A study of 4- and 7-day triple therapy with rabeprazole, high-dose levofloxacin and tinidazole rescue treatment for Helicobacter pylori eradication

BACKGROUND

Helicobacter pylori treatment failure is becoming an emergent problem in clinical practice. Shorter treatment duration should improve compliance to therapy and keep an acceptable H. pylori eradication rate.

AIMS

To evaluate the efficacy of two rabeprazole, high-dose levofloxacin and tinidazole-based regimens as 'rescue' treatment for H. pylori eradication in an open-label, randomized, pilot study carried out in a clinical practice setting.

METHODS

Eighty-five consecutive patients who have previously failed at least one H. pylori eradication attempt were randomized to receive rabeprazole (20 mg, b.d.), levofloxacin (500 mg, b.d.) and tinidazole (500 mg, b.d.) either for 4 (4-day RLT, n = 42) or 7 days (7-day RLT, n = 43). Cure of H. pylori infection was assessed by means of 13C-urea breath test.

RESULTS

The 7-day RLT achieved 84% (95% CI: 69-93%) and 86% (95% CI: 72-95%) eradication rates in intention-to-treat and per-protocol analyses respectively. The shorter treatment obtained an 83% (95% CI: 69-93%) eradication rate in both intention-to-treat and per-protocol analysis. Both regimens were well tolerated, although patients who received the 4-day RLT reported fewer side-effects.

CONCLUSIONS

In patients who have previously failed at least one H. pylori eradication attempt, both 4- and 7-day rabeprazole, high-dose levofloxacin, tinidazole-based regimens are effective in curing the infection in more than 80% of patients.

Application of the platelet count/spleen diameter ratio to rule out the presence of oesophageal varices in patients with cirrhosis: a validation study based on follow-up

BACKGROUND

Screening for oesophageal varices represents an important part of the diagnostic work-up of cirrhotic patients. We have previously shown that the platelet count/spleen diameter ratio is a parameter that can rule out the presence of oesophageal varices safely and in a cost-effective fashion.

AIM

To evaluate the prognostic and diagnostic accuracy of the platelet count/spleen diameter ratio for ruling out the presence of oesophageal varices in the follow-up of a cohort of cirrhotic patients without oesophageal varices at inclusion.

METHODS

After initial endoscopy, the 106 cirrhotic patients without oesophageal varices who participated in our previous study were followed-up with annual or biannual surveillance endoscopy. Patients were censored at the time of diagnosis of oesophageal varices or at their last visit, and at that time platelet count and spleen diameter were recorded. Sixty-eight patients made up the study cohort after excluding patients who were lost to follow-up or died before undergoing control endoscopy.

RESULTS

During the follow-up, 27 patients (40%) developed oesophageal varices. Patients with higher baseline platelet count/spleen diameter ratios (p<0.0001) as well as a ratio above 909 were less likely to develop oesophageal varices (p<0.0005). At follow-up, a platelet count/spleen diameter ratio < or = 909 had 100% negative predictive value and 84% efficiency in identifying the presence of oesophageal varices.

CONCLUSIONS

The use of the platelet count/spleen diameter ratio proved to be an effective means for ruling out the presence of oesophageal varices even in the longitudinal follow-up of patients.

Carditis in patients with gastro-oesophageal reflux disease: results of a controlled study based on both endoscopy and 24-h oesophageal pH monitoring

BACKGROUND

There are conflicting reports on the role of gastro-oesophageal reflux disease (GERD) and Helicobacter pylori infection in the aetiology of carditis.

AIM

The role of reflux and H. pylori infection in causing carditis was assessed in 113 consecutive patients with GERD and in 25 controls.

METHODS

All subjects underwent endoscopy and pH test and carditis was diagnosed on biopsies taken across the squamocolumnar junction. Helicobacter pylori was assessed by histology and rapid urease test. GERD was diagnosed by endoscopic oesophagitis or abnormal pH test.

RESULTS

Carditis was detected in 53 of 71 GERD patients and in 15 of 20 controls. Among patients, 18 showed absent, 39 mild and 14 marked cardia inflammation and their H. pylori infection rates were 17, 23 and 57%, respectively (P < 0.025). Most patients with carditis (68%) lacked H. pylori infection. pH-metry was abnormal in 15 of 18 patients with normal cardia, 33 of 39 with mild carditis and 12 of 14 with marked inflammation.

CONCLUSIONS

Carditis is a frequent finding in GERD and controls. Mild, non-active carditis is frequent in GERD patients. Marked inflammation is associated with both H. pylori and abnormal pH testing. Thus, both GERD and H. pylori infection may play a role in inducing carditis.

Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis

BACKGROUND AND AIMS

Cirrhotic patients frequently undergo screening endoscopy for the presence of oesophageal varices (OV). In the future, this social and medical burden will increase due to the greater number of patients with chronic liver disease and their improved survival. In this study, our aims were (1) to identify clinical, biochemical, and ultrasonographic parameters which might non-invasively predict the presence of OV in patients with liver cirrhosis; (2) to evaluate the reproducibility of the obtained results in a different, although related, further group of patients; and (3) to assess the predictiveness of the identified rules in patients with compensated cirrhosis.

METHODS

In the first part of the study we retrospectively evaluated the presence of OV in 145 cirrhotic patients, and in the second part we evaluated the reproducibility of the study results in a subsequent group of 121 patients. Finally, we evaluated these parameters in a subgroup of 145 patients with compensated disease. All 266 patients underwent a complete biochemical workup, upper digestive endoscopy, and ultrasonographic measurement of spleen bipolar diameter. Platelet count/spleen diameter ratio was calculated for all patients.

RESULTS

The prevalence rates of OV were 61% and 58% in the first and second groups of patients, respectively. In the first part of the study, we found that platelet count, spleen diameter, platelet count/spleen diameter ratio, and Child- Pugh class were significantly different among patients with or without OV, although the platelet count/spleen diameter ratio was the only parameter which was independently associated with the presence of OV in a multivariate analysis. A platelet count/spleen diameter ratio cut off value of 909 had 100% negative predictive value for a diagnosis of OV. This result was reproduced in the second group of patients as well as in patients with compensated disease. In a cost-benefit analysis, screening cirrhotic patients according to the "platelet count/spleen diameter ratio strategy" was far more cost effective compared with the "scope all strategy".

CONCLUSIONS

The platelet count/spleen diameter ratio is the only parameter which is independently associated with the presence of OV, and its negative predictive value is reproducible. Its use is of value even in the subgroup of patients with compensated disease, and it is also cost effective.

Helicobacter pylori infection is not involved in the pathogenesis of either erosive or non-erosive gastro-oesophageal reflux disease

BACKGROUND

The majority of reflux patients have non-erosive reflux disease.

AIM

To evaluate the influence of Helicobacter pylori on oesophageal acid exposure in patients with both non-erosive and erosive reflux disease and in a group of controls. The pattern and distribution of chronic gastritis were also assessed.

METHODS

One hundred and twelve consecutive patients with symptoms of gastro-oesophageal reflux disease agreed to undergo both upper gastrointestinal endoscopy and 24-h oesophageal pH-metry. Patients were grouped as H. pylori-positive or H. pylori-negative on the basis of both CLO-test and histology, and as cases with or without oesophagitis on the basis of endoscopy. The controls consisted of 19 subjects without reflux symptoms and with normal endoscopy and oesophageal pH-metry.

RESULTS

H. pylori was positive in 35 patients (31%) and in six controls (31%); oesophagitis was found in 44 patients (39%) and non-erosive reflux disease in 68 (61%). The prevalence of chronic gastritis in the antrum and corpus was higher in H. pylori-positive than in H. pylori-negative patients (P < 0.001), but was more frequently mild (P < 0.001) than moderate or severe. The percentage total time the oesophageal pH < 4.0 was higher in patients than in controls (P < 0.008-0.001), but there was no difference between H. pylori-positive and H. pylori-negative patients (12.3% vs. 12%, P = 0.43) or H. pylori-positive and H. pylori-negative controls (1.07% vs. 1.47%, P = 0.19).

CONCLUSIONS

H. pylori infection had the same prevalence in reflux patients and in controls. It did not affect oesophageal acid exposure, as there was no difference between H. pylori-positive and H. pylori-negative individuals. The high prevalence of mild body gastritis in H. pylori-positive patients suggests that H. pylori eradication is unlikely to lead to gastric functional recovery, which might precipitate or worsen symptoms and lesions in patients with gastro-oesophageal reflux disease.

Topical butyrate improves efficacy of 5-ASA in refractory distal ulcerative colitis: results of a multicentre trial

BACKGROUND

The treatment of distal ulcerative colitis, refractory to conventional 5-ASA/steroid treatment, is still a matter of debate. The present study aimed at confirming, with adequate statistical power, previous data indicating the usefulness of topical butyrate and 5-ASA in the treatment of this condition.

DESIGN

Double-blind, placebo-controlled, multicentre study. A total of 51 patients with distal (< 65 cm) ulcerative colitis, refractory to topical 5-ASA/cortisone, were randomly allocated to receive topical 5-ASA 2 g and 80 mM L-1 sodium-butyrate bid (Group A; 24 patients) or 5-ASA 2 g and 80 mL saline bid (Group B; 27 patients) for 6 weeks. Sigmoidoscopy with biopsies, as well as clinical and laboratory evaluations, were carried out at enrollment and at the end of the trial. Primary endpoints: remission or marked improvement in endoscopic, histologic and clinical findings.

RESULTS

Most parameters showed a significant improvement vs. baseline in both groups. Remission in six patients and improvement in 12 patients in Group A vs. one remission and 13 with improvement in Group B (P < 0.05). A significant difference in favour of Group A was recorded regarding the number of bowel movements (P < 0.01), urgency (P < 0.05) and the patients' self evaluation (P < 0.01).

DISCUSSION

The combined treatment with topical butyrate and 5-ASA is significantly more effective than 5-ASA alone in the management of refractory distal colitis. Further improvements in the treatment of refractory distal ulcerative colitis may be feasible based on the identification of patient subgroups and the association of two or more active drugs. Butyrate may well be one of them.

Circadian pattern of intragastric acidity in patients with non-erosive reflux disease (NERD)

BACKGROUND

Most patients with gastro-oesophageal reflux disease have non-erosive reflux disease. Proton pump inhibitors are less effective than expected in these patients, but no previous study has measured their 24-h gastric pH values.

AIMS

To evaluate whether there are differences in 24-h intragastric acidity between reflux patients with and without oesophagitis and controls. The influence of Helicobacter pylori on the gastric pH of reflux patients was also assessed.

METHODS

Sixty-three consecutive patients with gastro-oesophageal reflux disease symptoms who agreed to undergo endoscopy and 24-h pH-metry were recruited. Twenty-five (39%) had erosive oesophagitis and 38 (61%) did not. H. pylori was diagnosed by CLO test, histology and 13C-urea breath test. Gastric pH was also measured in 30 controls without digestive symptoms.

RESULTS

H. pylori was found in seven of the 25 (28%) patients with oesophagitis and 14 of the 38 (37%) patients with non-erosive reflux disease. Oesophageal pH-metry was abnormal in 21 of the 25 (84%) patients with oesophagitis and in 32 of the 38 (84%) patients with non-erosive reflux disease. The median gastric pH did not differ between patients with and without oesophagitis or between them and controls during the 24 h (P = 0.8) and other time intervals (P = 0.2-0.4). The gastric pH did not differ between infected and non-infected patients with oesophagitis (P = 0.2-0.4) or non-erosive reflux disease (P = 0.3-0.8).

CONCLUSIONS

The circadian pattern of intragastric acidity does not differ between patients with non-erosive reflux disease and oesophagitis. Moreover, the study confirms that H. pylori infection does not affect the gastric pH in either group of reflux patients.

Stool antigen assay (HpSA) is less reliable than urea breath test for post-treatment diagnosis of Helicobacter pylori infection

BACKGROUND

The diagnostic yield of the stool antigen test (HpSA) in evaluating the results of Helicobacter pylori eradication therapy is controversial, but many studies have used only the 13C-urea breath test (13C-UBT) as a gold standard which has greatly reduced their relevance.

AIM

To compare the reliability of HpSA and 13C-UBT in patients post-treatment using biopsy-based methods as reference tests.

METHODS

A total of 100 consecutive dyspeptic patients (42 male and 58 female; mean age, 56 +/- 18 years) were enrolled in our study. All patients were H. pylori positive on the basis of at least two biopsy-based methods, and underwent 1 week of treatment with various triple therapies. They were again endoscoped 4 weeks after completing therapy and six biopsy specimens were taken from the gastric antrum and corpus for rapid urease test, histology and culture. HpSA and 13C-UBT were also performed within 3 days of the second endoscopy.

RESULTS

On the basis of biopsy-based tests, infection was eradicated in 77 patients but continued in 23. Three false negatives were observed with HpSA and two with 13C-UBT. In contrast, the number of false positives was significantly higher (P < 0.01) with HpSA than with 13C-UBT (nine vs. one), confirming the lower specificity of the former test. The overall accuracy of HpSA was 88% vs. 97% for 13C-UBT (P < 0.02).

CONCLUSIONS

HpSA has lower diagnostic value than 13C-UBT in the evaluation of the outcome of anti-H. pylori therapy. 13C-UBT remains the first-line diagnostic method to monitor eradication results. The use of HpSA should be reserved for those settings in which 13C-UBT is not available.

Eradication of Helicobacter pylori may reduce disease severity in rheumatoid arthritis

BACKGROUND

A triggering infectious agent has long been postulated in rheumatoid arthritis. Data on the possible role of Helicobacter pylori infection are lacking.

AIM

To assess the effect of H. pylori eradication in patients with rheumatoid arthritis.

METHODS

Fifty-eight adult patients with established rheumatoid arthritis and dyspeptic symptoms were recruited - 28 were H. pylori-positive and 30 were H. pylori-negative on the basis of invasive tests. All infected patients were treated successfully. We evaluated the disease activity using clinical and laboratory parameters at baseline and every 4 months during 2 years, and compared the variations in the two subgroups.

RESULTS

H. pylori-eradicated rheumatoid arthritis patients showed progressive improvement over time (P < 0.0001) of all clinical indices compared with baseline, whereas H. pylori-negative rheumatoid arthritis patients remained substantially unchanged. After 2 years, H. pylori-eradicated rheumatoid arthritis patients differed significantly (P < 0.04-0.0001) from patients without H. pylori infection in terms of improvement of all clinical parameters. At the same time point, several laboratory indices (erythrocyte sedimentation rate, fibrinogen, alpha2-globulins and antinuclear antibody) showed significantly lower values (P < 0.02-0.0003) in the H. pylori-eradicated subgroup compared to the H. pylori-negative subgroup.

CONCLUSIONS

Our data suggest that H. pylori infection is implicated in the pathogenesis of rheumatoid arthritis, in that its eradication may induce a significant improvement of disease activity over 24 months. H. pylori eradication seems to be advantageous in infected rheumatoid arthritis patients, but controlled studies are needed.

Comparison of the main oesophageal pathophysiological characteristics between short- and long-segment Barrett's oesophagus

AIM

To assess the oesophageal manometric characteristics and 24-h pH profiles of patients with both short-segment and long-segment Barrett's oesophagus and compare them with those of patients with reflux oesophagitis and controls.

METHODS

Seventy-nine patients who had undergone upper digestive endoscopy were recruited: 16 had short-segment Barrett's oesophagus, 13 had long-segment Barrett's oesophagus, 25 had grade III oesophagitis according to the Savary-Miller classification and 25 were used as controls. The diagnosis of Barrett's oesophagus was based on the histological detection of specialized intestinal metaplasia, which extended < 3 cm into the oesophagus in patients with short-segment disease and > 3 cm in patients with long-segment disease. All subjects underwent oesophageal manometry and basal 24-h oesophageal pH monitoring.

RESULTS

The lower oesophageal sphincter pressure was significantly lower in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus than in controls (P=0.0004-0.0001), but there was no difference among the three reflux groups. The peristaltic wave amplitude of patients with long-segment Barrett's oesophagus was significantly lower than that of controls (P=0.002) and patients with short-segment Barrett's oesophagus (P=0.02), but was no different from that of patients with reflux oesophagitis. The percentage of non-propagated wet swallows was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus when compared with that of controls (P=0.0004-0.0001). The total percentage of time the oesophagus was exposed to pH < 4.0 was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus (P=0.0001) than in controls, and was higher in patients with long-segment disease than in those with short-segment disease (P=0.01).

CONCLUSIONS

Long-segment Barrett's oesophagus is characterized by a greater impairment of peristaltic wave amplitude and a higher oesophageal acid exposure than is short-segment Barrett's oesophagus. However, both forms are linked to increased acid reflux.

Application of Kohonen neural network for the elaboration of electrogastrograms

A method is presented for processing and analysis of electrogastrography (EGG) a noninvasive technique by which gastric myolectrical activity is recorded using abdominal surface electrodes. The analysis is based on FFT and on unsupervised artificial neural networks. Three kinds of patterns can be identified on the neurons of a Kohonen output map with 32 x 16 neurons: one relating to noisy spectral profiles, one relating to pre-prandial profiles, one relating post-prandial profiles. It is concluded that the described method is reliable and can be used for objective automated analysis of EGG and for investigation of possible relations of the EGG with gastric pathologies.

Negative effect of ranitidine on the results of urea breath test for the diagnosis of Helicobacter pylori

OBJECTIVES

In analogy with proton pump inhibitors, H2-antagonists may also be responsible for false-negative results on urea breath test for the detection of Helicobacter pylori. In this study we assessed the frequency and duration of false-negative urea breath tests in patients given different doses of ranitidine.

METHODS

A total of 120 consecutive dyspeptic patients infected with H. pylori on the basis of concomitant positive results of CLO-test, histology and urea breath test were recruited for this prospective, open, parallel-group study performed in an urban university gastroenterological clinic. They were randomized to receive an acute treatment with either ranitidine 300 mg once a day in the evening, ranitidine 300 mg once a day in the morning, ranitidine 150 mg b.i.d., or ranitidine 300 mg b.i.d. for 14 days. The urea breath test was performed on day 14 while patients were still taking ranitidine, and on day 21, 1 wk after completion of therapy. The test was repeated on day 28 in those patients who were still negative on day 21. Duplicate breath samples were collected after ingestion of 75 mg 13C-urea plus citric acid. A delta value >5/1000 was considered positive.

RESULTS

Of 118 patients infected with H. pylori, 15 (13%) had a negative urea breath test on day 14. The false-negative results were equally distributed among the four groups of ranitidine dosage. Nine of these patients reverted to positive at 7 days and the remaining six at 14 days after completion of therapy.

CONCLUSIONS

Our study shows that ranitidine negatively affects the results of urea breath testing, independent of the given dosage. Patients undergoing this examination for H. pylori diagnosis should discontinue use of H2-antagonists 2 wk before testing.

The impact of antibiotic resistance on the efficacy of three 7-day regimens against Helicobacter pylori

BACKGROUND

Antibiotic resistance affects the success of anti-Helicobacter pylori therapies and varies greatly from country to country.

AIM

To compare the efficacy of three short-term triple regimens in relation to H. pylori primary resistance in our region.

METHODS

We enrolled 210 H. pylori-positive dyspeptic patients for this randomized, open, parallel-group study. Three arms of 70 patients each received the following 1-week regimens: (1) ranitidine bismuth citrate 400 mg b.d. + clarithromycin 250 mg b.d. + metronidazole 500 mg b.d. (RCM); (2) bismuth subcitrate 240 mg b.d. + amoxycillin 1000 mg b.d. + metronidazole 500 mg b.d. (BAM); (3) omeprazole 20 mg o.d. + clarithromycin 250 mg b.d. + metronidazole 500 mg b.d. (OCM). H. pylori was assessed by CLO-test and histology before and 4 weeks after therapy. Antibiotic resistance was assessed by E-test.

RESULTS

On intention-to-treat analysis RCM was more effective than OCM (84% vs. 69%; P < 0.03) and BAM (84% vs. 63%; P < 0.004). MIC determination was successful in 117 out of 210 patients (55%); metronidazole resistance was present in 52 out of 117 patients (44%) and clarithromycin resistance was present in 17 out of 117 patients (14%). Excellent cure rates were achieved when strains were sensitive to both antibiotics (100% with RCM and BAM and 90% with OCM), whereas RCM was superior to OCM (P=0.009) and BAM (P=0.001) with respect to overall resistant strains (94% vs. 57% and 38%, respectively).

CONCLUSIONS

One-week RCM is the best regimen to eradicate H. pylori in our geographical area. This seems to be linked to the better ability of RCM compared to OCM and BAM in overcoming the high prevalence of H. pylori resistance to both metronidazole and clarithromycin in our region.

Effect of Helicobacter pylori eradication on 24-hour gastric pH and duodenal gastric metaplasia

Published data on the regression of the extent of duodenal gastric metaplasia (DGM) after the eradication of Helicobacter pylori infection and the normalization of the organism-induced alterations in gastric physiology are scanty and controversial. Therefore, we decided to assess the circadian pattern of gastric acidity and the degree of DGM before and one year after H. pylori eradication in a group of duodenal ulcer patients. Fifteen consecutive H. pylori-positive patients with endoscopically proven duodenal ulcer were recruited for this study. The diagnosis of H. pylori infection was based on CLO-test and histology, and DGM was assessed on four bulb biopsies taken before and one year after H. pylori eradication. At the same time, gastric pH was measured by 24-hr continuous intraluminal recording. H. pylori eradication was ascertained by means of concomitant negative CLO-test and histology performed both four weeks after the end of the eradicating treatment and at the one-year endoscopic control. After successful cure, all patients discontinued any antiulcer medication. The mean 24-hr gastric pH was 1.7 +/- 0.4 before and 1.6 +/- 0.4 after one year of H. pylori eradication (P = 0.75). DGM improved in three cases, worsened in four cases, and was unchanged in eight cases at the one-year control (P = 0.87). No correlation was found between 24-hr gastric pH and DGM (P = NS) both at baseline and one year after eradication. Our results show that neither circadian gastric acidity nor DGM change significantly one year after H. pylori eradication in duodenal ulcer patients. Thus, the disappearance of H. pylori infection does not determine any increase in gastric pH and any reversal of gastric-type epithelium in the duodenum.

Circadian gastric acidity and Helicobacter pylori infection in patients with chronic pancreatitis

A high prevalence of duodenal ulcer has been reported in patients with chronic pancreatitis. Data from previous studies on gastric acid secretion in these patients have provided conflicting results, and the potential role of H. pylori infection has been poorly investigated. The aim of this study was to assess the circadian pattern of gastric acidity and the prevalence of H. pylori infection in a group of patients suffering from this disease. Thirty-five patients with chronic pancreatitis ascertained by means of pancreatic calcifications or ductal alterations revealed by ERCP were recruited for this prospective study. They underwent 24-hr gastric pH-metry with glass minielectrodes positioned in the gastric corpus, and their profile of gastric acidity was compared with that of 35 healthy subjects, matched for age and sex. H. pylori infection was diagnosed by means of serology. There was no statistical difference (P = NS) in gastric pH of circadian, nocturnal, daytime, and postprandial periods between healthy subjects and patients with chronic pancreatitis. The prevalence of H. pylori infection was rather low (31%) in our patients and similar to that of a comparable control population (37%) in our geographical area. In conclusion, our study shows that patients with chronic pancreatitis have a circadian pattern of gastric acidity similar to that of normal subjects. Moreover, the prevalence of H. pylori infection is low in this population. These findings greatly differentiate the ulcer diathesis in chronic pancreatitis from that of patients with ordinary duodenal ulcer and suggest that other factors are implicated in the ulcerogenic process.

Comparative effects of levosulpiride and cisapride on gastric emptying and symptoms in patients with functional dyspepsia and gastroparesis

BACKGROUND

The efficacy of several prokinetic drugs on dyspeptic symptoms and on gastric emptying rates are well-established in patients with functional dyspepsia, but formal studies comparing different prokinetic drugs are lacking.

AIM

To compare the effects of chronic oral administration of cisapride and levosulpiride in patients with functional dyspepsia and delayed gastric emptying.

METHODS

In a double-blind crossover comparison, the effects of a 4-week administration of levosulpiride (25 mg t.d.s.) and cisapride (10 mg t.d.s.) on the gastric emptying rate and on symptoms were evaluated in 30 dyspeptic patients with functional gastroparesis. At the beginning of the study and after levosulpiride or cisapride treatment, the gastric emptying time of a standard meal was measured by 13C-octanoic acid breath test. Gastrointestinal symptom scores were also evaluated.

RESULTS

The efficacy of levosulpiride was similar to that of cisapride in significantly shortening (P < 0.001) the t1/2 of gastric emptying. No significant differences were observed between the two treatments with regards to improvements in total symptom scores. However, levosulpiride was significantly more effective (P < 0.01) than cisapride in improving the impact of symptoms on the patients' every-day activities and in improving individual symptoms such as nausea, vomiting and early postprandial satiety.

CONCLUSION

The efficacy of levosulpiride and cisapride in reducing gastric emptying times with no relevant side-effects is similar. The impact of symptoms on patients' everyday activities and the improvement of some symptoms such as nausea, vomiting and early satiety was more evident with levosulpiride than cisapride.

Data integration to assist gastric emptying data analysis

The diagnosis of dyspepsia is very difficult because the symptoms are clinically aspecific and the gastric emptying time tests are of complex interpretation. An integrated and automated analysis of clinical and instrumental data may improve the diagnostic process. We present a system to collect data on dyspeptic patient from different sources which has been set up to assist the clinician in the diagnosis of dyspepsia. The data base integrates a wide set of symptoms with data coming from laboratory tests. Moreover, we assess the feasibility of classifying gastric emptying profiles using both octanoid acid excretion data and electrogastrography.

Head-to-head comparison of 1-week triple regimens combining ranitidine or omeprazole with two antibiotics to eradicate Helicobacter pylori

BACKGROUND

Triple therapies containing omeprazole and ranitidine have been shown to be equivalent in eradicating H. pylori infection, but have been assessed either separately or head-to-head, only in small trials.

AIM

To carry out a large randomized controlled study comparing omeprazole and ranitidine combined with two antibiotic combinations for 1 week.

METHODS

Three hundred and twenty H. pylori-positive patients were randomly subdivided into four equal-sized groups and received one of the following treatments: OAM = omeprazole 20 mg b.d. + amoxycillin 1 g b.d. + metronidazole 500 mg b.d.; RAM = ranitidine 300 mg b.d. + amoxycillin 1 g b.d. + metronidazole 500 mg b.d.; OAC = omeprazole 20 mg b.d. + amoxycillin 1 g b.d. + clarithromycin 250 mg t.d.s.; RAC = ranitidine 300 mg b.d. + amoxycillin 1 g b.d. + clarithromycin 250 mg t.d.s. The assessment of H. pylori status was performed before and 4 weeks after the end of therapy by means of CLO-test and histology. H. pylori infection was considered to be eradicated when both tests were negative.

RESULTS

OAM and RAM eradicated H. pylori in 89% and 85% of cases on per protocol (P = 0.48) and in 77% and 75% of cases on intention-to-treat analyses (P = 0.71). OAC and RAC eradicated H. pylori in 67% and 70% of cases on per protocol (P = 0.68) and in 57% and 64% of cases on intention-to-treat analyses (P = 0.41). In contrast, there was significant difference between OAM and OAC (P<0.01) and between RAM and RAC (P<0.05). Side-effects occurred in 15%, 10%, 17% and 16% of patients with respect to the above four subgroups.

CONCLUSIONS

Omeprazole and ranitidine combined with two antibiotics for 1 week are equally effective in the eradication of H. pylori infection, and these results question the role of profound acid suppression in the eradication of the bacterium.

Comparison of isotope ratio mass spectrometry and nondispersive isotope-selective infrared spectroscopy for 13C-urea breath test

OBJECTIVES

The 13C-urea breath test (UBT) is a sensitive and noninvasive method to diagnose Helicobacter pylori infection, but mass spectrometry (IRMS) is very expensive. The aims of this study were to compare the new low-priced infrared spectroscopy with IRMS in detecting the infection and to assess the influence of feeding on test accuracy.

METHODS

One hundred thirty-four patients with dyspeptic symptoms were recruited. Of these, 74 were infected and 60 uninfected on the basis of both CLO-test and histology. A subgroup of 37 patients (22 H. pylori-positive and 15 H. pylori-negative) was studied under fasting and nonfasting conditions on two different days. Duplicate breath samples were analyzed with two IRMS systems (Breath Mat and ABCA) and an infrared spectrometer (IRIS) before, 15 min, and 30 min after ingestion of 75 mg 13C-urea with citric acid. In 37 patients the test was repeated the day after the fasted one and was performed 60 min after a meal of 800 Kcal.

RESULTS

There was a close correlation between IRIS and Breath Mat (r = 0.969 at 15 min and r = 0.977 at 30 min; p < 0.0001), IRIS and ABCA (r = 0.963 at 15 min and r = 0.985 at 30 min; p < 0.0001), and Breath Mat and ABCA (r = 0.987 at 15 min and r = 0.981 at 30 min; p = 0.0001). The sensitivity ranged from 97-100% at both times with all devices, although the specificity was slightly inferior with the infrared system than with the two IRMS machines (95% vs 98-100% at 30 min), but the difference was not significant (p = NS). Food intake produced three false negative results in all three machines and a systematic shift to lower 6 values in infected patients.

CONCLUSIONS

Infrared spectroscopy can be considered a valid alternative to mass spectroscopy for the diagnosis of H. pylori infection. Fasting is required to guarantee an accurate test.

Histological and functional recovery in patients with multifocal atrophic gastritis after eradication of Helicobacter pylori infection

BACKGROUND/AIMS

To assess the effect of Helicobacter pylori eradication on gastric histology and physiology in patients with multifocal atrophic gastritis over 1-year period.

PATIENTS

Fourteen consecutive patients with histological evidence of chronic gastritis and Helicobacter pylori infection diagnosed by histology and serology entered this study. Patients with pernicious anaemia, gastric ulcer or carcinoma, duodenal ulcer, reflux oesophagitis and regular intake of nonsteroidal anti-inflammatory drugs were excluded.

METHODS

Patients underwent triple anti-Helicobacter treatment for one week, which resulted successful in all subjects on the basis of negative CLO test and histology as well as 50% decrease in IgG antibodies after 4 weeks and 6 months of treatment, respectively. Histological and functional investigations were performed at baseline, 6 and 12 months after Helicobacter pylori eradication. Histological assessment of inflammatory cell infiltrates was performed on multiple biopsy specimens of the corpus and fundus. Functional tests were 24-hour continuous gastric pH-metry, fasting serum gastrin assay and pepsinogen I levels.

RESULTS

There was a progressive significant improvement (p < 0.01-0.001) in acute and chronic inflammatory cell infiltrates in the gastric mucosa throughout the 12-month period. Functional recovery with increase in gastric acidity (p < 0.01) and decrease in gastrin and pepsinogen I levels (p < 0.001) was more evident at the 6-month than at the 12-month checkpoint after Helicobacter pylori eradication (p = NS for gastric pH and p < 0.02 for the other two variables) between 6 and 12 months.

CONCLUSIONS

Eradication of Helicobacter pylori infection significantly improves the inflammatory status of oxyntic mucosa and this promotes an almost complete functional recovery. However, the non-parallel behaviour of gastric acidity, which was maximal at 6-month checkpoint, and histological parameters which continued to improve throughout the entire 12-month observation period, seems to indicate that removal of acid-inhibitory substances induced by Helicobacter pylori infection was also responsible for the more rapid recovery of gastric secretory function.

Optimal duration of therapy combining ranitidine bismuth citrate with clarithromycin and metronidazole in the eradication of Helicobacter pylori infection

BACKGROUND

Ranitidine bismuth citrate (RBC) co-prescribed with clarithromycin and metronidazole for 1 week has been shown to be an effective eradicating regimen for Helicobacter pylori.

AIM

To determine the optimal duration of this regimen.

METHODS

A series of 165 dyspeptic patients were recruited for this randomized, open, parallel-group study. They were subdivided into three groups receiving RBC 400 mg b.d. plus clarithromycin 250 mg b.d. and metronidazole 500 mg b.d. for three different periods (4, 7 and 10 days). H. pylori infection was assessed by the concomitant positivity of CLO-test and histology performed at the pre-entry endoscopy. The bacterium was considered eradicated on the basis of a negative 13C-urea breath test performed at least 28 days after the completion of treatment.

RESULTS

The three subgroups were well matched and 16 patients dropped out of the study for many reasons (six in the 4-day, five in the 7-day and five in the 10-day treatment regimens). Intention-to-treat cure rates were 60%, 84% and 85%, and the per-protocol rates 67%, 92% and 94% in the 4-day, 7-day and 10-day treatment regimens, respectively. There was a significant difference, P = 0.003-0.006 on intention-to-treat and P = 0.001-0. 002 on per protocol analysis between the 4-day and the 7-day and the 4-day and the 10-day periods, respectively. The 7-day and 10-day periods did not differ from each other. Side-effects were reported in 9%, 14% and 20% of the 4-, 7- and 10-day regimens. They led to stopping treatment in four cases (one in the 7-day and three in the 10-day period). There was no statistical difference among them.

CONCLUSIONS

Reducing the duration of RBC-based triple therapy to 4 days provides a low and unacceptable rate of H. pylori eradication. As there is no difference between 7 and 10 days of treatment, 1 week represents the optimal time period for this kind of treatment, based on RBC plus two antibiotics.

Risk of inflammatory bowel disease attributable to smoking, oral contraception and breastfeeding in Italy: a nationwide case-control study. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC)

BACKGROUND

Using data from a case-control study carried out in Italy 1989-1992, we estimated the odds ratios (OR) and the population attributable risks (AR) for inflammatory bowel diseases (IBD) in relation to smoking, oral contraception and breastfeeding in infancy.

METHODS

The study focused on 819 cases of IBD (594 ulcerative colitis: UC; 225 Crohn's disease: CD) originating from populations resident in 10 Italian areas, and age-sex matched paired controls.

RESULTS

Compared with non-smokers, former smokers were at increased risk of UC (OR = 3.0; 95% confidence interval [CI]: 2.1-4.3), whereas current smokers were at increased risk of CD (OR = 1.7; 95% CI: 1.1-2.6). Females who reported use of oral contraceptives for at least one month before onset of symptoms had a higher risk of CD (OR = 3.4; 95% CI: 1.0-11.9), whereas no significant risk was observed for UC. Lack of breastfeeding was associated with an increased risk of UC (OR = 1.5; 95% CI: 1.1-2.1) and CD (OR = 1.9; 95% CI: 1.1-3.3). Being a 'former smoker' was the factor with the highest attributable risk of UC both in males (AR = 28%; 95% CI: 20-35 %) and in females (AR = 12%; 95% CI: 5-18%). Smoking was the factor with the highest attributable risk for CD in males (AR = 31%; 95% CI: 11-50%). Lack of breastfeeding accounted for the highest proportion of CD in females (AR = 11%; 95% CI: 1-22%). Oral contraceptive use accounted for 7% of cases of UC and for 11% of cases of CD.

CONCLUSIONS

Taken together, the considered factors were responsible for a proportion of IBD ranging from 26% (CD females) to 36% (CD males). It is concluded that other environmental and genetic factors may be involved in the aetiology of IBD.

24-hour gastric pH and extent of duodenal gastric metaplasia in Helicobacter pylori-positive patients

BACKGROUND & AIMS

Gastric metaplasia (GM) is essential to explain duodenal colonization by Helicobacter pylori. It seems to be acid induced but also occurs in H. pylori-positive patients with nonulcer dyspepsia (NUD), who are not acid hypersecretors. The aim of this study was to assess the circadian gastric acidity of 47 patients with duodenal ulcers (DUs) and 32 patients with NUD, both H. pylori positive, and its correlation to duodenal GM extent.

METHODS

H. pylori was detected by histology and CLOtest, and GM was diagnosed and graded on four bulb biopsy specimens. Each patient underwent 24-hour gastric pH-metry, and the relation between gastric pH and GM extent was assessed by factorial analysis.

RESULTS

Gastric pH was greater in patients with NUD than in patients with DU during 24 hours, night and daytime (P < 0.03-0.005). Gastric pH differed significantly (P < 0.0002) in relation to GM extent between the two populations, whereas no difference was found among the pH values of GM degrees. A significant increase in 24-hour gastric pH was associated with greater GM in patients with DU, whereas the opposite occurred in patients with NUD (P < 0.007).

CONCLUSIONS

The lower gastric acidity in patients with NUD than in patients with DU and the lack of correlation between gastric pH and the various GM degrees in the two H. pylori-positive populations suggest that gastric hyperacidity is not associated with duodenal GM.

A new 1-week therapy for Helicobacter pylori eradication: ranitidine bismuth citrate plus two antibiotics

BACKGROUND

One-week triple regimens are currently the most recommended therapy for the eradication of Helicobacter pylori. No previous study has evaluated the efficacy of a short-term regimen combining ranitidine bismuth citrate with two antibiotics.

METHODS

Seventy-two consecutive H. pylori-positive dyspeptic patients were recruited for this randomized, three-centre, open, parallel-group study. They were subdivided into two groups receiving either ranitidine bismuth citrate 400 mg b.d. + clarithromycin 250 mg b.d. and metronidazole 500 mg b.d. (group A) or ranitidine bismuth citrate 400 mg b.d. + clarithromycin 250 mg b.d. and metronidazole 250 mg q.d.s (group B) for 1 week. H. pylori infection was assessed by CLO-test and histology on both antral and corpus biopsies before and at least 4 weeks after the end of therapy. The bacterium was considered eradicated when both tests were negative. Eradication rates and the number of side-effects were evaluated in each group. The Chi-squared test was used for statistical analysis.

RESULTS

One patient with only CLO-test positivity was erroneously randomized to group B and four patients dropped out of the study (two in group A and two in group B), mainly because they refused the second endoscopy. In group A, H. pylori was eradicated in 31 of 36 patients (intention-to-treat = 86%; 95% CI = 71-95% and per protocol 31/34 = 91%; 95% CI = 76-98%). Side-effects occurred in 10 patients (27%) and they were generally mild. In group B, H. pylori was eradicated in 29 of 35 patients (intention-to-treat = 83%; 95% CI = 66-93%; and per protocol 29/33 = 88%; 95% CI = 72-97%). Seven patients (20%) complained of modest side-effects. There was no significant difference between the two treatment arms (P = N.S.): no severe adverse events occurred and none of the patients was withdrawn from the study because of them.

CONCLUSIONS

The co-administration of ranitidine bismuth citrate plus clarithromycin at low dosage and metronidazole in twice daily doses for 1 week is a short, effective and well-tolerated regimen for the eradication of H. pylori. These findings should provide the impetus for large-scale investigations.

Chronic administration of levosulpiride and glycemic control in IDDM patients with gastroparesis

OBJECTIVE

We evaluated the effect of chronic administration of levosulpiride, a prokinetic drug that is a selective antagonist for D2 dopamine receptors, on the glycemic control of IDDM subjects.

RESEARCH DESIGN AND METHODS

The study was performed on 40 long-standing IDDM subjects with clinical signs of autonomic neuropathy and delayed gastric emptying. Gastric emptying time and glycemic parameters (diurnal glycemic profile and HbA1c) were checked under double-blind conditions before and after the administration of levosulpiride at the dosage of 25 mg t.i.d. orally for 6 months, or placebo.

RESULTS

No significant differences were noted in the glycemic and HbA1c values before and after 6 months of placebo administration. In contrast, after 6 months of levosulpiride, glycemic control had improved (HbA1c 6.7 +/- 0.4 and 5.7 +/- 0.3%, P < 0.01; mean daily glycemia 10.9 +/- 0.8 and 8.8 +/- 0.4 mmol/l, P < 0.05, at the start and at the end of the study), while the dosage of injected insulin (0.65 +/- 0.02 IU.kg-1.day-1) and the number of severe hypoglycemic episodes remained unchanged. After 6 months of levosulpiride therapy, the time of gastric emptying was significantly reduced from 321 +/- 14 to 261 +/- 9 min (P < 0.001) and dyspeptic symptoms had improved.

CONCLUSIONS

Our results show the importance of gastric emptying in the maintenance of glycemic control and the usefulness of chronic administration of levosulpiride in diabetic subjects with gastroparesis.

Circadian gastric acidity in Helicobacter pylori positive ulcer patients with and without gastric metaplasia in the duodenum

BACKGROUND

The presence of gastric metaplasia allows helicobacter pylori to colonise the duodenum and this condition is thought to be acquired as a response to acid hypersecretion. This functional disorder, however, is present only in a subgroup of duodenal ulcer patients and, in addition, surface gastric metaplasia has been frequently found in the proximal duodenum of normal subjects and patients with non-ulcer dyspepsia, who cannot be certainly considered as acid hypersecretors.

AIMS

To clarify the role of acid in inducing gastric type epithelium in the duodenum. This study aimed at assessing whether the pattern of circadian gastric acidity differs between H pylori positive duodenal ulcer patients with and without duodenal gastric metaplasia.

PATIENTS

Seventy one patients with duodenal ulcer confirmed by endoscopy and who were found to be positive for H pylori infection by histology on antrum biopsy specimens were enrolled into this study.

METHODS

Gastric type epithelium in the duodenum was found in 49 of 71 ulcer patients (69%). Continuous 24 hour gastric pH metry was performed in 50 healthy subjects and in the two subgroups of duodenal ulcer patients with and without gastric metaplasia in the duodenum. Gastric acidity was calculated for 24 hours (1700-1659), night (2000-0759) and day-time (0800-1959).

RESULTS

Ulcer patients without gastric metaplasia showed a significantly higher gastric acidity (p < 0.001) than controls for every time interval considered, while the ulcer subgroup with gastric metaplasia was more acid than healthy subjects (p < 0.001) during the whole 24 hour period and the daytime. There was no difference between the two subgroups of duodenal ulcer patients with and without gastric metaplasia during the various time segments analysed.

CONCLUSION

The findings confirm that the circadian gastric acidity of duodenal ulcer patients is higher than that of controls. As there is no difference in gastric pH between duodenal ulcer patients with and without gastric metaplasia, gastric hyperacidity is not specific to patients with duodenal gastric metaplasia. It is probable that this histological change is a non-specific response to mucosal injury resulting from various factors and not exclusively to acid.

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.

Time pattern of gastric acidity in Barrett's esophagus

Increased gastroesophageal acid reflux is frequently found in patients with Barrett's esophagus, and it has been hypothesized that gastric acid hypersecretion could be an important factor aggravating the exposure of esophageal mucosa to acid and then contributing to the development of this disorder. The aim of the present study was to assess whether the circadian pattern of gastric acidity differs between refluxer patients with and without Barrett's esophagus and normal subjects. Continuous 24-hr gastric pH monitoring was performed in 119 healthy volunteers, 20 patients with Barrett's esophagus, 37 patients with moderate and 10 patients with severe reflux esophagitis without Barrett's esophagus. In all these diseases the final diagnosis was ascertained by means of endoscopy plus biopsy. There was no difference in the 24-hr and daytime patterns of gastric pH between healthy subjects and patients with Barrett's esophagus, while nocturnal acidity was significantly lower (P < 0.05) in the latter population. Gastric acidity, in contrast, was higher (P < 0.05) in controls than in patients with both moderate and severe reflux esophagitis without Barrett's esophagus during the whole 24-hr period. There was no difference between refluxer patients with and without Barrett's esophagus in any of the three time intervals we analyzed. Because normal subjects had lower gastric pH than patients with Barrett's esophagus during the night and than patients with reflux esophagitis during the whole 24-hr period, gastric hyperacidity is not a relevant factor in the development of both metaplastic columnar epithelium and inflammatory changes in the distal esophagus, and other pathophysiological mechanisms are involved in these histological alterations.

The effects of omeprazole 20 and 40 mg twice daily on intragastric acidity in duodenal ulcer patients

BACKGROUND

The combination of omeprazole with amoxycillin or clarithromycin is used as treatment against Helicobacter pylori. It seems likely that the antibacterial activity of the antibiotic may be improved by increasing gastric pH towards neutrality, and a twice daily regimen of omeprazole is probably needed.

AIM

To assess the effects of twice daily administration of omeprazole 20 and 40 mg.

METHODS

Twelve duodenal ulcer patients in remission were randomized to receive in single-blind fashion either placebo, omeprazole 20 mg or omeprazole 40 mg twice daily (08.00 and 20.00 h). On the sixth day of dosing they underwent 24-h gastric pH-metry.

RESULTS

Omeprazole 20 and 40 mg b.d. produced marked decreases (P < 0.001) of 24-h gastric acidity (pH 5.4 +/- 0.9 and pH 5.7 +/- 0.6, respectively, vs. a basal pH of 1.4 +/- 0.2) and kept gastric pH at levels higher than 3.0 for almost 24 h. Gastric pH was kept above 5.0 for about 18 h and above 6.0 for about 10 h, while the time spent above 7.0 did not exceed 3 h. There were no significant differences between the two omeprazole dosages at any pH threshold.

CONCLUSION

Omeprazole 20 mg b.d. is sufficient to render the gastric milieu as anacidic as possible in duodenal patients.

Are duodenal ulcer seasonal fluctuations paralleled by seasonal changes in 24-hour gastric acidity and Helicobacter pylori infection?

The occurrence of duodenal ulcer is characterized by seasonal variation, for poorly understood reasons. No previous study has assessed whether 24-h intragastric acidity and Helicobacter pylori infection have similar seasonal fluctuations in patients with this disorder. For this reason, we evaluated retrospectively the circadian gastric pH in 319 new patients (226 men and 93 women, mean age 45.2 years) with endoscopically proven duodenal ulcer, who agreed to undergo this examination during the years 1987-1992 in our center. The month-by-month occurrence of the disease over the global 6-year period was assessed, and the mean pH values were calculated for each patient during three time intervals of interest: 24 h, daytime (08:00-19:59 h), and nighttime (20:00-07:59 h). The mean pH values of these three time periods were then calculated month by month throughout the annual cycle. H. pylori infection was sought by histology in 171 patients examined in the period from 1990 to 1992. The percentage of H. pylori-positive duodenal ulcer patients was then calculated for each season. The calendar fluctuation of duodenal ulcer occurrence showed an evident increase (p < 0.001) in fall (October-December) and in winter (January-March) compared with spring (April-June) and summer (July-September). Both 24-h and nighttime gastric acidity showed no significant variation by month, whereas daytime gastric pH varied significantly (p < 0.05) with two evident decreases, meaning higher acidity, in April and August. H. pylori infection was detected in 152 of 171 patients (89%), and the percentage of H. pylori-positive duodenal ulcers did not differ from season to season. We conclude that there was no parallel circannual fluctuation of duodenal ulcer, gastric acidity, and H. pylori infection in the restricted sample of patients we studied. This reduces the apparent relevance of acid in inducing ulcer seasonal fluctuation. Also, the responsibility of H. pylori in this phenomenon can be excluded until a reliable diagnostic method capable of distinguishing recent from old infection is found.

Gastrokinetic effects of levosulpiride in dyspeptic patients with diabetic gastroparesis

OBJECTIVE

Antidopaminergic drugs may be useful in diabetic gastroparesis because the inhibitory activity of hyperglycemia on gastric motility seems to be related to dopamine receptor stimulation. For this reason, we evaluated the effect of levosulpiride on gastric emptying, dyspeptic symptoms, and metabolic parameters of insulin-treated diabetic patients.

METHODS

Under double-blind conditions, 40 longstanding, insulin-treated dyspeptic patients with autonomic neuropathy and delayed gastric emptying were randomly submitted, with an interval of 15 days, to 4 wk of administration of both levosulpiride 25 mg t.i.d. and placebo according to a cross-over design. At the beginning of the study and after levosulpiride or placebo treatment, the gastric emptying time of a standard meal was measured ultrasonically; gastrointestinal symptom scores and glycaemic control were also evaluated.

RESULTS

Levosulpiride reduced significantly (p < 0.001) the gastric emptying time from 416 +/- 58 to 322 +/- 63 min, whereas placebo did not change it consistently (396 +/- 58 vs 372 +/- 72 min). Symptoms improved significantly (p < 0.001) with levosulpiride compared with placebo. However, there was no significant correlation between the acceleration of gastric emptying and the symptomatological improvement. The reduction of mean plasma glycosylated hemoglobin concentrations after levosulpiride (7.3 +/- 1.9 vs 5.8 +/- 1.3) was not significantly different (p = not significant) compared with placebo (6.8 +/- .7 vs 6.1 +/- 1.4).

CONCLUSIONS

Our study first demonstrates that levosulpiride has an accelerating effect on the emptying of solids from the stomach of patients with diabetic gastroparesis. The drug is also effective in relieving upper gastrointestinal symptoms in patients whose gastric emptying times remain very slow. Our findings suggest, but do not prove, that better blood glucose control could be achieved with reduction of gastric emptying time; further trials are needed in this field.

Limitations of continuous 24-h intragastric pH monitoring in the diagnosis of duodenogastric reflux

OBJECTIVE

Long term gastric pH monitoring has been proposed to diagnose abnormal duodenogastric reflux. This study analyses the in situ reproducibility of continuous intragastric pH measurements to assess the influence of artifactual factors in producing spontaneous variations of pH values that might be frequently misinterpreted as episodes of duodenogastric reflux.

METHODS

The investigation was carried out in 301 endoscopically proven duodenal ulcer patients (87 female, 214 male, mean age 46 yr). Each patient underwent 24-h gastric pH monitoring with two closely adjacent pH electrodes whose tips were about 2 mm apart. The two simultaneous pH tracings obtained from each patient were analyzed with regard to the number, characteristics, and discrepancies of unexpected alkalinization waves over the entire circadian cycle.

RESULTS

The simultaneous pH tracings of the two-channel datalogger we used ran almost superimposed for more than 23 h in 224 out of 301 (74%) duodenal ulcer patients. Major discrepancies between the two pH tracings of each recording were obtained in the remaining cases (77/301 = 26%). The most frequent event was represented by unexpected alkalinization waves that occurred mainly during nighttime and were recorded by only one of the two simultaneously measuring electrodes. As few as 16/244 (7%) patients showed synchronous, unexpected alkalinization waves that one might eventually consider to be duodenogastric refluxes.

CONCLUSIONS

It is rather common that only one of two closely adjacent pH electrodes placed within the stomach measures longlasting pH elevations, particularly during the nocturnal period. This discrepancy is due to a poor in situ reproducibility of simultaneous pH recordings and indicates that pH readings might be influenced by interference and artifacts. Thus, the frequent differences between two simultaneous pH readings and the indirect measurement of the backflow of duodenal contents with long term gastric pH-metry do not allow us to rely on this technique to diagnose duodenogastric reflux.

Effect of D2-dopamine receptor antagonist levosulpiride on diabetic cholecystoparesis: a double-blind crossover study

BACKGROUND

Abnormal gall-bladder motility has been reported in diabetics. The objective was to evaluate the effect of chronic D2-dopamine receptor inhibition on gall-bladder emptying in diabetic patients.

METHODS

Under double-blind placebo-controlled conditions and according to a crossover design, patients were randomly assigned to receive either 4 weeks treatment with levosulpiride 25 mg t.d.s. or 4 weeks treatment with placebo, with an interval of 15 days. Twenty-three consecutive long-standing, insulin-treated diabetics with autonomic neuropathy were studied.

MEASUREMENTS

At the beginning of the study and after levosulpiride or placebo treatment, gall-bladder emptying was measured ultrasonically by evaluating the gall-bladder volume in basal conditions and every 15 min for 90 min after the ingestion of a standard meal. Statistical analysis of the results was performed by means of analysis of variance.

RESULTS

Levosulpiride treatment reduced the basal mean gall-bladder volume from 21.6 +/- 2.3 to 18.6 +/- 2.3 mL (P < 0.05). Furthermore, the residual gall-bladder volume (9.3 +/- 1.4 mL) was significantly reduced compared to the corresponding pre-treatment volume (14.6 +/- 1.5 mL (P < 0.05). In placebo-treated patients, no significant differences were observed in gall-bladder volumes before and after treatment.

CONCLUSION

These results show that chronic oral administration of the D2-dopamine antagonist levosulpiride has a significant effect on gall-bladder motility in diabetic patients.

Circadian acidity pattern in gastric ulcers at different sites

OBJECTIVE

Continuous intragastric pH monitoring was used in a large group of gastric ulcer patients to assess whether the 24-h acidity pattern varies in relation to the ulcer location within the stomach and to assess whether there is a circadian rhythm of pH fluctuations in this disease.

METHODS

One hundred and thirty-three consecutive patients (79 male and 54 female, mean age 53 yr) with endoscopically and histologically proven benign gastric ulcer and 131 healthy subjects (70 male and 61 female, mean age 48 yr) were studied with a pH minielectrode positioned in the gastric corpus. Ulcer patients were divided into four subgroups in relation to the crater site: 1) above the angulus (n = 23); 2) angularis (n = 42); 3) antral (n = 26); and 4) prepyloric (n = 42).

RESULTS

Subgroups 1 and 2 are characterized by significantly lower acidity (p < 0.0001) than healthy subjects for every time segment examined (24-h, day and night). Antral ulcers are less acidic than normal for both the total 24-h period (p < 0.01) and the night period (p < 0.0001), whereas prepyloric ulcers are less acidic for the night only (p < 0.01). In all subgroups of gastric ulcer, the acidity is higher during the evening than the night.

CONCLUSIONS

The circadian acidity of gastric ulcer patients is significantly lower than normal, and this is particularly true during the nocturnal period. There is a gradient of gastric acidity that increases progressively as the lesion approximates to the pylorus. The well known circadian rhythm of gastric acidity with relatively higher acid levels during the evening than the night was maintained in all of the gastric ulcer subgroups we created.

Antisecretory effects of three omeprazole regimens for maintenance treatment in duodenal ulcer

This study was carried out to assess the antisecretory effects and their possible changes over time of three different dose regimens of omeprazole that could be proposed for maintenance treatment in duodenal ulcer. Forty-five patients with endoscopically proven duodenal ulcer were studied by means of 24-hr gastric pH-metry both in basal conditions and on the fifth day of acute treatment with omeprazole 20 mg in the morning. Ulcers healed after four weeks (in three cases after eight weeks) and afterwards, 15 patients were randomized to receive orally at 0800 hr in single-blind fashion omeprazole 10 mg daily (group A), 15 to receive omeprazole 40 mg on Saturday and Sunday followed by a five-day period without medication (group B), and 15 to receive omeprazole 20 mg every other day (group C) for up to three months. On the 20th and 80th days of these maintenance treatments 24-hr gastric pH-metry was repeated to assess the antisecretory effectiveness of each regimen over a two-month period. In patients of group B these tests began at 1700 hr on Friday, the last of five days off treatment, and in those of group C at 1700 hr of the day off medication. All three dose regimens of omeprazole were able to raise pH values significantly (P < 0.01-0.001) compared to basal levels. Omeprazole 20 mg every other day was more effective (P < 0.01) than omeprazole 40 mg weekend, but did not differ significantly from omeprazole 10 mg daily. The durations of acid inhibition (pH > 3.0 units/24 hr) were 12.44, 10.00, and 17.38 hr with groups A, B, and C, respectively. There was no significant difference between the pH profiles of the 20th and 80th days with every dose regimen. It is concluded that all three dose regimens of omeprazole are effective in reducing gastric acidity and their pharmacodynamic action does not change with time. Therefore they are suitable to be assessed in large clinical trials aimed at verifying the prevention of duodenal ulcer recurrence for longer periods.

Bolus infusion of famotidine: effects on gastric pH by repeated 12-hour doses of 20 mg in postoperative patients

This study was carried out to assess the efficacy of intravenous (IV) famotidine in suppressing gastric secretion over a 48-hour period. Twenty postoperative patients requiring a nasogastric tube received famotidine 20 mg IV every 12 hours and gastric pH was measured continuously by means of an indwelling probe. A baseline recording was performed over the first 4 hours and then the drug was infused every 12 hours (q12h) over a 15-minute period for the subsequent 48 hours. The mean pH value achieved during each time segment under active treatment was significantly higher (P < .001) than the mean basal value. Also the density distributions of minutes spent at the various pH units confirm that famotidine is highly effective (P < .001) in raising and maintaining gastric pH above 4.0 units during most of the drug-related period (44 hours). It can be concluded that repeated intravenous boli of famotidine 20 mg every 12 hours allow us to obtain an effective control of intragastric acidity. The antisecretory action is consistent over the total 48-hour period examined and therefore the use of intermittent infusion of famotidine seems to be advisable, as opposed to the recommended continuous IV administration of cimetidine and ranitidine. There is, however, a considerable intersubject variability in the antisecretory response to the drug.

Antisecretory effect of three premeal doses of cimetidine 400 mg versus a single morning dose of omeprazole 20 mg: pathophysiological implications for duodenal ulcer treatment

The success of omeprazole in the healing of duodenal ulcer has been attributed to its profound and almost around-the-clock inhibition of acid, but the relevance of reducing meal-stimulated acid secretion exclusively has recently been emphasized in several clinical trials. For this reason, we used 24-h continuous intragastric pH monitoring to compare the pharmacodynamic effects of placebo, three fractioned premeal doses of cimetidine 400 mg and omeprazole 20 mg mane. Fifteen patients with duodenal ulcer in clinical remission were randomized to receive the above medications in single-blind fashion on three separate occasions, at least 2 wk apart. Both active regimens produced higher pH values (p < 0.05-0.001) than placebo, but omeprazole was much more effective than cimetidine (p < 0.01-0.001) during the various time intervals analyzed (24 h, evening, nighttime, daytime). The greater effectiveness of omeprazole was confirmed by its longer-lasting antisecretory action, insofar as the drug increased gastric pH above 3.0 units for about 21 h, whereas the daytime cimetidine regimen maintained this threshold for 7.30 h (p < 0.001) over the circadian cycle. As these markedly different pharmacodynamic effects have been proven to produce similar fast rates of duodenal ulcer healing in clinical trials, it is reasonable to assume that a small but well addressed reduction of gastric acidity can ensure the same therapeutic benefit as a strong and continuous acid inhibition. In this light, the acid peaks in response to meals seem to be important pathophysiological events, whose control is sufficient to permit quick ulcer healing.

Are clinical patterns of dyspepsia a valid guideline for appropriate use of endoscopy? A report on 2253 dyspeptic patients

We studied 2253 consecutive dyspeptic patients, without clinical evidence of organic disease, who were referred to our open access endoscopy service. The aim was to assess whether the various clinical patterns of dyspepsia can be considered a valid guideline for the appropriate use of endoscopy. According to the symptomatological patterns, our patients were defined as sufferers from 1) ulcer-like (973 patients), 2) reflux-like (857), and 3) dysmotility-like dyspepsia (423). In our patient population, which reflects the general population of our city, the dysmotility-like type of dyspepsia was the least frequent (19%), whereas the ulcer-like (43%) and the reflux-like (38%) dyspepsia were almost equivalent. A negative endoscopy (35.7%) occurred significantly (p < 5 x 10(-4)) more often in dysmotility-like than in ulcer-like (26.3%) and reflux-like dyspepsia (25.7%). Furthermore, in dysmotility-like dyspepsia, we observed no malignancies in patients less than 60 yr old, and no gastric ulcers in patients less than 50 yr old. In the latter subgroup of patients (under 50 yr), duodenal ulcers and esophagitis were rare (occurring in only one and five, respectively, out of 145 patients). In ulcer-like and reflux-like dyspepsia, abnormal endoscopic findings occurred frequently (in 73.5% and 74.1%, respectively), and no relationship with patients' age was observed. Our data indicate that patients under 50 yr old with dysmotility-like dyspepsia can be considered a kind of population for which endoscopy is inappropriate. However, because the prevalence of dysmotility-like dyspepsia was 19% (423/2253) in our patient sample, and only 7.15% of them were under 50 yr old (161/2253), we can obtain only a small percentage of reduction in endoscopic service load if the guideline of age < 50 yr is adopted.

Hormonal therapy of pancreatic carcinoma. Rationale and perspectives

Exocrine pancreas carcinoma is still diagnosed at a relatively late stage, so that only a few cases can be cured by surgery. Therefore, it is desirable that an effective medical therapy be found first to stall the development of the disease and second to improve the life conditions of patients. On the basis of recent discoveries, a new therapeutic approach seems to derive from hormone manipulation. The growth of pancreatic carcinoma appears to be stimulated by various factors, such as Epidermal Growth Factor (EGF) and Insulin-like Growth Factor I (IGF-I), and by various hormones, such as androgens and cholecystokinin. Several studies performed on cell lines and on animal models of pancreatic carcinoma demonstrated an antitumoral effect of certain antihormones and of somatostatin. Taking such studies as a premise, the first clinical studies were finally started in patients suffering from nonoperable pancreatic cancer. Results are still partial and contradictory, but such research is certainly worthy of further study along the lines already taken.

Open access endoscopy: a large-scale analysis of its use in dyspeptic patients

We examined 2,253 consecutive dyspeptic patients referred to our endoscopy service by general practitioners ("open" group) and hospital clinicians ("clinic" group) to study the prevalence of the various endoscopic findings according to patient age and the route of endoscopic referral. The results obtained are representative of that specific population. Normal endoscopic findings progressively lessened as patients' age increased, and the overall rate was as low as 26.5% in the open and 30.3% in the clinic groups. Erosive prepyloric changes and duodenitis were the most frequently noted abnormalities in patients < 40 years of age (16.9% and 20.1%, respectively, in the open and 11.6% and 14.2% in the clinic groups). Chronic gastritis was prevalent in patients > 60 years of age. Duodenal ulcer decreased from 9.7% (open) and 18% (clinic) in patients < 40 to 2% and 1.1% in patients > 60. No malignancy was found in patients < 40, while only approximately 1% of those < 60 had neoplasms. All our endoscopic findings, both in the open and the clinic groups, were not significantly different. No significant differences in symptoms were observed among patients with different endoscopic findings. We conclude that (a) endoscopy is really useful only in a small group of patients < 40 years of age; (b) individual symptoms alone have a poorly discriminant diagnostic power; and (c) restriction of open access endoscopy is not justified.

Patterns of dyspepsia in patients with no clinical evidence of organic diseases

We studied 2000 dyspeptic patients with no obvious signs of organic disease at their first examination, in order to (1) verify how many diagnoses of idiopathic dyspepsia had really been made after exhaustive diagnostic procedures and (2) evaluate the diagnostic power of the symptoms in distinguishing organic from idiopathic dyspepsia. This latter was considered only when no structural abnormalities were found. In all the other cases, a distinction was made between "related" and "associated" organic dyspepsia according to whether or not there was a certain relationship between the abnormalities and the dyspeptic symptoms. The patients were referred to us as follows: (1) spontaneously, (2) sent by physicians collaborating with us, (3) referred to our open access endoscopic service. The results show the frequency of idiopathic dyspepsia was 26%, whereas associated structural abnormalities were present in 45.4%. Obvious organic causes of dyspepsia were seen in 28.6% (24% benign and 4.6% malignant diseases). When considered separately, no symptom alone allows a correct diagnosis. The simultaneous evaluation of the symptoms with linear discriminant analysis distinguishes between idiopathic and organic dyspeptic patients in about 70% of the cases. A higher discrimination percentage in about 70% of the cases. A higher discrimination percentage could probably be obtained using a wider range of clinical parameters and/or a more complex statistical analysis of the interrelationships which exist between the clinical symptoms and the final diagnosis.

Trophic response and morphological changes in pancreas of caerulein treated rats: dose and time dependent effects

The present study was performed to determine the effect of the duration of chronic caerulein administration given at different doses, on the rat pancreas. Four groups of rats, one treated with 0.9% NaCl (control) and the others with caerulein 2, 5 and 10 micrograms/Kg twice a day i.p. were used. After a treatment period of 15, 30 and 60 days, 6 rats from each group were anesthetized, the pancreas was removed, and growth and composition of pancreatic tissue were determined. Small samples were taken for histological examination. Caerulein induced pancreatic hyperplasia and hypertrophy. The dose of caerulein used and the length of the treatment did not significantly modify the trophic effect. Focal perivascular and periductular lymphomonocytic infiltrates associated with cellular abnormalities were seen at 30 and 60 days. The results suggest that 1) the trophic effect of caerulein is not dose-and-time dependent and 2) morphological abnormalities can appear during long term treatment with CCK analogous.

Different effects of intraperitoneal or subcutaneous administration of H2-antagonists on pancreatic response to chronic administration of caerulein in rats

This study deals with the effect of H2-receptor antagonists on pancreatic response to chronic administration of caerulein. Caerulein was administered alone or combined with cimetidine, ranitidine or famotidine twice a day in various regimes. At the end of treatment, pure pancreatic juice was collected after hormonal stimulation. Then, the rats were killed, and growth and composition of the pancreatic tissue were determined. Caerulein increased pancreatic weight and enzyme content as well as volume and enzyme activity of pancreatic juice. When given alone the three H2-receptor antagonists were totally ineffective. Both ranitidine and famotidine, but not cimetidine, significantly reduced pancreatic response to chronic administration of caerulein only when given intraperitoneally together with caerulein. On the contrary, separate applications of caerulein and ranitidine (or famotidine) did not influence caerulein-stimulated pancreatic growth or enzyme secretion. Moreover, in rats treated both intraperitoneally and subcutaneously with caerulein, the H2-antagonists reduced the pancreatic response only partially and in proportion to the intraperitoneal dose of caerulein. The responsiveness of pancreatic tissue to subcutaneous caerulein was not modified. The results suggest that H2-receptor antagonists induce (1) impaired uptake of caerulein when given together with peptide, but (2) have no specific inhibitory effect on pancreatic response to caerulein.

Fine-needle aspiration cytodiagnosis: a simple and safe procedure for cancer of the pancreas

One hundred fine-needle aspirations (45 percutaneous ultrasonically-guided and 55 intraoperative) were performed in 82 patients suspected of having pancreatic cancer, in order to evaluate the contribution of cytologic data to definitive diagnosis of this tumor. The overall success rate of both cytologic methods was 90.6 p. 100 in our 64 patients who were histologically proved to have pancreatic cancer. Sensitivity was 77.4 p. 100 with percutaneous and 75.5 p. 100 with intraoperative aspirations. In all 18 cases with the final diagnosis of chronic pancreatitis results of both techniques were negative. Neither relevant morbidity nor mortality were recorded in any of the 82 patients. These cytologic studies are at present reliable, rapid, highly cost-effective (especially percutaneous aspiration) and most important, safer than histologic examinations. We believe that fine-needle aspiration cytology has gained a primary role in the diagnostic process of pancreatic carcinoma. Therefore the old view of considering examination of cytologic material only as a screening procedure should be abandoned.