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

Changing trends and characteristics of peptic ulcer disease: A multicenter study from 2010 to 2019 in Korea

BACKGROUND

The clinical trend and characteristics of peptic ulcer disease (PUD) have not fully been investigated in the past decade.

AIM

To evaluate the changing trends and characteristics of PUD according to age and etiology.

METHODS

We analyzed seven hospital databases converted into the Observational Medical Outcomes Partnership-Common Data Model between 2010 and 2019. We classified patients with PUD who underwent rapid urease tests or Helicobacter pylori (H. pylori) serology into three groups: H. pylori-related, drug [nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin]-related, and idiopathic (H. pylori/NSAID/aspirin-negative) PUD and compared the yearly trends and characteristics among the three groups.

RESULTS

We included 26785 patients in 7 databases, and the proportion of old age (≥ 65 years) was 38.8%. The overall number of PUD exhibited no decrease, whereas PUD in old age revealed an increasing trend (P = 0.01 for trend). Of the 19601 patients, 41.8% had H. pylori-related, 36.1% had drug-related, and 22.1% had idiopathic PUD. H. pylori-related PUD exhibited a decreasing trend after 2014 (P = 0.01), drug-related PUD demonstrated an increasing trend (P = 0.04), and idiopathic PUD showed an increasing trend in the old-age group (P = 0.01) during 10 years. Patients with drug-related PUD had significantly more comorbidities and concomitant ulcerogenic drugs. The idiopathic PUD group had a significantly higher number of patients with chronic liver disease.

CONCLUSION

With the aging population increase, the effects of concomitant ulcerogenic drugs and preventive strategies should be investigated in drug-induced PUD. Further studies are required to clarify the relationship between idiopathic PUD and chronic liver disease.

Helicobacter pylori Infection in Cirrhotic Patients With Portal Hypertensive Gastropathy: A New Enigma?

The relationship between Helicobacter pylori (H. pylori) infection and Portal hypertensive gastropathy (PHG) is still a debatable matter. The aim of this study is to find out how common H. pylori infection is in cirrhotic patients with PHG and to see if there’s a link between H. pylori infection and PHG severity. Out of 340 cirrhotic patients who had upper Gastrointestinal Tract (GIT) endoscopy for early varices screening, 160 cirrhotic patients were selected and divided into 2 groups; 80 cirrhotic patients with PHG (cases) and 80 cirrhotic patients without PHG (controls). Gastric biopsies were taken from all enrolled patients for histological evaluation for the presence or absence of H. pylori infection. H. pylori was found in 44 cirrhotic patients (55%) who had PHG (cases), compared to 22 cirrhotic patients (27.5%) who did not have PHG (controls). The prevalence of H. pylori infection was significantly higher in patients with PHG (p < 0.001). The severity of PHG was associated with H. pylori infection (p < 0.001). The response to eradication therapy of H. pylori infection was must better in patients without PHG (p = 0.045). By multi-variant analysis, H. pylori infection, splenic diameter, and portal vein diameter were independent predictors for PHG presence. After treating H. pylori infection in patients who tested positive for H. pylori, there was a significant reduction in PHG severity (p < 0.001). Patients with PHG have a greater prevalence of H. pylori infection. PHG is more severe in patients infected with H. pylori. To improve PHG severity, cirrhotic patients must have their H. pylori infection eradicated.

Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review

BACKGROUND

Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.

AIM

To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.

METHODS

Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.

RESULTS

Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.

CONCLUSION

Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

Association of Helicobacter Pylori With Development of Peptic Ulcer Disease Among Cirrhotic Patients: An Evidence From Population-Based Study

BACKGROUND

 Helicobacter pylori (H. pylori) plays an important role in causing peptic ulcer disease (PUD) in the general population. However, the role of H. pylori in cirrhotic patients for causing PUD is obscure. There are various studies evaluating H. pylori association with PUD in cirrhotic patients, but the results have been controversial. We sought to analyze the association of H. pylori with the development of PUD in cirrhotic patients from the largest United States population-based database.

METHODS

 We analyzed Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) data from 2017. Adult hospitalizations due to cirrhosis were identified by previously validated ICD-10-CM codes. PUD and H. pylori were identified with the presence of ICD-10-CM codes in primary and secondary diagnosis fields, respectively. We performed weighted analyses using Chi-Square and paired Student's t-test to compare the groups. Multivariable survey logistic regression was performed to find an association of H. pylori with PUD in cirrhotic patients.

RESULTS

 Our study showed that the prevalence of H. pylori infection was 2.2% in cirrhotic patients with PUD. In regression analysis, H. pylori was found to be associated with PUD in cirrhotic patients (OR 15.1; 95% CI: 13.9-16.4; p <0.001) and non-cirrhotic patients (OR 48.8; 95% CI: 47.5-50.1; p <0.001). In the studied population, H. pylori was more commonly seen in the age between 50 and 64 years (49.4% vs 44.1%; p <0.0001), male (63.4% vs 59.9%; p <0.0413), African American (16.3% vs 10.6%; p <0.0001), and Hispanic (26.2% vs 14.9%; p <0.0001). H. pylori is more likely to be associated with complicated PUD hospitalizations (51.2% vs 44.2%; p <0.0067). Alcoholism and smoking were more common in H. pylori group compared to those without (43.6% vs 35.8%; p <0.0001 and 33.7% vs 24.8% p <0.0001, respectively). Factors associated with increased odds of H. pylori infection include African American (OR 2.3, 95% CI: 1.5-3.6), Hispanic (OR 2.6, 95% CI: 1.7-4.0), and smoking (OR 1.5, 95% CI: 1.1-2.2).

CONCLUSION

 H. pylori are associated with PUD and concurrent cirrhosis, although it is less prevalent than general population. African American, Hispanic, and smoking were independently associated with increased odds of H. pylori infection. Further studies are required to better understand the epidemiology and confirm our findings.

Helicobacter pylori infection and peptic ulcer disease in cirrhotic patients: An updated meta-analysis

BACKGROUND

Peptic ulcer (PU) is more prevalent in patients with liver cirrhosis. The role of Helicobacter pylori (H. pylori) infection in the pathogenesis of PU in patients with cirrhosis is still not elucidated.

AIM

To perform a meta-analysis on the prevalence of H. pylori infection and PU and their association in liver cirrhosis patients.

METHODS

We searched PubMed, EMBASE, Web of Science, Cochrane, CNKI, Wangfang, and CQVIP databases from inception to July 10, 2020. Odds ratio (OR) and 95% confidence interval (CI) were pooled using a random-effects model. The statistical heterogeneity among studies (I²-index), subgroup analyses, regression analysis, sensitivity analysis, and the possibility of publication bias were assessed.

RESULTS

A total of 14 studies (13 cross-sectional studies; 1 cohort study) involving 2775 individuals (611 cases with PU and 2164 controls) were included in our meta-analysis. The prevalence of PU in patients with cirrhosis was 22%. The prevalence of H. pylori infection was 65.6% in cirrhotic patients with PU, and 52.5% in those without. The pooled overall OR was 1.73 (95%CI: 1.16-2.56, I² = 66.2%, P < 0.001, Z = 2.7, P_z < 0.05). We did not find the cause of heterogeneity in the subgroup analyses and meta-regression analysis except for one study. Funnel plot did not show significant publication bias. The results of Begg’s test and Egger’s test indicated no evidence of substantial publication bias (P_Begg = 0.732, P_Egger = 0.557).

CONCLUSION

There is a weakly positive association between H. pylori infection and PU in patients with liver cirrhosis. It is suggested that H. pylori infection may play a role in the pathogenesis of PU in liver cirrhotic patients.

Endoscopic findings unrelated to portal hypertension in patients with liver cirrhosis undergoing a varicose vein screening programme

AIM

To determine the prevalence of endoscopic lesions unrelated with portal hypertension in patients with cirrhosis.

PATIENTS AND METHODS

Cross-sectional study including a consecutive cohort of patients with liver cirrhosis enrolled in a screening program of oesophageal varices who underwent an upper gastrointestinal endoscopy from November, 2013, to November, 2018. Clinical predictors of endoscopic lesions unrelated to portal hypertension were analyzed by univariate and multivariate logistic regression.

RESULTS

A total of 379 patients were included. The most frequent aetiology of liver disease was alcohol consumption (60.4%). The prevalence of endoscopic lesions unrelated with portal hypertension was 39.6% (n=150). Among 96 patients with peptic lesions, urease was obtained in 56.2% of patients (positive in 44.4% of them). The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. The prevalence of endoscopic lesions unrelated to portal hypertension was not associated with age, gender, liver function or ultrasound findings of portal hypertension. Smokers had a trend to increased prevalence of endoscopic lesions unrelated to portal hypertension (43.2% vs. 34.6%; p=0.09), particularly peptic ulcer (6.4% vs. 0.6%; p=0.05) and peptic duodenitis (17.3% vs. 6.3%; p=0.002). Active smoking was the only independent predictor of peptic ulcer or duodenitis (OR=2.56; p=0.017).

CONCLUSION

Active smoking is a risk factor for endoscopic lesions unrelated to portal hypertension. This finding should be further investigated to reassess endoscopic screening programs in cirrhotic smokers.

Gastroduodenal lesions in upper gastrointestinal endoscopy associated with positive Helicobacter pylori histology in cirrhotic patients at Sikasso Hospital: prevalence study

The presence of Helicobacter pylori is a major contributor to the genesis of peptic ulcer disease, although its role in the pathogenesis of ulcer in cirrhotic patients is yet to be well established. The aim of this work is to determine the prevalence of gastroduodenal lesions associated with histologically confirmed Helicobacter pylori in cirrhotic patients. This was a retrospective study which was conducted from January 2017 to May 2018 at Sikasso Hospital. The inclusion criteria were: presence of cirrhosis, endoscopic gastroduodenal lesions for which histological confirmation of the presence of Helicobacter pylori biopsies was made. The collected data was analyzed by Epi Info software version 7.0. Thirty four patients have been included, the mean age was 38 ± 17 years and a male/female sex ratio of 2.09. Gastrointestinal symptoms included epigastralgia (26.47%), nausea (8.82%), early postprandial vomiting (5.88%) and hematemesis (8.82%). Esophagogastroduodenoscopy revealed esophageal varices in 47%, which 1 case of esophageal varices grade III with red signs, 5.88% grade II with red signs, 8.82% grade I without red signs. A case of portal hypertension gastropathy was noted in 12 patients and gastroduodenal lesions in 33%. Anatomopathological examination of the biopsies revealed Helicobacter pylori in 57%, active chronic gastritis in 44.11% and chronic gastritis with intestinal metaplasia in 2.94% of cases. This study reveals a fairly high frequency of Helicobacter pylori in digestive lesions observed in cirrhotic patients. Helicobacter pylori infection in cirrhotic patients requires urgent therapeutic management to prevent the possible hemorrhagic complications.

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.

Impact of Helicobacter pylori Infection on Gastric Variceal Bleeding among Patients with Liver Cirrhosis

BACKGROUND AND AIMS

Currently, it is well known that Helicobacter pylori- (H. pylori-) related peptic ulcer is one of the main causes of nonvariceal bleeding in cirrhotic patients. However, there is a lack of data to identify the exact effect of H. pylori infection on variceal bleeding. This study was conducted to identify the impact of H. pylori infection on gastric variceal bleeding in cirrhotic patients.

PATIENTS AND METHODS

76 cirrhotic patients with gastric varices were included in this prospective study and divided into 2 groups: nonbleeding gastric varices (32 patients) and bleeding gastric varices (44 patients). The fasting serum gastrin level was measured. Mucosal biopsies from the gastric body and antrum were examined to determine the patterns of gastritis and the presence of H. pylori.

RESULTS

The frequency of H. pylori infection in the studied patients was 59.2%. There were significant differences between both groups regarding liver decompensation (P = 0.001), red color sign over gastric varices (P = 0.0011), prevalence of H. pylori infection (P = 0.0049), histological patterns of gastritis (P = 0.0069), and serum gastrin level (P = 0.0200). By multivariate analysis, Child C cirrhosis, red color sign over gastric varices, and H. pylori-induced follicular gastritis were independent risk factors for bleeding from gastric varices.

CONCLUSION

H. pylori-induced follicular gastritis is considered as an additional risk factor for bleeding from gastric varices.

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Helicobacter pylori: Effect of coexisting diseases and update on treatment regimens

The presence of concomitant diseases is an independent predictive factor for non-Helicobacter pylori (H. pylori) peptic ulcers. Patients contracting concomitant diseases have an increased risk of developing ulcer disease through pathogenic mechanisms distinct from those of H. pylori infections. Factors other than H. pylori seem critical in peptic ulcer recurrence in end stage renal disease (ESRD) and cirrhotic patients. However, early H. pylori eradication is associated with a reduced risk of recurrent complicated peptic ulcers in patients with ESRD and liver cirrhosis. Resistances to triple therapy are currently detected using culture-based and molecular methods. Culture susceptibility testing before first- or second-line therapy is unadvisable. Using highly effective empiric first-line and rescue regimens can yield acceptable results. Sequential therapy has been included in a recent consensus report as a valid first-line option for eradicating H. pylori in geographic regions with high clarithromycin resistance. Two novel eradication regimens, namely concomitant and hybrid therapy, have proven more effective in patients with dual- (clarithromycin- and metronidazole-) resistant H. pylori strains. We aim to review the prevalence of and eradication therapy for H. pylori infection in patients with ESRD and cirrhosis. Moreover, we summarized the updated H. pylori eradication regimens.

Dysregulated iron homeostasis is strongly associated with multiorgan failure and early mortality in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is an ailment with high incidence of multiorgan failure (MOF) and consequent mortality. Dysregulated iron homeostasis and macrophage dysfunction are linked to increased incidence of MOF. We investigated whether a panel of circulating iron-regulating proteins are associated with development of MOF and can predict 15- or 30-day mortality in ACLF patients. One hundred twenty patients with ACLF, 20 patients with compensated cirrhosis, and 20 healthy controls were studied. Relative protein expression profiling was performed in the derivative cohort and confirmed in the validation cohort. A panel of iron regulators and indices were determined. Multiparametric flow cytometry for quantitation of labile iron pool (LIP) was performed. Validation studies confirmed lower serum transferrin (Tf) and ceruloplasmin levels in ACLF and ACLF-MOF, compared to patients with cirrhosis and controls (P < 0.01). Serum iron and ferritin levels were markedly elevated (P < 0.001; P < 0.05) and hepcidin levels were lower (P < 0.001) in ACLF patients with MOF than those without and other groups (P < 0.001). Percentage Tf saturation (%SAT) was higher in ACLF-MOF (39.2%; P < 0.001) and correlated with poor outcome (hazard ratio: 6.970; P < 0.01). Intracellular LIP indices were significantly elevated in the subsets of circulating macrophages in ACLF-MOF, compared to other groups (P < 0.01). Whereas expression of iron-regulatory genes was markedly down-regulated, genes related to endoplasmic reticulum stress, apoptosis, and inflammation were up-regulated in ACLF patients, compared to patients with cirrhosis. Severe dysregulation of autophagy mechanisms was also observed in the former.

CONCLUSIONS

Iron metabolism and transport are severely deranged in ACLF patients and more so in those with MOF. %SAT, circulating hepcidin, and LIP in macrophages correlate with disease severity and %SAT could be used for early prognostication in ACLF patients.

Association between cirrhosis and Helicobacter pylori infection: a meta-analysis

Cirrhosis is a severe threat to public health. Some studies have suggested that cirrhosis is associated with Helicobacter pylori infection, but the results remain controversial. This meta-analysis was conducted to quantify the association between cirrhosis and H. pylori infection. Published articles on H. pylori prevalence in patients with cirrhosis were collected to assess the potential associations between H. pylori infection and cirrhosis risk. Twenty-one eligible studies were included for the analysis. Data on publication year, geographic region, and etiology were summarized. Metaregression models and subgroup analyses were established to screen the factors for heterogeneity. Of the 322 articles retrieved, 21 met the inclusion criteria. These studies involved 6135 cases, with a total H. pylori infection rate of 52.26%. This meta-analysis showed significant difference in H. pylori infection between patients with cirrhosis and controls [odd ratio (OR)=2.05, 95% confidence interval (CI): 1.33-3.18, P<0.0001]. The subgroup analysis revealed, in contrast to Asia (OR=0.90, 95% CI: 0.48-1.66, P<0.0001), Europe (OR=2.98, 95% CI: 2.02-4.39, P<0.0001), and America (OR=4.75, 95% CI: 1.42-15.95, P=0.249), a significantly higher prevalence of H. pylori infection in patients with cirrhosis. On the basis of etiology, there was a higher prevalence of H. pylori infection due to primary biliary cirrhosis (OR=1.75, 95% CI: 1.15-2.64, P=0.147) and viral cirrhosis (OR=2.66, 95% CI: 1.24-5.71, P<0.0001) compared with alcohol cirrhosis (OR=0.77, 95% CI: 0.04-16.59, P<0.0001). The pooled data suggest that there is a significantly high prevalence of H. pylori infection in patients with cirrhosis. Large-scale and multicenter studies are needed to further investigate the relation between cirrhosis and H. pylori infection.

Peptic ulcer disease in liver cirrhosis and chronic hepatitis: impact of portal hypertension

OBJECTIVE

The pathophysiology of peptic ulcer disease (PUD) in liver cirrhosis (LC) and chronic hepatitis has not been established. The aim of this study was to assess the role of portal hypertension from PUD in patients with LC and chronic hepatitis.

MATERIALS AND METHODS

We analyzed the medical records of 455 hepatic vein pressure gradient (HVPG) and esophagogastroduodenoscopy patients who had LC or chronic hepatitis in a single tertiary hospital. The association of PUD with LC and chronic hepatitis was assessed by univariate and multivariate analysis.

RESULTS

A total of 72 PUD cases were detected. PUD was associated with LC more than with chronic hepatitis (odds ratio [OR]: 4.13, p = 0.03). In the univariate analysis, taking an ulcerogenic medication was associated with PUD in patients with LC (OR: 4.34, p = 0.04) and smoking was associated with PUD in patients with chronic hepatitis (OR: 3.61, p = 0.04). In the multivariate analysis, taking an ulcerogenic medication was associated with PUD in patients with LC (OR: 2.93, p = 0.04). However, HVPG was not related to PUD in patients with LC or chronic hepatitis.

CONCLUSION

According to the present study, patients with LC have a higher risk of PUD than those with chronic hepatitis. The risk factor was taking ulcerogenic medication. However, HVPG reflecting portal hypertension was not associated with PUD in LC or chronic hepatitis (Clinicaltrial number NCT01944878).

H. pylori eradication lower ulcers in cirrhosis. [Corrected]

OBIECTIVE

The study aimed to investigate whether early Helicobacter pylori (H. pylori) eradication therapy in cirrhotic patients caused a dramatic reduction of recurrent peptic ulcers compared with those treated with a late eradication.

METHODS

We identified cirrhotic patients using the International Classifications of Diseases, Revision 9 (ICD-9-CM). Decompensated cirrhotic patients can apply for a catastrophic illness card and were identified via the ICD-9-CM codes 571.2, 571.5 and 571.6. Compensated cirrhotic patients were identified via the ICD-9-CM codes 571.2, 571.5 and 571.6, after excluded decompensated cirrhotic patients. We categorized patients into early (time lag ≤365 days after peptic ulcer diagnosis) and late (time lag >365 days) H. pylori eradication therapy groups. The end-point was the occurrence of recurrent peptic ulcers. Cox proportional hazards model was used to calculate the hazard ratios (HRs).

RESULTS

Altogether, 154 cirrhotic patients were included in the early H. pylori eradication group and 103 in the late H. pylori eradication group. Cirrhotic patients had a higher risk of recurrent peptic ulcers in the late H. pylori eradication group (HR 1.58, 95% CI 1.09-2.28, P = 0.015). However, the risk of recurrent peptic ulcers in alcoholic cirrhotic patients in both groups (HR 1.47, 95% CI 0.77-2.83, P = 0.247) was similar.

CONCLUSIONS

Early H. pylori eradication is associated with a lower risk of recurrent peptic ulcers in cirrhotic patients. H. pylori eradication is the mainstay for treating cirrhotic patients who have contracted peptic ulcers.

Management of portal hypertensive gastropathy and other bleeding

A major cause of cirrhosis related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Less common causes of gastrointestinal bleeding are peptic ulcers, malignancy, angiodysplasia, etc. Upper gastrointestinal bleeding has been classified according to the presence of a variceal or non-variceal bleeding. Although non-variceal gastrointestinal bleeding is not common in cirrhotic patients, gastroduodenal ulcers may develop as often as non-cirrhotic patients. Ulcers in cirrhotic patients may be more severe and less frequently associated with chronic intake of non-steroidal anti-inflammatory drugs, and may require more frequently endoscopic treatment. Portal hypertensive gastropathy (PHG) refers to changes in the mucosa of the stomach in patients with portal hypertension. Patients with portal hypertension may experience bleeding from the stomach, and pharmacologic or radiologic interventional procedure may be useful in preventing re-bleeding from PHG. Gastric antral vascular ectasia (GAVE) seems to be different disease entity from PHG, and endoscopic ablation can be the first-line treatment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

AIM

To review NVGI bleeding in cirrhosis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence of Helicobacter pylori and occurrence of gastroduodenal lesions in patients with liver cirrhosis

BACKGROUND/AIMS

The role of H. pylori in the pathogenesis of ulcer disease in cirrhotic patients is poorly defined. Therefore, we sought to investigate the prevalence of H. pylori infection and the occurrence of gastroduode-nal lesions in patients with liver cirrhosis.

METHODS AND PATIENTS

Seroprevalence of H. pylori was tested in 110 patients with liver cirrhosis and 44 asymptomatic patients with chronic hepatitis without cirrhosis using an anti-H. pylori-IgG-ELISA. Cirrhotic patients underwent upper intestinal endoscopy for macroscopic and histological evaluation of gastric mucosa, and for the detection of mucosal colonisation of H. pylori using Giemsa staining and urease test.

RESULTS

There was no significant difference between the H. pylori seroprevalence in patients with liver cirrhosis (76/110; 69%) and patients with chronic viral hepatitis (27/44, 63%, p=0.465). Gastric mucosal colonization with H. pylori in cirrhotic patients was significantly lower than the serologically determined H. pylori prevalence (45% vs. 69%, p=0.001). Etiology of liver cirrhosis did not influence the prevalence of H. pylori infection. 8 of 110 cirrhotic patients had gastric ulcers and 10 had duodenal ulcers. 61% of cirrhotic patients with peptic ulcers were asymptomatic. H. pylori was histologically identified in 61% of gastroduodenal ulcers, and 47% of gastroduodenal erosions.

CONCLUSIONS

Patients with liver cirrhosis have a high prevalence of gastroduodenal ulcers. The lack of a firm association between H. pylori prevalence and ulcer frequency in cirrhotic patients argues against a pivotal role of H. pylori in the etiology of ulcers in cirrhotic patients.

[Guidelines of treatment for peptic ulcer disease in special conditions]

The pathogenesis, incidence, complication rates, response to acid suppression and Helicobacter pylori (H. pylori) eradication therapy in peptic ulcer associated with chronic disease such as liver cirrhosis, chronic renal failure, diabetes mellitus, and critically ill conditions are different from those with general population, so that the management strategies also should be differentiated. The eradication of H. pylori are not so effective for preventing recurrence of peptic ulcer in liver cirrhosis patients as shown in general population, and conservative managements such as preventing deterioration of hepatic function and decrease in portal pressure are mandatory to reduce the risk of ulcer recurrence. The standard triple therapy for H. pylori eradication are as effective in chronic renal failure patients as in normal population, but the frequency of side effects of amoxicillin is higher in the patients not receiving dialysis therapy. Delay in eradication therapy until beginning of dialysis therapy or modification of eradication regimen should be considered in such cases. High prevalence of asymptomatic peptic ulcers and increased mortality in complicated peptic ulcer disease warrant regular endoscopic surveillance in diabetic patients, especially with angiopathy. The prolongation of duration of eradication therapy also should be considered in diabetic patients with angiopathic complication because of lower eradication rate with standard triple regimens as compared to normal population. Prophylactic acid suppressive therapy is highly recommended in critically ill patients with multiple risk factors. Herein, we propose evidence-based treatment guidelines for the management of peptic ulcer disease in special conditions based on literature review and experts opinion.