gastric body. The presence of H. pylori infection was assessed by a rapid urease test and histology. The antral biopsies were used for gastric cell proliferation assessment by an immunohistochemical analysis (Ki-67). There was no significant difference in epithelial cell proliferation between cirrhotics and controls. Gastric proliferation values were higher in patients with H. pylori infection compared with uninfected patients, both in cirrhotic (P = 0.003) and in control groups (P = 0.06). Among the cirrhotic group, we found a progressive increase in gastric cell proliferation values related to the degree of CG, the highest values being observed in cirrhotic patients with severe CG. Moreover, cirrhotics with both severe CG and H. pylori infection had the highest proliferation values when compared with all other subgroups. In conclusion, this study found that: (1) CG significantly affects epithelial cell proliferation in gastric mucosa in cirrhotic patients, (2) H. pylori infection plays a similar role in gastric cell proliferation in both cirrhotic and non-cirrhotic patients, and (3) CG and H. pylori could act synergistically in this process.

Gastric mucosal responses to intrahepatic portosystemic shunting in patients with cirrhosis

BACKGROUND & AIMS

The response of gastric mucosal lesions in cirrhotic patients with portal hypertension, namely, portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE), to transjugular intrahepatic portosystemic shunts (TIPS) is not known.

METHODS

Clinical and laboratory evaluation, upper gastrointestinal endoscopy, and Doppler ultrasonography were performed before placement of TIPS and 6 weeks, 3 months, and 6 months after TIPS in 54 patients. Thirty patients had mild PHG, 10 had severe PHG, and 14 had GVE.

RESULTS

Approximately 75% of the patients with severe PHG responded to TIPS as shown by improvement in endoscopic findings and by a decrease in transfusion requirements; 89% of patients with mild PHG had endoscopic resolution. Patients with GVE had neither endoscopic resolution nor a decrease in transfusion requirements after TIPS. There was no difference in mortality between the 2 groups.

CONCLUSIONS

The results support the position that severe PHG and GVE may be different lesions. Mild and severe PHG respond to TIPS. Because GVE does not respond to TIPS, we recommend that TIPS be avoided for the treatment of gastrointestinal bleeding associated with GVE.

Pharmacokinetics of clarithromycin in Helicobacter pylori eradication therapy in patients with liver cirrhosis

BACKGROUND

Proton pump inhibitor triple therapy with clarithromycin and metronidazole has been widely used for Helicobacter pylori eradication. However, the efficacy and the safety of this therapy in patients with liver cirrhosis have not been established.

AIM

To evaluate the effect of hepatic dysfunction on metabolism of clarithromycin as it is used for H. pylori eradication therapy in patients with liver cirrhosis, and the efficacy of eradication therapy in those patients.

METHODS

Serum levels of clarithromycin and its metabolite. 14-(R)-hydroxyclarithromycin, were examined in 18 subjects (five normal controls and 13 hospitalized patients with liver cirrhosis) on a selected day between days 7 and 10 of a 2-week course of eradication therapy. This therapy consisted of lansoprazole (30 mg, once a day) together with clarithromycin (200 mg, twice a day) and metronidazole (250 mg, twice a day). In addition, 118 H. pylori-positive out-patients, 88 with peptic ulcer and 30 with liver cirrhosis, underwent the same eradication therapy.

RESULTS

Values for the area under the 0-6 h concentration-time curve (AUC) for clarithromycin were not significantly different among the groups. However, the AUC (0-6 h) values of 14-(R)-hydroxyclarithromycin were significantly lower in the Child-Pugh C group than in either the normal controls or the Child-Pugh A/B group. The cure rate for the peptic ulcer patients was 84% on a per protocol analysis (95% CI: 80%-88%) and 81% on an intention-to-treat analysis (95% CI: 77%-85%), while in the liver cirrhosis patients it was 89% in a per protocol analysis (95% CI: 78%-99%) and 83% in an intention-to-treat analysis (95% CI: 70%-97%). Mild adverse effects were observed in 10% of the peptic ulcer patients and 13% of the liver cirrhosis patients, with none leading to premature withdrawal from the study.

CONCLUSION

The 2-week low-dose lansoprazole-based triple therapy tested is a simple, effective and well-tolerated regimen for H. pylori eradication in patients with liver 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.

Portal-hypertensive gastropathy

In the present article we describe updated information concerning the clinical feature of portal-hypertensive gastropathy (PHG), which is characterized by mucosal and submucosal vascular dilatation without inflammation. Although this lesion represents non-variceal bleeding, there is a wide variation of its prevalence. Portal pressure and some humoral factors may play important roles in its pathogenesis. Gastric acid secretory activity is reduced, whereas the gastric mucosal barrier is impaired. With regard to gastric mucosal haemodynamics, whether 'overflow' (i.e. active congestion) or 'stasis' (i.e. passive congestion) cause gastric mucosal hyperaemia is not known. A severe lesion is a potential source of bleeding, while mild lesions are of little clinical significance and endoscopic variceal obliteration aggravates PHG in some patients. In the treatment of PHG, pharmacological (e.g. propranolol), surgical (e.g. portosystemic shunt) and radiological (e.g. transjugular intrahepatic portosystemic shunt) procedures may be useful in preventing bleeding from PHG.

Helicobacter pylori infection and peptic ulcer disease in cirrhosis

An increased frequency of peptic ulcer disease is noted in patients with cirrhosis, but the role of H. pylori in this disorder remains to be determined. The diagnosis of cirrhosis was confirmed by a combination of clinical, biochemical, radiological, and histological methods. The severity of cirrhosis was assessed by Pugh's modification of Child's criteria. Upper gastrointestinal endoscopy was performed consecutively to evaluate the presence of varices and gastroduodenal mucosa. H. pylori status was assessed by histology, urease test, and serology. In all, 130 patients with cirrhosis were recruited into the study; there were 86 males and 44 females with a mean (SD) age of 54.4 (12.7) years. The H. pylori prevalence was 76.2%. There was no difference in age between the H. pylori-positive and -negative cirrhotics (P = 0.29). The H. pylori prevalence revealed no difference among cirrhotics with Child A (77.8%), Child B (72.9%), and Child C (78.6%) (P = 0.8), and neither was there a difference in H. pylori prevalence in cirrhotics with and without congestive gastropathy (77% vs 73.7%, P = 0.84). The prevalence of H. pylori in cirrhotics with and without varices did not show a statistical difference (75% vs 81.8%, P = 0.68). There also was no difference in the H. pylori prevalence between cirrhotic patients with and without peptic ulcers (84.4% vs 69.7%, P = 0.09). In conclusion, the prevalence of H. pylori or peptic ulcer is independent of the severity of cirrhotic liver disease. The association between H. pylori infection and peptic ulcer disease is weak in cirrhosis.

High prevalence of Helicobacter pylori in liver cirrhosis: relationship with clinical and endoscopic features and the risk of peptic ulcer

In 153 consecutive patients with cirrhosis we assessed: (1) the prevalence of IgG to Helicobacter pylori and compared it with that found in 1010 blood donors resident in the same area; and (2) the relationships of IgG to Helicobacter pylori with clinical and endoscopic features and with the risk of peptic ulcer. The IgG to Helicobacter pylori prevalence of cirrhotics was significantly higher than in blood donors (76.5% vs 41.8%; P < 0.0005) and was not associated with sex, cirrhosis etiology, Child class, gammaglobulins and hypertensive gastropathy. In both groups, the prevalence of IgG to Helicobacter pylori was significantly higher in subjects over 40. Among patients with cirrhosis a significantly higher prevalence of Helicobacter pylori was found in patients with previous hospital admission (P = 0.02) and/or upper gastrointestinal endoscopy (P = 0.01) and patients with peptic ulcer (P = 0.0004). Multivariate analysis identified increasing age and male sex as risk factors for a positive Helicobacter pylori serology and no independent risk factors for peptic ulcer. The high prevalence of Helicobacter pylori-positive serology found in the present series is related to age and sex and might also be explained by previous hospital admissions and/or upper gastrointestinal endoscopy. Our results do not confirm the role of Helicobacter pylori as risk factor for peptic ulcer in patients with liver cirrhosis.

Helicobacter pylori infection among patients with alcoholic and nonalcoholic cirrhosis

BACKGROUND

The prevalence of Helicobacter pylori in patients with alcoholic and nonalcoholic cirrhosis is uncertain. The present study was aimed at determining the prevalence of H. pylori infection among cirrhotic patients and to explore its relationship to demography, etiology of cirrhosis, and liver function.

MATERIALS AND METHODS

Thirty-three cirrhotic patients were included. H. pylori infection was determined by the 14C urea breath test (n = 30) and endoscopy with antral biopsy (n = 4). Etiology of cirrhosis was classified as alcoholic or nonalcoholic. The rate of H. pylori infection was related to age, gender, etiology, Child-Pugh grading, portal hypertension, and portal-systemic encephalopathy (PSE). None of the patients received antibiotics for at least the last 3 months.

RESULTS

Twelve alcoholic and 21 nonalcoholic cirrhotics, with a median age of 57 years and a male:female ratio of 1:1.4 were studied. Overall H. pylori prevalence was 45.5%. This prevalence varied from 47.1% to 43.8% in those younger and older than the median age, and from 35.7% to 52.6% in men and women, respectively. Fifty percent of alcoholic and 42.9% of nonalcoholic cirrhotics were H. pylori-positive. According to Child-Pugh grading, 69% of grade A, 40% of grade B, and 0% of grade C were infected (p = .03). Among patients with PSE, 25% were H. pylori-positive compared to 52% of those without PSE (p = .24).

CONCLUSIONS

The prevalence of H. pylori infection in cirrhotics is 45.5%. Prevalence was unrelated to age, gender, and etiology of cirrhosis. An inverse relation to the Child-Pugh grading and a tendency to a lower prevalence in PSE was found.

Portal Hypertensive gastropathy

The term portal hypertensive gastropathy (PHG) defines a wide spectrum of diffuse macroscopic lesions that appear in the gastric mucosa of patients with portal hypertension. Histologically, these lesions correspond to dilated vessels in the mucosa and submucosa in the absence of erosions or inflammation. Endoscopically, the lesions are classified as mild when mosaic pattern or superficial reddening are present, and severe when gastric mucosa appear with diffuse cherry red spots. Mild lesions are highly prevalent (65-90%), whereas severe lesions are present in only 10-25% of cirrhotic patients. The pathogenesis of PHG is not well known, but both venous congestion related with raised portal pressure and increased gastric blood flow seem to be crucial factors for its development. Variceal sclerosis may contribute to the development or aggravation of the lesions. Bleeding is the unique clinical manifestation of PHG, and occurs only in those patients with severe lesions. During a 5-year follow-up, the risk of overt bleeding or chronic bleeding, which induces anaemia, is 60 % and 90%, respectively, for patients with severe PHG. Propranolol is the only pharmacological treatment that has been proven useful in preventing bleeding from PHG. Porto-systemic shunts and liver transplantation are also effective.

Seroprevalence and epidemiology of Helicobacter pylori infection in patients with cirrhosis

BACKGROUND

Helicobacter pylori infection is the major pathogenic factor for peptic ulcer disease. Its epidemiology is not fully known; few data are available in patients with chronic liver disease.

AIMS

To investigate the seroprevalence and factors associated with Helicobacter pylori infection in a series of liver cirrhosis patients.

METHODS

Two hundred and twenty consecutive patients were prospectively included in a study aimed to evaluate the effect of dietary intervention on cirrhosis complications and survival. At inclusion, an epidemiological and clinical questionnaire was completed. Sera were obtained and stored at -70 degrees C until analyzed. They were tested for Helicobacter pylori antibodies using a commercial ELISA kit.

RESULTS

Eleven out of 220 patients had borderline anti-Helicobacter pylori IgG titers. Of the remaining 209 patients, 105 (50.2%) showed positive titers of Helicobacter pylori IgG. Univariate analysis showed that Helicobacter pylori infection was more frequent in older patients, those born outside Catalonia, and in patients with a low educational level. Past ethanol consumption and current smoking correlated negatively with Helicobacter pylori infection. Multivariate analysis selected age (OR 3.1. 95% CI 1.46-6.45), educational level (OR 2.2. 95% CI 1.18-4.2) and alcohol consumption (OR 0.7. 95% CI 0.45-0.99) as the variables independently related to Helicobacter pylori infection.

CONCLUSIONS

Helicobacter pylori infection in cirrhosis has the same epidemiological pattern as in the general population. Suggestions that the etiology or the severity of the liver disease could be related to Helicobacter pylori infection were not confirmed by our study.

Helicobacter pylori infection in congestive gastropathy

BACKGROUND

This study determines the prevalence and significance of Helicobacter pylori infection in portal hypertensive patients.

MATERIALS AND METHODS

Patients numbered 118 and consisted of 90 patients with portal hypertension (66 men; 24 women; mean age, 49.1 +/- 2.1 years) and 28 noncirrhotic patients with nonulcer dyspepsia, (12 men; 16 women; mean age, 47.6 +/- 2.8 years), who made up the control group. In all patients, diagnostic upper endoscopy was performed, and gastric biopsies were taken for histological examination and diagnosis of H. pylori.

RESULTS

Of the portal hypertensive patients, 42 (47%) had congestive gastropathy, 11 (26%) of whom were positive for H. pylori, and 48 (53%) did not have gastropathy, 12 (25%) of whom were positive for H. pylori. In the control group, 15 of 28 (54%) were positive for H. pylori. H. Pylori was found less frequently in congestive gastropathy patients than in the control group. We found also that the presence and severity of congestive gastropathy is independent of H. pylori status.

CONCLUSIONS

We conclude that the role of H. pylori in the pathogenesis of congestive gastropathy is unlikely, and we suggest that there is no need for its routine eradication in cirrhotic patients.

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.

Portal hypertensive gastropathy in children with extrahepatic portal venous obstruction: role of variceal obliteration by endoscopic sclerotherapy and Helicobacter pylori infection

We aimed to determine the frequency of portal hypertensive gastropathy (PHG) in children with extrahepatic portal venous obstruction (EHPVO) and to find out the role of esophageal variceal obliteration by endoscopic injection sclerotherapy (EIS) and Helicobacter pylori (H. pylori) infection in the pathogenesis of PHG. Twenty consecutive children were studied before EIS and 20 after esophageal varices obliteration. Diagnosis of PHG was established by endoscopic assessment. Helicobacter pylori infection was diagnosed by rapid urease test, H. pylori culture, smear, and histopathologic examination of antral biopsy specimens. Portal hypertensive gastropathy was characterized and graded by endoscopy according to previously established criteria. In the pre-EIS group, eight (40%) had PHG (mild in all) compared with 16 (80%; mild in eight, severe in eight) in the post-EIS group (p < 0.05). Portal hypertensive gastropathy was more extensive in the post-EIS group. There was no significant difference between frequency of gastric varices and H. pylori infection in the pre-EIS and post-EIS groups. We conclude that PHG is common in children with EHPVO; its frequency, extent, and severity increase after esophageal variceal obliteration by EIS, and H. pylori infection does not play any role in its development.

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.

Nature of non-ulcer dyspepsia and related conditions

To date, the precise role of Helicobacter pylori in the pathogenesis of NUD remains uncertain. There is some evidence to suggest that the organism is implicated in specific subgroups (mostly the ulcer-like form), but it is not enough for any firm conclusions to be drawn as to the importance of the bacterium as a cause of dyspeptic symptoms or as to the efficacy of anti-infective regimens in the treatment of NUD. Large, well-designed prospective studies with a long-term follow-up are needed to establish which subgroups of dyspeptic patients may benefit most from eradication of H. pylori.

Peptic ulcer and its course in cirrhosis: an endoscopic and clinical prospective study

The epidemiological and clinical characteristics of peptic ulcer were studied in 324 of 368 consecutive patients with cirrhosis of the liver during a mean period of 1.2 (+/- 0.61) years. Peptic ulcer prevalence rates in patients with cirrhosis were as follows: point prevalence 11.7%, period prevalence 15.1%, and life-time prevalence 24.2%. The annual incidence rate observed in 140 patients with cirrhosis undergoing endoscopic follow up was 4.3%. Ulcers were asymptomatic in more than 70% of patients. The peptic ulcer complication rate at entry was 20% in the whole group and 40% in those who had not a previous diagnosis of peptic ulcer when admitted to the study. Peptic ulcer was more frequent among HBsAg+ cirrhotics (p = 0.05). Patients with more severely decompensated cirrhosis also had a higher frequency of asymptomatic ulcers (p = 0.04), gastric ulcers (p = 0.01) and asymptomatic gastric ulcers (p = 0.005). After diagnosis, during endoscopic follow up, gastric ulcer in patients with cirrhosis tended to heal slowly and recurred with higher frequency than in controls without cirrhosis (p = 0.04). Seventy-nine per cent of peptic ulcer recurrences were asymptomatic in patients with cirrhosis. There were no complications during the follow-up period: this could be due to the regular timing of endoscopy, which permitted early detection and treatment of the recurrences, thus preventing further complications.

Colonization by Helicobacter pylori and its relationship to histological changes in the gastric mucosa in portal hypertension

In order to investigate the relationship between Helicobacter pylori infection of the gastric mucosa and mucosal changes in portal hypertension, gastric fundic and antral biopsies were obtained from 66 patients with portal hypertension and 49 controls with non-ulcer dyspepsia (NUD). Gastric mucosa from portal hypertensive patients exhibited typical vascular dilatation and congestion, while mild dilatation of lamina propria blood vessels was not uncommon in NUD patients with histological evidence of gastritis. Colonization of the gastric mucosa by H. pylori infection was significantly less in portal hypertension (51.5%) compared to controls (75.5%; P < 0.01). The difference was more apparent in patients with marked vascular dilatation (18.8% colonization) compared to patients with minimal vascular dilatation (66.7%). H. pylori infection was significantly associated with active superficial gastritis (P < 0.001), and with atrophic gastritis (P < 0.001), in both study groups. H. pylori-negative superficial gastritis was significantly more common in portal hypertension (25/66 patients) than in controls (7/49; P < 0.05). H. pylori infection was not more common in patients who had undergone repeated sclerotherapy. The results suggest that the gastric mucosa of portal hypertension does not provide a hospitable environment for H. pylori colonization, particularly when mucosal congestion is marked. H. pylori infection does not add significantly to the gastropathy of portal hypertension.

Gastric secretion and peptic ulceration in cirrhosis

Stomach function and secretions are altered significantly in patients with cirrhosis, both with or without portal hypertension. This review covers the abnormalities of gastric acid and pepsin secretion, and gastrin release. Histological and endoscopic changes, and the impaired cytoprotection associated with cirrhosis, are discussed in the context of abnormal gastric secretion. In addition, the symptomatology and association of H. pylori, and treatment of duodenal ulceration in cirrhosis are discussed. It is clear from this review that additional studies are needed to further understand gastric function in cirrhotic patients.

Reduced gastric mucosal blood flow in patients with portal-hypertensive gastropathy

Although congestive gastric mucosal circulation has been suggested in patients with portal-hypertensive gastropathy, whether it is due to "active" (overflow) or "passive" (stasis) congestion is not known. To answer this question, we assessed regional gastric mucosal blood flow with laser Doppler flowmetry in 57 patients with portal hypertension and 30 controls. Twelve patients had portal-hypertensive gastropathy of the antrum: in eight it was mild and in four it was severe. Portal-hypertensive gastropathy of the corpus was seen in 32 patients: it was mild in 24 and severe in 8. Thus prevalence of portal-hypertensive gastropathy was higher in the corpus than in the antrum (p < 0.01). In the antrum, gastric mucosal blood flow was significantly lower (p < 0.05) in patients with severe portal-hypertensive gastropathy (0.54 +/- 0.27 V) than in controls (1.12 +/- 0.44 V), whereas the values in patients without portal-hypertensive gastropathy (0.90 +/- 0.35 V) and with mild portal-hypertensive gastropathy (0.91 +/- 0.31 V) were not significantly different from the values in controls (p < 0.05 on one-way analysis of variance). In the corpus, gastric mucosal blood flow was significantly lower in patients with mild (0.75 +/- 0.25 V) or severe portal-hypertensive gastropathy (0.42 +/- 0.22 V) than in controls (1.16 +/- 0.37 V) (p < 0.01 and p < 0.01, respectively) whereas the value in patients without portal-hypertensive gastropathy (0.99 +/- 0.37 V) was not significantly different from values in controls (p < 0.01 on one-way analysis of variance).(ABSTRACT TRUNCATED AT 250 WORDS)

Congestive jejunopathy in portal hypertension

Twenty six patients with portal hypertension of different aetiologies were studied for endoscopic evidence of congestive gastroduodenopathy and histological evidence of congestive gastropathy and jejunopathy. Per oral biopsies of jejunum were taken by Watson's capsule. Normal biopsy tissues obtained from the antrum (26), fundus (10), and jejunum (26) were used as controls. Endoscopy showed congestive changes in the fundus (17 cases), antrum (17), and duodenum (4). Duodenopathy correlated with changes in the antrum but not in the fundus. Histology showed an increase in the size and number of vessels in the jejunal villi ('congestive jejunopathy') in 22 patients. These correlated with histological evidence of gastropathy in the fundus but not in the antrum. The incidence of congestive jejunopathy did not correlate with the Child-Pugh score in patients with cirrhosis or with the number of sclerotherapy sessions received. Congestive jejunopathy is part of the spectrum of congestive gastroenteropathy and occurs at least as frequently as changes in the stomach and duodenum. The clinical import of these jejunal changes remains to be explained.