European Registry on Helicobacter pylori management (Hp-EuReg): patterns and trends in first-line empirical eradication prescription and outcomes of 5 years and 21 533 patients

OBJECTIVE

The best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.

DESIGN

International multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed.

RESULTS

30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%-90%).

CONCLUSION

Management of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.

Helicobacter pylori and Nonmalignant Diseases

Helicobacter pylori is responsible for most peptic ulcers, plays a role in functional dyspepsia and is thought by some to influence the course of gastroesophageal reflux disease. This article addresses recent studies that have been published in connection with these diseases. H. pylori-associated peptic ulcer is declining in prevalence but the incidence of perforation and bleeding remains high especially in the elderly. All H. pylori associated peptic ulcers should be treated by eradication of the infection. Dyspepsia is a common disorder that affects up to 25% of the population. About 8% of cases that are infected with H. pylori will respond to treatment of the infection. The association between H. pylori and gastroesophageal reflux disease continues to be debated, a number of studies have shown that there is a negative association between H. pylori infection and Gastroesophageal reflux disease but treatment of H. pylori has not been shown to induce reflux or to affect the response to medication. Gastric atrophy is known to extend when acid suppression is used in infected patients implying that H. pylori treatment should be used in infected patients who are to undergo long-term Proton Pump Inhibitor therapy.

The natural history of gastro-oesophageal reflux symptoms in the community and its effects on survival: a longitudinal 10-year follow-up study

BACKGROUND

Gastro-oesophageal reflux symptoms (GERS) are common in the community. However, few studies have examined their long-term natural history, or impact on survival.

AIM

To examine these issues in individuals recruited into a community-based screening programme for Helicobacter pylori in 1994.

METHODS

Data on mortality and cause of death at 10 years were obtained from the Office for National Statistics. Baseline demographic data, lifestyle factors, gastrointestinal symptoms and quality of life were recorded at study entry. The effect of all these factors on persistent and new-onset GERS, and 10-year mortality, were examined using univariate and multivariate analysis, with results expressed as odds ratios (ORs) or hazard ratios (HR) with 99% confidence intervals (CI).

RESULTS

Of 3967 individuals providing complete GERS data at baseline and 10 years, 549 (13.8%) had GERS at baseline. Of these, 183 (33.3%) had persistent symptoms. Among 3418 individuals asymptomatic at baseline, approximately 0.8% per year developed new-onset GERS. No predictors of persistent GERS were identified. New-onset symptoms were associated with lower quality of life or presence of irritable bowel syndrome (IBS) at baseline, and higher body mass index (BMI) at 10 years. There were 8331 (99.1%) of 8407 subjects providing complete GERS data at baseline, 1289 (15.5%) of whom were symptomatic. Presence of GERS at baseline did not affect survival (HR: 0.84; 99% CI: 0.44-1.59).

CONCLUSIONS

Gastro-oesophageal reflux symptoms persisted in one-third of individuals, whilst new-onset gastro-oesophageal reflux symptoms were associated with poor quality of life, irritable bowel syndrome and higher body mass index. Gastro-oesophageal reflux symptoms did not impact adversely on survival.

Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report

Management of Helicobacter pylori infection is evolving and in this 4th edition of the Maastricht consensus report aspects related to the clinical role of H pylori were looked at again in 2010. In the 4th Maastricht/Florence Consensus Conference 44 experts from 24 countries took active part and examined key clinical aspects in three subdivided workshops: (1) Indications and contraindications for diagnosis and treatment, focusing on dyspepsia, non-steroidal anti-inflammatory drugs or aspirin use, gastro-oesophageal reflux disease and extraintestinal manifestations of the infection. (2) Diagnostic tests and treatment of infection. (3) Prevention of gastric cancer and other complications. The results of the individual workshops were submitted to a final consensus voting to all participants. Recommendations are provided on the basis of the best current evidence and plausibility to guide doctors involved in the management of this infection associated with various clinical conditions.

Review article: methods of measuring gastric acid secretion

BACKGROUND

Gastric acid has an important pathophysiological role in human beings. Numerous methods have been evaluated over the years in an attempt to measure gastric acid and stomach acidity, to study the role of gastric acid in gastrointestinal diseases in humans and to evaluate the effects of acid suppressing drugs.

AIM

To review methods that have been used to measure gastric acid and gastric acidity.

METHODS

Searches of the electronic databases PUBMED, MEDLINE and EMBASE, were performed with articles restricted to English language and human subjects. References were also identified from the bibliographies of selected articles.

RESULTS

Methods for measuring gastric acid include both invasive and non-invasive techniques. Invasive tests include the conventional gastric acid aspiration tests, gastric pH measurement techniques and endoscopic methods. Non-invasive methods use urinary analysis, breath analysis, serum pepsinogens assay, scintigraphic techniques, impedence tomography and alkaline tide for measurement of gastric acid.

CONCLUSIONS

Several methods of measuring gastric acid exist. Invasive tube tests are uncomfortable and time consuming, whereas most of the non-invasive methods are at best semiquantitative and useful in detecting low or absent acid secretion. Further attempts to explore new methods for measuring gastric acid are therefore warranted.

Epidemiology of Helicobacter pylori infection and public health implications

This article summarizes the published literature concerning the epidemiology and public health implications of Helicobacter pylori infection published from April 2009 through March 2010. Prevalence of infection varied between 7 and 87% and was lower in European studies. All retrieved studies examining transmission of infection concluded that spread is from person-to-person. One study collecting stool and vomitus samples from patients with acute gastroenteritis detected H. pylori DNA in 88% of vomitus and 74% of stool samples. Proposed risk factors for infection included male gender, increasing age, shorter height, tobacco use, lower socioeconomic status, obesity, and lower educational status of the parents in studies conducted among children. Decision analysis models suggest preventing acquisition of H. pylori, via vaccination in childhood, could be cost-effective and may reduce incidence of gastric cancer by over 40%. As yet, no country has adopted public health measures to treat infected individuals or prevent infection in populations at risk.

Throat spray, sedation or anaesthetic?

Digestive endoscopy covers a wide variety of procedures; the need for sedation is governed by the invasiveness and length of the procedure, the wishes of the patient, the desire of the operator for a compliant patient, and safety. Many patients are prepared to undergo upper digestive endoscopy using throat spray without sedation, while fewer accept unsedated colonoscopy. There are clinical advantages as well as disadvantages in employing sedation and sometimes general anaesthesia is the preferred option. This paper provides an introduction to the choices available and the approaches that are employed in endoscopic sedation practice.

Sedation in digestive endoscopy: the Athens international position statements

BACKGROUND

Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field.

AIM

To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy.

METHODS

Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll.

RESULTS

The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures.

CONCLUSIONS

While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Fluctuation of gastrointestinal symptoms in the community: a 10-year longitudinal follow-up study

BACKGROUND

There are few studies examining the stability of gastrointestinal symptoms during prolonged periods of follow-up.

AIM

To examine this issue in individuals previously recruited into a community screening programme for Helicobacter pylori providing symptom data at study entry.

METHODS

All traceable participants were sent dyspepsia and IBS questionnaires by post at 10 years. Symptom subgroups were assigned at baseline and 10-year follow-up. Individuals symptomatic at both time points who changed subgroup were compared with those symptomatic and remaining in the same subgroup.

RESULTS

Three-thousand eight hundred and nineteen individuals provided data. At baseline, 2417 (63%) were asymptomatic or did not meet diagnostic criteria for a subgroup. Of these, 1648 (68%) remained asymptomatic at 10 years, whilst 769 (32%) reported symptoms. Of the 1402 individuals symptomatic at baseline, 404 (29%) remained in the same subgroup at 10 years, 603 (43%) changed subgroup and symptoms resolved or did not meet criteria for a subgroup in 395 (28%). Symptom stability was more likely in males [odds ratio (OR): 1.50; 99% confidence interval (CI): 0.97-2.31] and older subjects (OR per year: 1.09; 99% CI: 1.01-1.17).

CONCLUSION

Of those subjects symptomatic at baseline, almost three-quarters remained symptomatic at 10 years, but over 40% changed symptom subgroup.

Irritable bowel syndrome: a 10-yr natural history of symptoms and factors that influence consultation behavior

OBJECTIVE

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. The natural history of the condition has been studied extensively, but few studies have examined factors that predict its new onset or health care-seeking behavior.

METHODS

Individuals, now aged 50-59 yr, originally enrolled in a population-screening program for Helicobacter pylori (H. pylori) were contacted via postal questionnaire, utilizing the Manning criteria for IBS diagnosis. Baseline demographic data, quality of life, and IBS and dyspepsia symptom data were already on file. Consent to examine primary care records was sought, and data regarding IBS- and dyspepsia-related consultations were extracted.

RESULTS

Of 8,407 individuals originally involved, 3,873 (46%) provided symptom data at baseline and 10-yr follow-up. Of 3,659 individuals without IBS at baseline, 542 (15%) developed new-onset IBS at 10-yr follow-up. After multivariate logistic regression, lower quality of life at baseline (odds ratio [OR] 4.41, 99% confidence interval [CI] 2.92-6.65), dyspepsia at baseline (OR 1.77, 99% CI 1.28-2.46), and female gender (OR 2.14, 99% CI 1.56-2.94) were significant risk factors for new-onset IBS. Of 651 individuals with IBS at either baseline or 10-yr follow-up, 113 (17%) consulted a primary care physician with symptoms. H. pylori infection (OR 1.93, 99% CI 1.03-3.62) and any dyspepsia-related consultation (OR 2.14, 99% CI 1.15-4.00) significantly increased the likelihood of consultation.

CONCLUSIONS

Poor quality of life at baseline was a strong predictor of new-onset IBS, but not of IBS-related consultation behavior, which was associated with consultation for dyspepsia during the study period.

Mycophenolate mofetil therapy for refractory inflammatory bowel disease

BACKGROUND

Mycophenolate mofetil (MMF) is an immunomodulatory drug, and its use in inflammatory bowel disease has previously been reported. The aim of this study was to review the Leeds Colitis Clinic experience of the safety and efficacy of MMF in treating patients with refractory Crohn's disease (CD) and ulcerative colitis (UC). This is an extension of a previously published study from our center with a longer follow-up period and approximately twice the number of patients.

METHODS

A retrospective analysis was performed of the records of all patients treated with MMF for inflammatory bowel disease over a 5-year period.

RESULTS

Of 70 patients identified, 67 had previously been treated with azathioprine unsuccessfully. Seventeen of the 70 patients had been successfully maintained in remission with MMF for an average duration of 33 months. Treatment with MMF was discontinued for 53 patients, 17 because of side effects and 36 because they had not responded to the treatment.

CONCLUSIONS

In our series, 17 patients (24.3%) had a sustained steroid-free remission with MMF therapy. Nineteen patients (27%) experienced side effects, of which 17 (24.3% of the total group) had to discontinue therapy. An additional 36 (51.4%) required an escalation in medical therapy or surgery because of failure of the MMF therapy. MMF may have a role in the treatment of refractory inflammatory bowel disease, especially in patients who have previously failed standard therapies such as azathioprine.

Clinical trial: knowledge of negative Helicobacter pylori status reduces subsequent dyspepsia-related resource use

BACKGROUND

Screening for Helicobacter pylori reduces dyspepsia and dyspepsia-related costs in positive individuals.

AIMS

To assess effect of knowledge of H. pylori status on healthcare-seeking in negative individuals.

METHODS

H. pylori-negative subjects in a community screening programme were randomized to placebo triple therapy or informed of their negative H. pylori status. Dyspepsia-related resource data were extracted from primary care records at 2 years, and National Health Service reference costs were applied to calculate the total cost per subject. Proportions of individuals incurring any cost were compared using a relative risk (RR) and 95% confidence interval (CI). Differences in costs were compared using an independent sample t-test.

RESULTS

A total of 1353 H. pylori-negative individuals were randomized to placebo whilst 1355 were informed of their infection status. In the placebo arm, 212 (16%) subsequently incurred any dyspepsia-related cost compared to 172 (13%) informed of their infection status (RR of incurring cost = 0.81; 95% CI: 0.67-0.97). Those informed of their infection status incurred lower costs (mean saving per individual = pound 11.02; 95% CI: - pound 3.52 to 25.56).

CONCLUSIONS

H. pylori-negative individuals informed of infection status sought health care for dyspepsia less often than those who were unaware. Population screening may reduce dyspepsia-related costs in uninfected, as well as infected individuals.

Effect of sibling number in the household and birth order on prevalence of Helicobacter pylori: a cross-sectional study

BACKGROUND

Infection with Helicobacter pylori (H. pylori) is acquired mainly in childhood, with studies demonstrating this is related to living conditions. Effects of sibling number and birth order on prevalence of infection have not been extensively studied.

METHODS

The authors performed a cross-sectional survey of adults, aged between 50 and 59 years, previously involved in a community-screening programme for H. pylori in Leeds and Bradford, UK. Prevalence of H. pylori was assessed at baseline with urea breath test. All individuals who were alive, and could be traced, were contacted by postal questionnaire in 2003 obtaining information on number of siblings and birth order. Data concerning childhood socioeconomic conditions were stored on file from the original study.

RESULTS

3928 (47%) of 8407 original participants provided data. Prevalence of infection increased according to sibling number (20% in those with none vs 63% with eight or more). Controlling for childhood socioeconomic conditions and birth order using multivariate logistic regression, infection odds were substantially increased with three siblings compared with none [odds ratio (OR) 1.51; 95% confidence interval (CI) 1.06-2.15], and a gradient of effect continued up to eight or more siblings (OR 5.70; 95% CI 2.92-11.14). Odds of infection also increased substantially with birth order, but the positive gradient disappeared on adjustment for sibling number and childhood socioeconomic conditions.

CONCLUSIONS

: In this cross section of UK adults, aged 50-59 years, sibling number in the household, but not birth order, was independently associated with prevalence of H. pylori infection.

Low-grade dysplasia in Barrett's esophagus has a high risk of progression

BACKGROUND AND STUDY AIMS

Surveillance in Barrett's esophagus relies on the detection of dysplasia by histopathology. However, the natural history of this condition, particularly that of low-grade dysplasia (LGD) is poorly understood. This paper describes our experience of LGD over a period of 21 years.

PATIENTS AND METHODS

Between 1984 and January 1995, 357 patients with Barrett's esophagus without dysplasia were recruited for annual surveillance: 34 of these patients developed LGD during this period. This was a retrospective cohort study of this group in terms of survival and cancer outcomes >/= 8 years after the original diagnosis of LGD, comparing them with the patients who did not develop LGD over the same period, with a histopathological review of the original diagnoses of LGD. The outcomes of 356/357 (99.7 %) of the patients were established in December 2004.

RESULTS

After 8 years, high-grade dysplasia (HGD) or cancer had developed in 9/34 patients with LGD (27 %) and in 16/322 controls (5 %). Cox's proportional hazards model revealed that the time from the first diagnosis of Barrett's esophagus to the first "event" of either HGD, esophageal cancer, or death did not show a statistically significant difference between the two groups. A further analysis treating death as "loss to follow-up" showed a significantly increased risk for the LGD group to progress to HGD or cancer (hazard ratio 5.9 [95 % confidence interval 2.6 - 13.4], P< 0.001). The histopathology review demonstrated a fair level of agreement between pathologists, with a kappa value of 0.48.

CONCLUSIONS

Patients diagnosed with LGD during surveillance of Barrett's esophagus are at a considerably increased risk of progressing to develop esophageal cancer over an 8-year period but most deaths are not cancer-related.

Who consults with dyspepsia? Results from a longitudinal 10-yr follow-up study

OBJECTIVE

Dyspepsia is common, and the condition is often chronic, with a relapsing and remitting nature. Factors influencing the decision to consult a physician with symptoms remain unclear.

METHODS

The authors conducted a 10-yr follow-up longitudinal survey of individuals originally involved in a community-screening program for Helicobacter pylori (H. pylori). All surviving, traceable participants were contacted by validated postal dyspepsia questionnaire. Baseline demographic data, dyspepsia and irritable bowel syndrome (IBS) symptom data, and quality of life at study entry were already on file. Consent to examine primary care records was requested, and data regarding nonsteroidal anti-inflammatory drug and aspirin use, and dyspepsia and IBS-related consultations over the 10-yr study period were extracted from these.

RESULTS

Of 8,407 individuals originally involved, 3,266 (39%) gave consent to examination of primary care records. The mean age of included individuals was 55 yr, and 1,467 (45%) were male. 1,738 (53%) had dyspepsia, and 729 (42%) of these consulted a primary care physician as a result. Following multivariate logistic regression, H. pylori infection (odds ratio [OR] 1.76, 99% confidence interval [CI] 1.30-2.39), lower socioeconomic status (OR 1.68, 99% CI 1.02-2.76), frequent (OR 2.61, 99% CI 1.69-4.01) or severe (OR 1.87, 99% CI 0.99-3.52) symptoms, and increasing age (OR per year 1.06, 99% CI 1.0-1.11) were independent risk factors for consultation.

CONCLUSIONS

Reasons for consulting a physician with dyspepsia are multifactorial, but H. pylori infection, lower socioeconomic status, frequent or severe symptoms, and increasing age are independent predictors of consultation.

Initial poor quality of life and new onset of dyspepsia: results from a longitudinal 10-year follow-up study

BACKGROUND

Numerous studies examining the prevalence and natural history of dyspepsia in the general population have been conducted. However, few have reported the effect of quality of life on the development of dyspepsia. A 10-year longitudinal follow-up study examining the effect of quality of life on subsequent dyspepsia was performed.

METHODS

Individuals originally enrolled in a population-screening programme for Helicobacter pylori were contacted through a validated postal dyspepsia questionnaire. Baseline demographic data, quality of life at original study entry, and dyspepsia and irritable bowel syndrome (IBS) symptom data were already on file. Consent to examine primary-care records was sought, and data regarding non-steroidal anti-inflammatory drugs (NSAID) and aspirin use were obtained from these.

RESULTS

Of 8407 individuals originally involved, 3912 (46.5%) provided symptom data at baseline and 10-year follow-up. Of 2550 (65%) individuals asymptomatic at study entry, 717 (28%) developed new-onset dyspepsia at 10 years, an incidence of 2.8% per year. After multivariate logistic regression, lower quality of life at study entry (OR 2.63; 99% CI 1.86 to 3.71), higher body mass index (OR per unit 1.05; 99% CI 1.02 to 1.08), presence of IBS at study entry (OR 3.1; 99% CI 1.51 to 6.37) and use of NSAIDs and/or aspirin (OR 1.32; 99% CI 0.99 to 1.75) were significant risk factors for new-onset dyspepsia.

CONCLUSIONS

The incidence of new-onset dyspepsia was almost 3% per year. Low quality of life at baseline exerted a strong effect on the likelihood of developing dyspepsia at 10 years.

Relationship between Helicobacter pylori gastritis, gastric cancer and gastric acid secretion

Epidemiological evidence strongly indicates that Helicobacter pylori infection is an essential factor for the development of most non-cardia gastric cancer. Furthermore, the identification of an effective animal model and a plausible biological hypothesis provide further compelling evidence for its pathogenic role. Nevertheless, it will be some years before prospective studies in humans are able to confirm cause and effect beyond any doubt. In the meantime sceptics point out that the prevalence of Helicobacter pylori in different countries do not always correlate with the incidence of gastric cancer. It is unclear why patients with duodenal ulcer (who are almost invariably infected) are protected from the disease. Cancer often develops in patients from whom Helicobacter disappeared from the stomach years previously. This paper discusses the relationship between Helicobacter pylori infection, the development of gastritis and its evolution to non-cardia gastric cancer. It also addresses possible reasons why the incidence of gastric cancer does not always mirror the prevalence of Helicobacter infection throughout the world and why patients with duodenal ulcer may be protected from developing gastric cancer.

Randomized crossover study that used methylene blue or random 4-quadrant biopsy for the diagnosis of dysplasia in Barrett's esophagus

BACKGROUND

Barrett's esophagus is generally accepted to be a premalignant condition. Previous studies have suggested the use of methylene blue (MB) chromoendoscopy to aid the identification of dysplasia in Barrett's esophagus surveillance programs, but a recent study has raised the concern that MB might induce oxidative damage of DNA.

OBJECTIVE

The aim of this study was to compare MB directed biopsies (MBDB) with our current standard, which is random 4 quadrant biopsies (RB).

DESIGN

A randomized prospective crossover study.

SETTING

Single center.

PATIENTS

Patients with a diagnosis of dysplasia identified in Barrett's esophagus within a 2-year period before entering the study.

INTERVENTIONS

Either 4 random quadrant biopsies taken every 2 cm through the length of the Barrett's esophagus or MBDB from unstained or heterogenously stained mucosa.

MAIN OUTCOME MEASUREMENTS

The number of patients with a diagnosis of dysplasia by each intervention.

LIMITATIONS

Thirty-six percent of eligible patients declined the invitation to participate.

RESULTS

Thirty patients completed the crossover study. The median length of Barrett's esophagus was 5 cm (interquartile range [IQR] 3-9 cm). At baseline histology, grades were as follows: 17 low-grade dysplasia (LGD), 3 high-grade dysplasia (HGD), and 10 no dysplasia. At completion, there were 10 LGD, 8 HGD, and 12 no dysplasia. Overall, dysplasia was identified in 17 of 18 patients by RB and in 9 of 18 by MBDB (McNemar test, p = 0.02).

CONCLUSIONS

Our study showed MBDB to be significantly less sensitive in detecting dysplasia than RB in Barrett's esophagus. Hence, we discourage its use during routine surveillance of Barrett's esophagus.

A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial

BACKGROUND & AIMS

Population screening and treatment of Helicobacter pylori has been advocated as a means of reducing mortality from gastric cancer, as well as dyspepsia and dyspepsia-related resource use. Previous programs have failed to demonstrate a significant effect on mortality or resource use, but follow-up was only for 1 or 2 years. We aimed to determine the effect of screening for H pylori on dyspepsia and dyspepsia-related resource use over 10 years.

METHODS

H pylori-positive individuals, aged 40-49 years, enrolled in a community screening program, randomized to eradication therapy or placebo in 1994, were sent a validated dyspepsia questionnaire by mail 10 years later, and primary care records were reexamined. Consultation, referral, prescribing, and investigation data related to dyspepsia were extracted. United Kingdom costs were applied to derive total cost per person (1 pound = 1.8 dollars).

RESULTS

Of 2324 original participants, 1864 (80%) were traced and contacted. Of these, 1086 (47%) responded, and 919 (40%) agreed to a review of their primary care records. There was a 10-year mean saving in total dyspepsia-related costs of 117 dollars per person (95% confidence interval [CI] = 11 dollars-220 dollars, P = .03) with eradication therapy. Those symptomatic at baseline showed a nonsignificant trend toward resolution of symptoms at 10 years with eradication therapy (relative risk of remaining symptomatic, 0.89; 95% CI: 0.77-1.03).

CONCLUSIONS

There were significant reductions in total dyspepsia-related health care costs. The savings made were greater than the initial cost of H pylori screening and treatment.

Review article: gastro-oesophageal reflux disease--the extent of the problem

There have been little review data on the period prevalence of heartburn symptoms in the community. We analysed reflux symptom data from a test-and-treat trial that evaluated community Helicobacter pylori levels and added these to data identified from a literature search. We found 31 papers reporting on 77,671 subjects who provided information on the frequency of heartburn symptoms in the community. Pooled data from these papers suggested that, in Western populations, 25% had symptoms at least once per month, 12% had symptoms at least weekly and 5% had heartburn daily. Reflux symptoms were less common in East Asian populations with only 7% having heartburn at least once per month. Heartburn is a significant problem in Western societies.

Gastro-oesophageal reflux is more prevalent in Western dyspeptics: a prospective comparison of British and South-East Asian patients with dyspepsia

BACKGROUND

There is a paucity of data directly comparing dyspepsia in Western and Eastern populations.

AIM

To compare clinical symptoms, epidemiological factors and endoscopic diagnoses in two sample populations with dyspepsia from the United Kingdom and South-East Asia in a cross-sectional study.

METHODS

Patients with uncomplicated dyspepsia attending endoscopy units in Leeds, UK, and Kuala Lumpur, Malaysia, were prospectively interviewed and underwent subsequent endoscopy.

RESULTS

A total of 1003 Malaysian patients (January 2002 to August 2003) and 597 Caucasian British patients (January 2000 to October 2002) were studied. The mean age was 48.7 +/- 15.8 and 47.5 +/- 13.8 years for the Malaysian and British patients respectively (P = NS). There was a higher proportion of cigarette smoking (35.7% vs. 12.4%, P < 0.0001) and alcohol consumption (34.4% vs. 2.0%, P < 0.0001) amongst British patients, but no difference in non-steroidal anti-inflammatory drug use nor having Helicobacter pylori infection. Gastro-oesophageal reflux disease (GERD) symptoms were more common in British compared with South-East Asian patients [heartburn (72% vs. 41%), regurgitation (66% vs. 29.8%) and dysphagia (21.1% vs. 7.3%), P < 0.0001]. This correlated with an increased endoscopic finding of oesophagitis (26.8% vs. 5.8%) and columnar-lined oesophagus (4.4% vs. 0.9%) amongst British patients (P < 0.001). A logistic regression model revealed that British Caucasian race (OR 9.7; 95% CI = 5.0-18.8), male gender (OR 2.0; 95% CI = 1.4-2.9) and not having H. pylori infection (OR 0.5; 95% CI = 0.3-0.7) were independent predictors for oesophagitis.

CONCLUSION

GERD is more common in British compared with South-East Asian dyspeptic patients suggesting that race and/or western lifestyle are important risk factors.

Cost-effectiveness and long-term impact of Helicobacter pylori 'test and treat' service in reducing open access endoscopy referrals

INTRODUCTION

We have shown that the introduction of a carbon urea breath test (13C-UBT) service for Helicobacter pylori screening and eradication is effective in reducing the rate of open access endoscopy referrals in patients aged < 40 years in the short term. This has been substantiated by several randomized controlled trials comparing a 'test and treat' strategy with early endoscopy in these patients. However, the long-term impact of such a strategy is not established.

OBJECTIVE

To ascertain the influence of 13C-UBT services on open access endoscopy referral rates in dyspeptic patients under the age of 40 years over a period of 5 years.

METHODS

Retrospective analysis of open access endoscopy referral rates between August 1990 and July 2000. Cost minimization analysis was performed with a Decision Analysis Model using Treeage Data 3.5.

RESULTS

The total number of open access referrals for endoscopy during 1990-1995 was between 765 and 1325 per year. The proportion of endoscopies performed in patients < 40 years ranged between 33.4% and 34.6%. The total number of endoscopy referrals during 1995-2000 after the introduction of the 13C-UBT services was between 1178 and 1321 per year. However, there was a sustained reduction in the proportion of patients aged < 40 years, ranging between 23.2% and 26.2% (Chi2 = 153.9, degrees of freedom = 9, P < 0.0001) during this period.

CONCLUSIONS

The H. pylori screening and treatment strategy using the 13C-UBT service results in a sustained reduction of the number of endoscopy referrals and is cost effective in dyspeptic patients under the age of 40 years, enabling better utilization of available resources.

Personal view: to treat or not to treat? Helicobacter pylori and gastro-oesophageal reflux disease - an alternative hypothesis

Helicobacter pylori causes acute on chronic gastritis and is responsible for most peptic ulcers and gastric cancer. However, recent papers have suggested that it may protect against gastro-oesophageal reflux, Barrett's oesophagus and oesophageal cancer. Furthermore, the rapid increase in gastro-oesophageal reflux disease, Barrett's oesophagus and adenocarcinoma of the oesophagus in the developed world has been attributed by some to the falling prevalence of H. pylori. These considerations have led to the suggestion that H. pylori infection should not necessarily be treated, especially in patients with gastro-oesophageal reflux disease. Conversely, data from prospective randomized studies have shown that H. pylori eradication does not cause gastro-oesophageal reflux disease in patients with duodenal ulcer or in the normal population, nor does it worsen the outcome of pre-existing gastro-oesophageal reflux disease. Therefore, although H. pylori is negatively associated with gastro-oesophageal reflux disease, its eradication does not induce the disease. A hypothesis is presented suggesting that the increased prevalence of gastro-oesophageal reflux disease is a result of rising acid secretion in the general population, which, in turn, is a consequence of the increased linear height (a predictor of acid secretion). The greater acid secretion could also explain the decline in the prevalence of H. pylori and perhaps account for the inverse relationship between H. pylori and gastro-oesophageal reflux disease. These considerations are explored in discussing whether H. pylori infection should be treated in infected patients presenting with gastro-oesophageal reflux disease.

Ten year follow up of ulcerative colitis patients with and without low grade dysplasia

BACKGROUND AND AIMS

Low grade dysplasia (LGD) is believed to predispose to colorectal cancer (CRC), and proctocolectomy has been advocated when this is identified. Between 1978 and 1990, 160 patients with longstanding extensive ulcerative colitis (UC) were recruited for annual colonoscopic surveillance and 40 developed LGD at some stage. We report the outcome of this cohort 10 years after the original study ended.

METHODS

Retrospective cohort study and histopathological review of the original diagnoses of LGD. The outcome of 158/160 (98.8%) patients was established in 2000.

RESULTS

Of the 128 patients still alive and with an intact colon at the end of 1990, two were not traceable, 29 had LGD, and 97 had no dysplasia (controls). After 10 years, high grade dysplasia (HGD) or CRC developed in 3/29 LGD (10%) and in 4/97 controls (4.0%). Kaplan-Meier analysis from 1991 to death or colectomy did not show a statistically significant difference between the two groups (log rank test p=0.63). Histopathological review demonstrated the unreliability of LGD diagnosis. Agreement between pathologists was uniformly poor: kappa <0.4 for all comparisons.

CONCLUSION

LGD diagnosis is not sufficiently reliable to justify prophylactic colectomy. Conservative management of established LGD cases should not be ruled out.

Mycophenolate mofetil in refractory inflammatory bowel disease

BACKGROUND

Mycophenolate mofetil has been claimed to be effective and well tolerated in refractory inflammatory bowel disease although there is little information regarding its use in clinical practice.

AIM

To review our experience in achieving and maintaining remission in refractory inflammatory bowel disease and to document tolerability, major toxicity and efficacy.

METHODS

A retrospective audit was performed of the records of all patients with inflammatory bowel disease treated with mycophenolate mofetil (1-2 g/day) over a 3-year period.

RESULTS

Thirty-nine patients were identified. Almost all had been intolerant of, or had not responded to azathioprine, and 38 were steroid-dependent. mycophenolate mofetil was discontinued in 22 patients, 11 due to intolerance and 10 because of lack of efficacy. Of the 17 on treatment at the end of the study period 16 were in remission and off all steroid therapy, but one needed infliximab to maintain remission. No major toxicity was noted and there was no major sepsis.

CONCLUSIONS

Approximately 40% of patients with severe refractory inflammatory bowel disease achieved remission and complete steroid withdrawal on mycophenolate mofetil therapy, almost 30% could not tolerate the drug, and a further 30% did not respond. Mycophenolate mofetil therapy may have a role for steroid-dependent patients refractory to azathioprine.

The effect of Helicobacter pylori infection on levels of DNA damage in gastric epithelial cells

BACKGROUND

Helicobacter pylori infection leads to an increased risk of developing gastric cancer. The mechanism through which this occurs is not known. We aimed to determine the effect of H. pylori and gastritis on levels of DNA damage in gastric epithelial cells.

METHODS

Epithelial cells were isolated from antral biopsies from 111 patients. DNA damage was determined using single cell gel electrophoresis and the proportion of cells with damage calculated before and 6 weeks after eradication of H. pylori. Cell suspensions generated by sequential digestions of the same biopsies were assayed to determine the effect of cell position within the gastric pit on DNA damage.

RESULTS

DNA damage was significantly higher in normal gastric mucosa than in H. pylori gastritis [median (interquartile range) 65% (58.5-75.8), n = 18 and 21% (11.9-29.8), n = 65, respectively, p <.001]. Intermediate levels were found in reactive gastritis [55.5% (41.3-71.7), n = 13] and H. pylori negative chronic gastritis [50.5% (36.3-60.0), n = 15]. DNA damage rose 6 weeks after successful eradication of H. pylori[to 39.5% (26.3-51.0), p =.007] but was still lower than in normal mucosa. Chronic inflammation was the most important histological factor that determined DNA damage. DNA damage fell with increasing digestion times (r = -.92 and -.88 for normal mucosa and H. pylori gastritis, respectively).

CONCLUSIONS

Lower levels of DNA damage in cells isolated from H. pylori infected gastric biopsies may be a reflection of increased cell turnover in H. pylori gastritis. The investigation of mature gastric epithelial cells for DNA damage is unlikely to elucidate the mechanisms underlying gastric carcinogenesis.

Bile reflux gastritis and intestinal metaplasia at the cardia

BACKGROUND AND AIMS

Intestinal metaplasia (IM) at the cardia is likely to be a precursor of cardia cancer. Previous work has shown that it is associated with chronic inflammation attributable to either gastro-oesophageal reflux disease (GORD) or Helicobacter pylori infection. An alternative aetiological factor is bile reflux. Duodenogastric reflux brings about histological changes in the gastric mucosa that can be graded and used to calculate a bile reflux index (BRI). We used the BRI to assess whether reflux of bile plays a part in the development of cardia IM.

METHODS

Histological changes in simultaneous gastric antrum and cardia biopsies from 267 dyspeptic patients were independently graded by two pathologists. The association between cardia IM and age, sex, clinical group, H pylori status, increased BRI (>14), and inflammation at the cardia were evaluated using logistic regression.

RESULTS

A total of 226 patients had adequate cardia and antral biopsies; 149 had GORD and 77 had non-ulcer dyspepsia. Cardia IM was present in 66 (29%) patients, of whom 28 (42%) had complete IM. Increasing age, male sex, chronic inflammation, and a high BRI emerged as significant independent associations with cardia IM. Clinical group and H pylori status were not independent risk factors.

CONCLUSIONS

Histological evidence of bile reflux into the stomach is associated with cardia IM. This could have an important bearing on carcinogenesis at this site.

Symposium: Helicobacter pylori and clinical risks--focus on gastro-oesophageal reflux disease

Helicobacter pylori is a gastric pathogen that is a major cause of peptic ulcer disease, has a role in mucosa-associated lymphoid tissue (MALT) lymphoma and is associated with gastric cancer. Yet, in a large proportion of the human population, H. pylori infection has no apparent adverse clinical consequences. Furthermore, recent research suggests that H. pylori may even confer protection against gastroesophageal reflux disease. The conflicting evidence surrounding H. pylori infection was discussed at a sponsored symposium in Helsinki, introduced by Professor P. Malfertheiner, with papers presented by Dr H. J. O'Connor, Professor R. M. Genta, Dr P. Unge and Professor A. T. R. Axon. Emerging epidemiological and retrospective evidence suggests that the presence of H. pylori infection may provide some protection against gastroesophageal reflux disease, but there is other evidence that shows no benefit of H. pylori for the protection of the oesophagus. It was felt that prospective, multicentre studies are needed to explore the H. pylori-gastroesophageal disease relationship further, to avoid confusing potential benefits with known risks. Following the symposium, a discussion on the relative risks and benefits for H. pylori eradication was provided by Professor Axon and Professor Blaser. Eradication of H. pylori has been recommended in a series of management guidelines issued by consensus groups. However, accurate estimates of the relative risks and benefits of H. pylori infection in the general population, as well as in specific patient groups, is essential in order to develop a management strategy.

Relation of adult lifestyle and socioeconomic factors to the prevalence of Helicobacter pylori infection

INTRODUCTION

The influence of adult socioeconomic status, co-habitation, gender, smoking, coffee and alcohol intake on risk of Helicobacter pylori infection is uncertain.

METHODS

Subjects between aged 40-49 years were randomly invited to attend their local primary care centre. Participants were interviewed by a researcher on smoking, coffee and alcohol intake, history of living with a partner, present and childhood socioeconomic conditions. Helicobacter pylori status was determined by 13C-urea breath test.

RESULTS

In all, 32 929 subjects were invited, 8429 (26%) were eligible and 2327 (27.6%) were H. pylori positive. Helicobacter pylori infection was more common in men and this association remained after controlling for childhood and adult risk factors in a logistic regression model (odds ratio [OR] = 1.15; 95% CI: 1.03-1.29). Living with a partner was also an independent risk factor for infection (OR = 1.30; 95% CI: 1.01-1.67), particularly in partners of lower social class (social class IV and V-OR = 1.47; 95% CI: 1.19-1.81, compared with social class I and II). Helicobacter pylori infection was more common in lower social class groups (I and II-22% infected, III-29% infected, IV and V-38% infected) and there was a significant increase in risk of infection in manual workers compared with non-manual workers after controlling for other risk factors (OR = 1.18; 95% CI: 1.03-1.34). Alcohol and coffee intake were not independent risk factors for infection and smoking was only a risk factor in those smoking >35 cigarettes a day.

CONCLUSIONS

Male gender, living with a partner and poor adult socioeconomic conditions are associated with increased risk of H. pylori infection.

The cost-effectiveness of population Helicobacter pylori screening and treatment: a Markov model using economic data from a randomized controlled trial

BACKGROUND

Economic models have suggested that population Helicobacter pylori screening and treatment may be a cost-effective method of reducing mortality from gastric cancer. These models are conservative as they do not consider that the programme may reduce health service peptic ulcer and other dyspepsia costs. We have evaluated the economic impact of population H. pylori screening and treatment over 2 years in a randomized controlled trial and have incorporated the results into an economic model exploring the impact of H. pylori eradication on peptic ulcer disease and gastric cancer.

METHODS

Subjects between the ages of 40 and 49 years were randomly invited to attend their local primary care centre. H. pylori status was evaluated by (13)C-urea breath test and infected individuals were randomized to receive omeprazole, 20 mg b.d., clarithromycin, 250 mg b.d., and tinidazole, 500 mg b.d., for 7 days or identical placebos. Economic data on health service costs for dyspepsia were obtained from a primary care note review for the 2 years following randomization. These data were incorporated into a Markov model comparing population H. pylori screening and treatment with no intervention.

RESULTS

A total of 2329 of 8407 subjects were H. pylori positive: 1161 were randomized to receive eradication therapy and 1163 to receive placebo. The cost difference favoured the intervention group 2 years after randomization, but this did not reach statistical significance (11.42 ponds sterling per subject cost saving; 95% confidence interval, 30.04 ponds sterling to -7.19 pounds sterling; P=0.23). Analysis by gender suggested a statistically significant dyspepsia cost saving in men (27.17 ponds sterling per subject; 95% confidence interval, 50.01 pounds sterling to 4.32 pounds sterling; P=0.02), with no benefit in women (-4.46 per subject; 95% confidence interval, -33.85 pounds sterling to 24.93 pounds sterling). Modelling of these data suggested that population H. pylori screening and treatment for 1,000,000 45-year-olds would save over 6,000,000 pounds sterling and 1300 years of life. The programme would cost 14, 200 pounds sterling per life year saved if the health service dyspepsia cost savings were the lower limit of the 95% confidence intervals and H. pylori eradication had only a 10% efficacy in reducing mortality from distal gastric cancer and peptic ulcer disease.

CONCLUSIONS

Modelling suggests that population H. pylori screening and treatment are likely to be cost-effective and could be the first cost-neutral screening programme. This provides a further mandate for clinical trials to evaluate the efficacy of population H. pylori screening and treatment in preventing mortality from gastric cancer and peptic ulcer disease.

ADAMs (a disintegrin and metalloproteinase) messenger RNA expression in Helicobacter pylori-infected, normal, and neoplastic gastric mucosa

Helicobacter pylori is a risk factor for gastric cancer, and bacterial-epithelial interactions may be critical in this association. Studies using complementary DNA arrays indicated that the ADAM (A disintegrin and metalloproteinase) genes in gastric epithelial cells are differentially expressed after bacterial-epithelial interactions. Reverse-transcription polymerase chain reaction analysis of gastric biopsy specimens from patients with and without H. pylori showed that infection was associated with increased expression of ADAM 10 and ADAM 17 (tumor necrosis factor-alpha-converting enzyme) in antral mucosa, but no increases in ADAM 15 and ADAM 20 were observed. Increased ADAM 10 transcripts were observed only in cagA-negative infections. High levels of ADAM 10, ADAM 17, and ADAM 20 transcripts were present in gastric carcinoma. H. pylori stimulated temporal changes in ADAM 10 and ADAM 17 transcripts in gastric epithelial cells. Chronic infection with H. pylori may result in persistent mucosal increases in members of the ADAMs family. ADAMs-mediated ectodomain shedding may have a role in gastric carcinogenesis.

Antioxidant vitamin supplements do not reduce reactive oxygen species activity in Helicobacter pylori gastritis in the short term

Reactive oxygen species have been implicated in Helicobacter pylori-mediated gastric carcinogenesis, whereas diets high in antioxidant vitamins C and E are protective. We have examined the effect of vitamin C and E supplements in combination with H. pylori eradication on reactive oxygen species activity in H. pylori gastritis. H. pylori-positive patients were randomized into four groups: triple therapy alone (Bismuth chelate, tetracycline, and metronidazole for 2 weeks), vitamins alone (200mg vitamin C and 50mg vitamin E, both twice per day for 4 weeks), both treatments or neither. Plasma and mucosal ascorbic acid, malondialdehyde and reactive oxygen species were determined before and after treatment. Compared with normal controls (n 61), H. pylori-positive patients (n 117) had higher mucosal reactive oxygen species and malondialdehyde levels and lower plasma ascorbic acid. Plasma ascorbic acid doubled in both groups of patients receiving vitamins and mucosal levels also increased. Malondialdehyde and reactive oxygen species fell in patients in whom H. pylori was eradicated but vitamin supplements were not effective either alone or in combination with H. pylori eradication. Supplements of vitamins C and E do not significantly reduce mucosal reactive oxygen species damage in H. pylori gastritis.