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Whitson MJ, Lynch KL, Yang YX, Metz DC, Falk GW. Lack of proton pump inhibitor trial prior to commencing therapy for eosinophilic esophagitis is common in the community. Dis Esophagus 2018; 31:4774511. [PMID: 29293904 DOI: 10.1093/dote/dox143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis is characterized by eosinophil inflammation restricted to the esophagus and the resulting symptoms of esophageal dysfunction. Critical to the diagnosis of eosinophilic esophagitis is a trial of proton pump inhibitor therapy to exclude alternative causes of esophageal eosinophilia such as proton pump inhibitor-responsive esophageal eosinophilia. While consensus guidelines recommend a proton pump inhibitor trial prior to diagnosis, little is known about its implementation in clinical practice. The primary aim of this study is to assess the frequency of proton pump inhibitor trial prior to the diagnosis of eosinophilic esophagitis in community practice. The secondary aim is to assess the frequency of other treatments for eosinophilic esophagitis, including topical steroids and/or dietary therapy, in patients who did not undergo a proton pump inhibitor trial prior to diagnosis or who had an alternative diagnosis to eosinophilic esophagitis upon completed workup. We conducted a single-center, case series of patients referred to the Hospital of the University of Pennsylvania for eosinophilic esophagitis management between 2010 and 2015. This case series consisted of 125 patients who were referred from community practitioners with a presumptive diagnosis of eosinophilic esophagitis. Upon review, 90 out of 125 (72%) patients had not had a proton pump inhibitor trial or esophageal pH testing prior to the diagnosis of eosinophilic esophagitis being made. Of these patients, 77.8% (70/90) had already received either topical steroid or dietary therapy for presumed eosinophilic esophagitis. Of the 125 patients initially diagnosed with eosinophilic esophagitis, 32 (25.6%) were found to have an alternative diagnosis, and 79.2% of this subset of patients (25/32) had previously received topical steroid or dietary therapy. This study demonstrates that a substantial number of patients with presumed eosinophilic esophagitis have not had a proton pump inhibitor trial prior to diagnosis in community practice. This led to the misclassification of patients and potentially to the use of less optimal medical therapies in a substantial number of these patients.
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Affiliation(s)
- M J Whitson
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K L Lynch
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Y-X Yang
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - D C Metz
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - G W Falk
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Lynch KL, Yang YX, Metz DC, Falk GW. Clinical presentation and disease course of patients with esophagogastric junction outflow obstruction. Dis Esophagus 2017; 30:1-6. [PMID: 28475741 DOI: 10.1093/dote/dox004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/11/2017] [Indexed: 12/11/2022]
Abstract
Esophagogastric junction outflow obstruction, characterized by preserved peristalsis in conjunction with an elevated integrated relaxation pressure, can result from specific anatomic variants or may represent achalasia in evolution. There is limited information on the clinical significance of this diagnosis. The aim of this study is to describe the clinical characteristics and outcomes in our cohort of patients with esophagogastric junction outflow obstruction.Consecutive adult patients who had undergone high-resolution esophageal manometry between February 2013 and November 2015 with a diagnosis of esophagogastric junction outflow obstruction were identified. Electronic medical records were reviewed to determine: (1) secondary causes of esophagogastric junction outflow obstruction; (2) treatment; and (3) natural history. Improvement in symptoms noted during follow-up evaluation was considered to be a favorable outcome. Worsening of symptoms or no change in symptoms was considered to be an unfavorable outcome.Of 874 manometries performed during this time period, 83 met the criteria for esophagogastric junction outflow obstruction. Of these patients, 11 had secondary causes: paraesophageal hernia (4), Nissen fundoplication (2), esophageal stricture (3), prior laparoscopic band placement (1), and diverticulum (1). All of these secondary causes were identified by barium esophagram. The remaining 72 patients were categorized as idiopathic esophagogastric junction outflow obstruction. Two patients developed type II achalasia on follow-up. An additional two patients had no symptoms as testing was performed for preoperative evaluation prior to bariatric surgery, leaving 68 patients for symptom follow-up analysis. Of these, 19 had a favorable outcome, 18 had an unfavorable outcome, and 31 were lost to follow-up. Of those with a favorable outcome, 6 patients underwent treatment: medication (3), botulinum toxin injection followed by laparoscopic Heller myotomy (1), botulinum toxin injection and medication (1), and bougie dilation (1). Of the 18 patients with an unfavorable outcome, 6 patients underwent treatment: botulinum toxin injection (5) and medication (1). Computed tomography scan or endoscopic ultrasound was performed in 40% of patients with available follow-up and none of these studies revealed secondary causes. The overall median follow-up time was 5 months.Esophagogastric outflow obstruction is a manometric finding of unclear significance. Secondary causes should first be excluded with structural studies. The evolution of esophagogastric junction outflow obstruction to achalasia is rare. Symptoms in patients with esophagogastric junction outflow obstruction do not always require treatment and treatment response is variable. The challenge in managing these patients lies in distinguishing which patients will need intervention. Further studies are needed for consideration of subgrouping this disease or modifying the categorization into clinically relevant entities.
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Affiliation(s)
- K L Lynch
- Department of Internal Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Y-X Yang
- Department of Internal Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - D C Metz
- Department of Internal Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - G W Falk
- Department of Internal Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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3
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Leiman DA, Riff BP, Morgan S, Metz DC, Falk GW, French B, Umscheid CA, Lewis J. Alginate therapy is effective treatment for GERD symptoms: a systematic review and meta-analysis. Dis Esophagus 2017; 30:1-9. [PMID: 28375448 PMCID: PMC6036656 DOI: 10.1093/dote/dow020] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 11/15/2016] [Indexed: 12/11/2022]
Abstract
In patients with gastroesophageal reflux disease (GERD) and erosive esophagitis, treatment with proton pump inhibitors (PPIs) is highly effective. However, in some patients, especially those with nonerosive reflux disease or atypical GERD symptoms, acid-suppressive therapy with PPIs is not as successful. Alginates are medications that work through an alternative mechanism by displacing the postprandial gastric acid pocket. This study performed a systematic review and meta-analysis to examine the benefit of alginate-containing compounds in the treatment of patients with symptoms of GERD. PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through October 2015 for randomized controlled trials comparing alginate-containing compounds to placebo, antacids, histamine-2 receptor antagonists (H2RAs), or PPIs for the treatment of GERD symptoms. Additional studies were identified through a bibliography review. Non-English studies and those with pediatric patients were excluded. Meta-analyses were performed using random-effect models to calculate odds ratios (OR). Heterogeneity between studies was estimated using the I2 statistic. Analyses were stratified by type of comparator. The search strategy yielded 665 studies and 15 (2.3%) met inclusion criteria. Fourteen were included in the meta-analysis (N = 2095 subjects). Alginate-based therapies increased the odds of resolution of GERD symptoms when compared to placebo or antacids (OR: 4.42; 95% CI 2.45-7.97) with a moderate degree of heterogeneity between studies (I2 = 71%, P = .001). Compared to PPIs or H2RAs, alginates appear less effective but the pooled estimate was not statistically significant (OR: 0.58; 95% CI 0.27-1.22). Alginates are more effective than placebo or antacids for treating GERD symptoms.
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Affiliation(s)
- D. A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - B. P. Riff
- Division of Gastroenterology, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | | | | | - B. French
- Center for Evidence-based Practice,Department of Biostatistics and Epidemiology,Leonard Davis Institute of Health Economics,Center for Clinical Epidemiology and Biostatistics
| | - C. A. Umscheid
- Center for Evidence-based Practice,Department of Biostatistics and Epidemiology,Leonard Davis Institute of Health Economics,Center for Clinical Epidemiology and Biostatistics,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J. D. Lewis
- Division of Gastroenterology,Department of Biostatistics and Epidemiology,Leonard Davis Institute of Health Economics,Center for Clinical Epidemiology and Biostatistics
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4
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Leiman DA, Riff BP, Morgan S, Metz DC, Falk GW, French B, Umscheid CA, Lewis JD. Alginate therapy is effective treatment for gastroesophageal reflux disease symptoms: a systematic review and meta-analysis. Dis Esophagus 2017; 30:1-8. [PMID: 27671545 DOI: 10.1111/dote.12535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In patients with gastroesophageal reflux disease (GERD) and erosive esophagitis, treatment with proton pump inhibitors (PPIs) is highly effective. However, in some patients, especially those with non-erosive reflux disease or atypical GERD symptoms, acid suppressive therapy with PPIs is not as successful. Alginates are medications that work through an alternative mechanism by displacing the post-prandial gastric acid pocket. We performed a systematic review and meta-analysis to examine the benefit of alginate-containing compounds in the treatment of patients with symptoms of GERD.PubMed/MEDLINE, Embase and the Cochrane library electronic databases were searched through October 2015 for randomized controlled trials comparing alginate-containing compounds to placebo, antacids, histamine-2 receptor antagonists (H2RAs) or PPIs for the treatment of GERD symptoms. Additional studies were identified through bibliography review. Non-English studies and those with pediatric patients were excluded. Meta-analyses were performed using random-effects models to calculate odds ratios (OR). Heterogeneity between studies was estimated using the I2 statistic. Analyses were stratified by type of comparator. The search strategy yielded 665 studies and 15 (2.3%) met inclusion criteria. Fourteen were included in the meta-analysis (N = 2095 subjects). Alginate-based therapies increased the odds of resolution of GERD symptoms when compared to placebo or antacids (OR: 4.42; 95% CI 2.45-7.97) with a moderate degree of heterogeneity between studies (I2 = 71%, P = .001). Compared to PPIs or H2RAs, alginates appear less effective but the pooled estimate was not statistically significant (OR: 0.58; 95% CI 0.27-1.22). Alginates are more effective than placebo or antacids for treating GERD symptoms.
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Affiliation(s)
- D A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - B P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - S Morgan
- Center for Evidence-based Practice, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - D C Metz
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - G W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - B French
- Center for Evidence-based Practice, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Biostatistics and Epidemiology, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Leonard Davis Institute of Health Economics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - C A Umscheid
- Center for Evidence-based Practice, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Biostatistics and Epidemiology, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Leonard Davis Institute of Health Economics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J D Lewis
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Leonard Davis Institute of Health Economics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, niversity of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Metz DC. Commentary: netazepide for gastric acid suppression--another kid on the block? Aliment Pharmacol Ther 2012; 36:294-5. [PMID: 22747455 DOI: 10.1111/j.1365-2036.2012.05183.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- D C Metz
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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6
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Abstract
Proton pump inhibitors are highly effective acid suppressants with decades of use highlighting positive outcomes in millions of patients worldwide, and they offer minimal risk of adverse events. PPIs are considered overutilised when prescribed without an appropriate indication, when patients are left on them 'indefinitely' without appropriate indications and when they are continued after being utilised for most cases of hospital SUP. While several adverse outcomes have been linked to PPI therapy, most data are from retrospective observational studies that may be subject to confounding and bias.
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Affiliation(s)
- J J Heidelbaugh
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.
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Hasskarl J, Kaufmann M, Schmid H, Metz DC. The potential role of somatostatin analogues in the treatment of gastrointestinal (GI) cancers. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.4_suppl.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
150 Background: Somatostatin receptors (sstr) are expressed in various normal and malignant tissues, including non-neuroendocrine GI solid tumors. Gastric cancer (GC) cells mainly express sstr2 and sstr5, colorectal cancer (CRC) cells predominantly express sstr1 followed by sstr5 and sstr2, and hepatocellular carcinoma (HCC) cells express mainly sstr5 as well as sstr1,2,3. Somatostatin analogues (SAs) may have direct and indirect antitumor activity. Octreotide and lanreotide primarily target sstr2, whereas the new agent pasireotide has high affinity for sstr1,2,3 and sstr5. Methods: Published data evaluating the antitumor properties of SAs in GI tumors were reviewed. Results: The table lists the results of clinical studies in which SAs were evaluated as antitumor therapies in GI cancers. Conclusions: Although octreotide and lanreotide are efficacious in the treatment of symptoms of neuroendocrine tumors, these agents have demonstrated mixed results in the antitumor treatment of non-neuroendocrine GI tumors. Data suggesting potential favorable outcomes with SAs alone or in combination with other agents have been seen in solid tumors with predominant sstr2 expression such as GC. Novel SAs such as pasireotide may have improved antitumor effects in non-neuroendocrine solid tumors expressing multiple sstr compared with octreotide and lanreotide. [Table: see text] [Table: see text]
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Affiliation(s)
- J. Hasskarl
- Novartis Pharma AG, Basel, Switzerland; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - M. Kaufmann
- Novartis Pharma AG, Basel, Switzerland; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - H. Schmid
- Novartis Pharma AG, Basel, Switzerland; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - D. C. Metz
- Novartis Pharma AG, Basel, Switzerland; University of Pennsylvania School of Medicine, Philadelphia, PA
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Peura DA, Metz DC, Dabholkar AH, Paris MM, Yu P, Atkinson SN. Safety profile of dexlansoprazole MR, a proton pump inhibitor with a novel dual delayed release formulation: global clinical trial experience. Aliment Pharmacol Ther 2009; 30:1010-21. [PMID: 19735233 DOI: 10.1111/j.1365-2036.2009.04137.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Dexlansoprazole MR is a dual delayed release formulation of dexlansoprazole, an enantiomer of lansoprazole. AIM To assess safety of dexlansoprazole MR in phase 3 clinical trials. METHODS Data from 4270 patients receiving dexlansoprazole MR 30 mg (n = 455), 60 mg (n = 2311) or 90 mg (n = 1864); lansoprazole 30 mg (n = 1363); or placebo (n = 896) in six randomized controlled trials and a 12-month safety study were pooled. Safety was assessed via adverse events, vital signs, electrocardiograms, clinical laboratory results and gastric biopsies. Adverse events were summarized per 100 patient-months of exposure to account for imbalances in study drug exposure. RESULTS The number of patients with > or =1 treatment-emergent adverse event per 100 patient-months was higher in placebo (24.49) and lansoprazole (21.06) groups than in any dexlansoprazole MR (15.64-18.75) group. Fewer patients receiving dexlansoprazole MR discontinued therapy because of an adverse event (P < or = 0.05 vs. placebo). Seven patients died of events considered unrelated to study drug. Mean serum gastrin rose in all groups except placebo; increases were not dose-related. No clinically concerning trends were seen in gastric biopsy results. Endocrine cell hyperplasia, dysplasia and neoplasia were not observed. CONCLUSION Dexlansoprazole MR 30-90 mg has a safety profile comparable to that of lansoprazole.
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Affiliation(s)
- D A Peura
- University of Virginia Health Sciences Center, Charlottesville, VA, USA.
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9
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Metz DC, Vakily M, Dixit T, Mulford D. Review article: dual delayed release formulation of dexlansoprazole MR, a novel approach to overcome the limitations of conventional single release proton pump inhibitor therapy. Aliment Pharmacol Ther 2009; 29:928-37. [PMID: 19298580 DOI: 10.1111/j.1365-2036.2009.03984.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) provide the most effective pharmacotherapy for treating acid-related disorders. However, PPIs do not completely control acid over 24 h with once-daily dosing. AIMS To discuss limitations inherent in the pharmacokinetics (PK) and pharmacodynamics of conventional PPI formulations, which provide a single drug release. Also, to consider approaches to extending the duration of acid suppression focusing on dexlansoprazole MR, a PPI with a novel Dual Delayed Release (DDR) formulation. METHOD We reviewed the available literature regarding marketed and investigational PPIs. RESULTS Non-standard dosing of currently marketed PPIs has produced incremental advances in acid control. Multiple approaches are being evaluated to enhance acid suppression with PPIs. Dexlansoprazole MR is a DDR formulation of dexlansoprazole, an enantiomer of lansoprazole, with two distinct drug release periods to prolong the plasma dexlansoprazole concentration-time profile and extend duration of acid suppression. Clinical studies show that dexlansoprazole MR produces a dual-peak PK profile that maintains therapeutic plasma drug concentrations longer than lansoprazole, with a single-peak PK profile, and increases the percentage of time that intragastric pH >4. CONCLUSIONS Novel drug delivery platforms, including the dexlansoprazole MR DDR formulation, may improve acid suppression and offer benefits over conventional single release PPI formulations.
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Affiliation(s)
- D C Metz
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Metz DC, Howden CW, Perez MC, Larsen L, O'Neil J, Atkinson SN. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther 2009; 29:742-54. [PMID: 19210298 DOI: 10.1111/j.1365-2036.2009.03954.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dexlansoprazole MR heals all grades of erosive oesophagitis (EO). AIM To assess efficacy and safety of dexlansoprazole MR in maintaining healed EO and heartburn relief. METHODS In this randomized, double-blind trial, 445 patients with healed EO received dexlansoprazole MR 30 mg or 60 mg or placebo once daily for 6 months. This trial assessed maintenance of endoscopic healing (primary endpoint) and continued symptom relief based on daily diaries (secondary endpoints). RESULTS Dexlansoprazole MR 30 mg and 60 mg were superior to placebo for maintaining healed EO (P < 0.0025; Hochberg's). By life-table analysis, maintenance rates were 75%, 83% and 27% for dexlansoprazole MR 30 mg, 60 mg and placebo respectively. Crude maintenance rates were 66% for both dexlansoprazole MR doses and 14% for placebo. Dexlansoprazole MR controlled heartburn (medians of 91-96% for 24-h heartburn-free days, 96-99% for heartburn-free nights). The only more common adverse event occurring at a significantly higher rate in dexlansoprazole MR groups than placebo when analysed per patient-months of exposure was upper respiratory tract infection. CONCLUSIONS Dexlansoprazole MR effectively maintained EO healing and symptom relief; most patients were heartburn-free for >90% of days. Both doses were well tolerated.
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Affiliation(s)
- D C Metz
- University of Pennsylvania School of Medicine, Division of Gastroenterology, Philadelphia, PA, USA
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11
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Levin DA, Watermeyer G, Mohamed N, Epstein DP, Hlatshwayo SJ, Metz DC. Evaluation of a locally produced rapid urease test for the diagnosis of Helicobacter pylori infection. S Afr Med J 2007; 97:1281-1284. [PMID: 18264610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND The rapid urease test (RUT) is used at Groote Schuur Hospital for diagnosing Helicobacter pylori infection. This is an in-house method, which has not been validated. OBJECTIVE To validate our practice of reading the RUT immediately after endoscopy (RUT(0)), by comparing this with a reading at 24 hours (RUT(24)) and with histological analysis. DESIGN Ninety consecutive patients undergoing upper endoscopy over a 6-week period from October 2005 to November 2005, and in whom rapid urease testing was indicated, were included in the study. Patients with recent exposure (within 2 weeks of endoscopy) to proton pump inhibitors (PPIs), histamine receptor antagonists (H2RAs) and antibiotics (confounders) were noted and included in the cohort. Two antral and two body biopsies were taken for histological examination and a third antral biopsy was placed in the RUT bottle. Both haematoxylin and eosin and modified Giemsa staining methods were used to identify H. pylori. The RUT was read immediately (within 5 minutes of upper endoscopy) (RUT(0)), as per our current practice, and each specimen was re-read at 24 hours (RUT(24)). Sensitivity, specificity, positive and negative predictive values and the impact of confounders were calculated. RESULTS Of the 90 patients undergoing rapid urease testing, 39% were male and 61% were female, with a mean age of 55 years (range 22-79 years). Histological examination revealed H. pylori in 67.8% (N=61) of the biopsy specimens. In the 65 patients without confounders, the sensitivity and specificity of the RUT(0) were 65.9% and 100% respectively, and 90.9% and 100% for RUT(24). After including the 25 patients with confounders, the sensitivity and specificity were 68.8% and 100% for RUT(0), and 90.1% and 100% for RUT(24) respectively. Thirteen RUT(0) specimens (30.9%) that were initially negative became positive at the RUT(24) reading. There were 6 (9.8%) RUT(0)- and RUT(24)-negative but histology-positive specimens. Four of these 6 false-negative RUT(24) results could be accounted for by a low H. pylori density on histological analysis (2 patients were taking PPIs). Confounders did not alter the sensitivity and specificity outcomes or impact on the number of false-negative RUTs. CONCLUSIONS Our locally prepared RUT is a specific test for the detection of H. pylori infection. The sensitivity is greatly enhanced by reading the test at 24 hours. The use of PPIs, H(2)RAs and antibiotics preceding endoscopy did not impact significantly on the results.
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Affiliation(s)
- D A Levin
- Gastrointestinal Clinic, University of Cape Town and Groote Schuur Hospital, Cape Town.
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12
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Abstract
Several studies suggest that older adults with gastroesophageal reflux disease (GERD) are more likely to develop complications, including erosive esophagitis, but it is unclear whether erosive esophagitis is more difficult to treat in older patients. The purpose of this study was to determine if adults > or = 65 years with erosive esophagitis are more difficult to treat than younger adults. The study was a post hoc analysis of two double-blind, randomized, multicenter trials of patients with erosive esophagitis. Patients received pantoprazole 40 mg once daily, nizatidine 150 mg twice daily or placebo. Patients were evaluated for endoscopic healing at 4 and 8 weeks. Patients recorded typical reflux symptoms using a daily diary to note presence or absence of symptoms. Results showed that 44, 13 and 11 patients > or = 65 years and 210, 69, and 71 patients < 65 received pantoprazole 40 mg daily, nizatidine 150 mg twice daily, or placebo, respectively. Eighty-six percent (86%[76%, 97% CI]) of older and 83% (78%, 88% CI) of younger pantoprazole-treated patients were healed at 8 weeks; 46% (19%, 73% CI) and 35% (24%, 46% CI) of nizatidine-treated and 27% (1%, 54% CI) and 34% (23%, 45% CI) of placebo-treated were healed at 8 weeks. Median time to persistent absence of GERD-related symptoms was similar for older and younger patients treated with pantoprazole. We conclude that older patients with erosive esophagitis do not appear to have more difficult-to-treat disease. Erosive esophagitis is effectively healed and GERD symptoms are controlled in older patients using pantoprazole 40 mg daily.
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Affiliation(s)
- K R DeVault
- Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida 32224, USA.
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13
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Jensen RT, Metz DC, Koviack PD, Feigenbaum KM. Prospective study of the long-term efficacy and safety of lansoprazole in patients with the Zollinger-Ellison syndrome. Aliment Pharmacol Ther 2007; 7 Suppl 1:41-50, discussion 61-6. [PMID: 8490079 DOI: 10.1111/j.1365-2036.1993.tb00588.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The long-term safety and efficacy of lansoprazole were studied in 21 patients with Zollinger-Ellison syndrome. The initial maintenance dose was determined by acid inhibition studies. In all patients lansoprazole controlled gastric acid hypersecretion and peptic symptoms in both the short and long term. Patients were treated for a mean of 31 months (range 1-43 months) with all but 4 patients followed for > 18 months. The mean initial dose was 60 mg/day, with 2 patients requiring a twice daily dose and the others a single daily dose. During long-term treatment 6 patients required an increased dosage, 5 within the first year. Long-term maintenance doses were reduced in 5 of the 6 patients in whom this was attempted. No changes in serum gastrin concentration, haematological parameters, liver function studies or other biochemical parameters occurred due to lansoprazole. No patient developed a gastric carcinoid tumour while being treated with lansoprazole. These results demonstrate that long-term treatment with lansoprazole is both safe and effective in patients with Zollinger-Ellison syndrome, and suggest that this drug will be useful in such patients. Furthermore, maintenance doses of lansoprazole, determined by the currently recommended method of acute acid titration studies in patients with Zollinger-Ellison syndrome, are too high.
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Affiliation(s)
- R T Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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Howden CW, Metz DC, Hunt B, Vakily M, Kukulka M, Amer F, Samra N. Dose-response evaluation of the antisecretory effect of continuous infusion intravenous lansoprazole regimens over 48 h. Aliment Pharmacol Ther 2006; 23:975-84. [PMID: 16573800 DOI: 10.1111/j.1365-2036.2006.02849.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Attainment of intragastric pH < 6.0 may require high-dose continuously infused proton pump therapy. AIM To assess the pharmacokinetic and pharmacodynamic dose-responses of continuous infusion regimens of lansoprazole. METHODS Healthy adult subjects were assigned to lansoprazole 60-mg intravenous bolus, followed by 6-mg/h continuous infusion; a 90-mg intravenous bolus followed by 6-, 7.5-, or 9-mg/h continuous infusion; or placebo. RESULTS Mean intragastric pH values for lansoprazole regimens ranged from 4.8 to 5.2 (0-24 h), 5.5 to 6.0 (>24 to 48 h) and 5.2 to 5.6 (0-48 h). Within these three intervals, the percentages of time intragastric pH exceeded 4, 5 and 6 ranged from 65% to 96%, 54% to 88% and 30% to 61% respectively. Pharmacokinetic parameters were dose-independent with steady-state plasma concentrations achieved within 6-12 h postdose and maintained over 48 h. The mean systemic clearance of lansoprazole was lower in CYP2C19 heterozygous metabolizers than in homozygous extensive metabolizers (9.2 vs. 16.5 L/h), with substantial variability resulting in overlapping ranges of clearance values for both subpopulations. All lansoprazole regimens were well-tolerated. CONCLUSIONS Lansoprazole administered as a 60-mg intravenous bolus followed by 6-mg/h continuous infusion produced intragastric pH effects comparable with those of higher dosage regimens.
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Affiliation(s)
- C W Howden
- Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA.
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15
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Metz DC, Amer F, Hunt B, Vakily M, Kukulka MJ, Samra N. Lansoprazole regimens that sustain intragastric pH > 6.0: an evaluation of intermittent oral and continuous intravenous infusion dosages. Aliment Pharmacol Ther 2006; 23:985-95. [PMID: 16573801 DOI: 10.1111/j.1365-2036.2006.02850.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Orally and intravenously administered proton pump inhibitors have been shown to reduce rebleeding rates, surgery and transfusion requirement. AIM To compare lansoprazole intravenous and orally disintegrating tablet (Prevacid SoluTab) regimens with a pantoprazole intravenously administered regimen in sustaining intragastric pH >6.0. METHODS Two similarly designed three-way, randomized crossover studies each enrolled 36 Helicobacter pylori-negative healthy volunteers. Study 1 regimens included intravenously administered bolus followed by 24-h continuous infusion (lansoprazole 90 mg, 6 mg/h; lansoprazole 120 mg, 6 mg/h; pantoprazole 80 mg, 8 mg/h). Study 2 regimens included intravenous bolus followed by lansoprazole orally disintegrating tablet or intravenous continuous infusion for 24 h (lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg every 6 h; lansoprazole 120 mg, 9 mg/h; pantoprazole 80 mg, 8 mg/h). Percentage of time pH >6.0 was assessed with 24-h intragastric pH monitoring. RESULTS All regimens produced comparable gastric acid suppression. In both studies, regimens superior to pantoprazole included lansoprazole 90 mg, 6-mg/h; lansoprazole 90 mg, lansoprazole orally disintegrating tablet 60 mg q.d.s. and lansoprazole 120 mg, 9 mg/h (P < or = 0.013). The lansoprazole 120-mg, 6-mg/h regimen (P = 0.082) was not superior to pantoprazole in percentage of time intragastric pH >6.0. Mild reaction at the intravenous injection site was the most frequently reported adverse event. CONCLUSIONS The intravenous bolus and continuously infused lansoprazole or intravenous bolus and intermittent lansoprazole orally disintegrating tablet regimens are as effective as intravenous pantoprazole in sustaining intragastric pH >6.0.
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Affiliation(s)
- D C Metz
- University of Pennsylvania Health Sciences, Philadelphia, 19004, USA.
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16
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Metz DC, Comer GM, Soffer E, Forsmark CE, Cryer B, Chey W, Pisegna JR. Three-year oral pantoprazole administration is effective for patients with Zollinger-Ellison syndrome and other hypersecretory conditions. Aliment Pharmacol Ther 2006; 23:437-44. [PMID: 16423003 PMCID: PMC6736592 DOI: 10.1111/j.1365-2036.2006.02762.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Zollinger-Ellison syndrome and idiopathic hypersecretion are gastrointestinal hypersecretory conditions requiring long-term maintenance. AIMS The safety and efficacy data for short-term (6-month) treatment of Zollinger-Ellison syndrome and idiopathic hypersecretion with oral pantoprazole were previously published. This study extends the initial observations to 3 years. METHODS The primary efficacy end point for this report was the control of gastric acid secretion in the last hour before the next dose of oral pantoprazole (acid output of <10 mmol/h; <5 mmol/h in subjects with prior acid-reducing surgery). Dose titration was permitted to a maximum of 240 mg per 24 h. RESULTS Twenty-four subjects completed the study. The acid output of 28 of 34 subjects was controlled at initial enrolment. The mean acid output rates were <10 mmol/h throughout the 36 months of treatment for 90-100% of the patients. The majority of the patients were controlled with b.d. doses of 40 or 80 mg pantoprazole at 36 months (acid output was controlled in 24 of 24 subjects). Pantoprazole was generally well tolerated with minimal adverse events reported. CONCLUSIONS Maintenance oral pantoprazole therapy up to 3 years at dosages of 40-120 mg b.d. was effective and well tolerated in patients with Zollinger-Ellison syndrome and other hypersecretory conditions.
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Affiliation(s)
- D C Metz
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Medical Center, Philadelphia, PA, USA
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17
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Metz DC, Miner PB, Heuman DM, Chen Y, Sostek M. Comparison of the effects of intravenously and orally administered esomeprazole on acid output in patients with symptoms of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2005; 22:813-21. [PMID: 16225490 DOI: 10.1111/j.1365-2036.2005.02659.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intravenous esomeprazole may be beneficial for patients who cannot take oral medications. AIM To compare intravenous esomeprazole with oral esomeprazole for effects on maximal acid output during pentagastrin stimulation in patients with gastro-oesophageal reflux disease symptoms. METHODS In four separate open-label, randomized, two-way crossover studies, adult patients were administered esomeprazole 20 or 40 mg once daily either orally or intravenously (by 15-min infusion or 3-min injection) for 10 days and switched to the other formulation with no washout period. Basal acid output and maximal acid output were measured on days 11, 13 and 21. RESULTS In the four studies (total of 183 patients), least-squares mean maximal acid output ranged from 3.0 to 4.1 mmol/h after intravenous esomeprazole 40 or 20 mg and from 2.2 to 3.3 mmol/h after oral esomeprazole 20 or 40 mg. Differences between formulations were small and not statistically significant but did not meet the prospectively defined criterion for non-inferiority of the intravenous formulation. Median basal acid output values ranged from 0.04 to 0.27 mmol/h after intravenous administration and from 0.05 to 0.25 mmol/h after oral esomeprazole. CONCLUSIONS Intravenous esomeprazole is an acceptable alternative to the oral formulation for treatment of up to 10 days of duration.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
BACKGROUND Measurement of oesophageal acid exposure parameters postprandially has been shown to distinguish gastro-oesophageal reflux disease patients from normal individuals. AIMS To calculate the accuracy of postprandial oesophageal integrated acidity in diagnosing gastro-oesophageal reflux disease. METHODS Ambulatory 24-h pH studies of 626 patients were analysed retrospectively. Gastro-oesophageal reflux disease, defined as pH < 4 for > 4.2% of time, was identified in 305 subjects. Postprandial oesophageal integrated acidity was measured for 2 and 3 h after the largest meal peak as determined from gastric pH. Postprandial symptom-associated probability was calculated. RESULTS Gastro-oesophageal reflux disease subjects had a greater postprandial oesophageal integrated acidity than non-gastro-oesophageal reflux disease subjects [median (IQR): 0.57 (0.08-2.66) vs. 0.03 (0.01-0.15) mmol*h/L]. Median postprandial oesophageal integrated acidity did not differ with gender or age in gastro-oesophageal reflux disease and non-gastro-oesophageal reflux disease subjects (P > 0.05 for all). A 3-h postprandial oesophageal integrated acidity value of 0.121 mmol*h/L had a 71.1% sensitivity and 71.7% specificity in diagnosing gastro-oesophageal reflux disease. Gastro-oesophageal reflux disease subjects with symptoms had a higher postprandial oesophageal integrated acidity than those without (P = 0.043), whereas non-gastro-oesophageal reflux disease subjects with and without symptoms did not differ (P = 0.74). The correlation between symptom-associated probability and postprandial oesophageal integrated acidity was poor (gastro-oesophageal reflux disease: r = 0.15; non-gastro-oesophageal reflux disease: r = 0.25). CONCLUSION Postprandial oesophageal integrated acidity provides a robust estimation of oesophageal acid exposure and may predict symptoms in gastro-oesophageal reflux disease patients.
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Affiliation(s)
- G L Shih
- Division of Gastroenterology, University of Pennsylvania Health Systems, Philadelphia, PA 19104, USA
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Abstract
BACKGROUND Effective symptom control is a primary concern of most heartburn suffers. AIM To compare the safety and efficacy of pantoprazole, placebo and the H2 antagonist nizatidine in relieving symptoms in patients with erosive oesophagitis. METHODS Data from two randomized, double-blind studies were pooled. Patients received pantoprazole 10, 20 or 40 mg, or placebo daily (study 1, n = 603), or pantoprazole 20 or 40 mg daily or 150-mg nizatidine b.d. (study 2, n = 243) for either 4 or 8 weeks. Endoscopy was performed at baseline, week 4 and week 8. Persistent absence of symptoms was defined as the first day that no symptoms were reported by the patient on that day or any subsequent study day. RESULTS A significantly higher percentage (P < 0.05) of pantoprazole patients reported elimination of all symptoms by week 8. Daytime heartburn, night-time heartburn and regurgitation were significantly better controlled with pantoprazole (with a dose-response at most time-points). Absence of symptoms was a powerful predictor of healing; presence of symptoms correlated poorly. CONCLUSION Pantoprazole is more effective than placebo or nizatidine for controlling heartburn and acid regurgitation in patients with erosive oesophagitis. Relief of GERD symptoms is highly predictive of healing of erosive oesophagitis at 4 and 8 weeks.
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Affiliation(s)
- W J Bochenek
- Clinical Research and Development, Wyeth Research, Collegeville, PA, USA
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Kovacs TOG, Lee CQ, Chiu YL, Pilmer BL, Metz DC. Intravenous and oral lansoprazole are equivalent in suppressing stimulated acid output in patient volunteers with erosive oesophagitis. Aliment Pharmacol Ther 2004; 20:883-9. [PMID: 15479360 DOI: 10.1111/j.1365-2036.2004.02188.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Some patients requiring acid suppression may be unable to take oral medications. AIM To compare the gastric acid inhibition effects of lansoprazole 30 mg administered either intravenous or orally in erosive oesophagitis patients. METHODS The study included 87 Helicobacter pylori-negative patients with erosive oesophagitis. Each patient received 7 days of lansoprazole 30 mg orally prior to being randomized in a 3:1 fashion to intravenously lansoprazole 30 mg or intravenously placebo for 7 days. Basal acid output and pentagastrin-stimulated acid output were measured on days 8, 9 and 15. RESULTS Median pentagastrin-stimulated acid output was 7.2 mmol/h after 7 days of oral lansoprazole. The median pentagastrin-stimulated acid output increased to 7.6 mmol/h after 7 days of intravenous lansoprazole compared with 26.9 mmol/h after intravenous placebo (P < 0.001). CONCLUSIONS Lansoprazole 30 mg administered intravenous was equivalent to the 30 mg oral capsule in gastric acid suppression. Intravenous proton pump inhibitor therapy represents an important treatment option for those with acid-related diseases who are unable to take oral medications.
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Affiliation(s)
- T O G Kovacs
- VA Greater Los Angeles Healthcare System, CURE Clinic, Los Angeles, CA 90073, USA.
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Abstract
OBJECTIVES To compare the safety and efficacy of pantoprazole with ranitidine for the maintenance of endoscopically documented healed (grade 0 or 1) erosive oesophagitis. METHODS Patients (371) were randomly assigned to receive pantoprazole 10, 20 or 40 mg or ranitidine 150 mg. Endoscopies were performed after 1, 3, 6 and 12 months or when symptoms suggesting relapse (grade = 2) developed. Gastric biopsies were obtained at baseline and on at least one postbaseline visit. Symptom-free days and Gelusil use were assessed. RESULTS Pantoprazole was significantly (P < 0.001) more effective in maintaining erosive oesophagitis healing. After 12 months, 33%, 40%, 68% and 82% of patients remained healed for the ranitidine and pantoprazole 10, 20 and 40 mg groups, respectively. Daytime and night-time heartburn were eliminated in > 90% of days for the pantoprazole 40 mg group. Gelusil use was significantly lower with pantoprazole 20 and 40 mg than with ranitidine (P < 0.02) during the first 9 months. CONCLUSIONS Twelve months of maintenance therapy with pantoprazole (10-40 mg once daily) was superior to ranitidine (150 mg twice daily) in maintaining erosive oesophagitis healing. Pantoprazole 40 mg provided the most consistent efficacy and was well tolerated.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, 3400 Spruce Street, 3 Dulles, Philadelphia, PA 19104-4283, USA.
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Dheer S, Levine MS, Redfern RO, Metz DC, Rubesin SE, Laufer I. Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection. Br J Radiol 2002; 75:805-11. [PMID: 12381689 DOI: 10.1259/bjr.75.898.750805] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.
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Affiliation(s)
- S Dheer
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Abstract
The importance of ammonia-producing Helicobacter pylori infection as a cause of subclinical encephalopathy in cirrhosis was investigated. In addition, a single psychometric test that can reliably detect subclinical hepatic encephalopathy was sought. Out-patients with cirrhosis and no overt encephalopathy underwent [14C]urea breath testing once and psychometric testing on two separate occasions, with an intervening course of clarithromycin/omeprazole if they had subclinical encephalopathy (two of four psychometric tests abnormal). Subclinical encephalopathy was present in 27 of 69 patients (39%), and Helicobacter pylori infection in 14 of 69 (20%). There was no association between the two conditions (P = 0.769). Subclinical encephalopathy resolved in 75% of treated Helicobacter pylori-positive patients and 37.5% of treated Helicobacter pylori-negative patients (P = 0.285). Number connection test-B had high reproducibility among untreated patients (R = 0.655) and high correlation (P < or = 0.01) with three surrogate gold standards. In stable cirrhotic patients, subclinical hepatic encephalopathy was found to: (1) have a high prevalence, (2) not be associated with Helicobacter pylori infection, and (3) be readily detected with the number connection test-B alone.
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Affiliation(s)
- I A Scotiniotis
- Division of Gastroenterology, Brigham & Women's Hospital, Boston, Massachusetts, USA
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Metz DC, Forsmark C, Lew EA, Starr JA, Soffer EF, Bochenek W, Pisegna JR. Replacement of oral proton pump inhibitors with intravenous pantoprazole to effectively control gastric acid hypersecretion in patients with Zollinger-Ellison syndrome. Am J Gastroenterol 2001; 96:3274-80. [PMID: 11774936 DOI: 10.1111/j.1572-0241.2001.05325.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In patients with Zollinger-Ellison syndrome (ZES) or other conditions requiring oral doses of proton pump inhibitors, it frequently becomes necessary to use parenterally administered gastric acid inhibitors. However, i.v. histamine-2 receptor antagonists are not effective at usual doses and lose their effectiveness because of tachyphlaxis. With the approval in the United States of i.v. pantoprazole, a substituted benzimidazole available in i.v. formulation, it will become possible to acutely manage gastric acid secretion in the acute care setting of a hospital. This study was developed to monitor the safety and establish the efficacy of i.v. pantoprazole as an alternative to oral proton pump inhibitors for the control of gastric acid hypersecretion in patients with ZES. METHODS The efficacy of replacing oral PPI therapy with i.v. pantoprazole was evaluated in 14 ZES patients. After study enrollment, patients taking their current doses of oral PPI (omeprazole or lansoprazole) were switched to pantoprazole i.v. for 6 days during an 8-day inpatient period in the clinical research center. Effective control was defined as an acid output (AO) of < 10 mEq/h (< 5 mEq/h in patients with prior gastric acid-reducing surgery). RESULTS The mean age of the 14 patients enrolled in the study was 52.4 yr (range = 38-67). Mean basal AO was 0.55 +/- 0.32 mEq/h and mean fasting gastrin was 1089 pg/ml (range = 36-3720). Four patients were also diagnosed with the multiple endocrine neoplasia type I syndrome, nine were male, and two had previously undergone acid-reducing surgery. Before study enrollment, gastric acid hypersecretion was controlled in nine of 14 patients with omeprazole (20-200 mg daily) and five of 14 with lansoprazole (30-210 mg daily). In the oral phase of the study all patients had adequate control of gastric acid secretion, with a mean AO of 0.55 +/- 0.32 mEq/h (mean +/- SEM). Thereafter, 80 mg of i.v. pantoprazole was administered b.i.d. for 7 days by a brief (15 min) infusion and the dose was titrated upward to a predetermined maximum of 240 mg/24 h to control AO. A dose of 80 mg b.i.d. of i.v. pantoprazole controlled AO in 13 of 14 of the patients (93%) for the duration of the study (p > 0.05 compared to baseline values for all timepoints). One sporadic ZES patient (oral control value = 0.65 mEq/h on 100 mg of omeprazole b.i.d. p.o.) was not controlled with 80 mg of i.v. pantoprazole b.i.d. and dosage was titrated upward to 120 mg b.i.d. after day 2. CONCLUSIONS There were no serious adverse events observed. Intravenous pantoprazole provides gastric acid secretory control that is equivalent to the acid suppression observed with oral proton pump inhibitors. Most ZES patients (93%) maintained effective control of AO previously established with oral PPIs when switched to 80 mg of i.v. pantoprazole b.i.d.; however, for difficult-to-control patients, doses > 80 mg b.i.d. may be required.
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Affiliation(s)
- D C Metz
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
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Metz DC, Buchanan M, Purich E, Fein S. A randomized controlled crossover study comparing synthetic porcine and human secretins with biologically derived porcine secretin to diagnose Zollinger-Ellison Syndrome. Aliment Pharmacol Ther 2001; 15:669-76. [PMID: 11328261 DOI: 10.1046/j.1365-2036.2001.00976.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although biologically-derived porcine secretin is approved for the diagnosis of Zollinger-Ellison Syndrome, it is no longer available in the United States. Pure human and porcine secretins have now been synthesized and new drug applications have been filed with the Federal Drug Administration (FDA). METHODS In the current study we compared secretin testing results in six confirmed Zollinger-Ellison Syndrome patients using the biologically-derived product and both synthetic products (human and porcine) in a three-way, randomized, single-blind Latin-squares crossover study. RESULTS Using the FDA-approved criterion for positive secretin testing (i.e. a serum gastrin concentration increase of > 110 pg/mL), there was complete agreement between all three agents for all patients. With the more stringent NIH criterion (i.e. a serum gastrin concentration increase of > 200 pg/mL), positive results persisted in five out of six, six out of six and four out of six patients using biologically-derived secretin, synthetic porcine secretin, and synthetic human secretin, respectively (six out of six, six out of six and four out of six if a positive test was defined as a 50% increase in serum gastrin concentration). The time to peak serum gastrin concentration after secretin injection occurred within 15 min in all studies (in 94% by 10 min and in 77% by 5 min). Three-way comparisons of serum gastrin concentrations showed a single statistically significant difference (the change from baseline at 15 min between synthetic human and synthetic porcine secretin, P=0.0274). Statistically significant changes from baseline occurred at 1, 2 and 5 min for biologically-derived porcine secretin and at 2 and 5 min for both synthetic porcine and synthetic human secretin, in keeping with the expected time curve for positive tests. All three agents were well-tolerated. CONCLUSIONS These data suggest that either synthetic secretin product, when released onto the United States market, can be used to confirm Zollinger-Ellison Syndrome.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, Hospital of The University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, PA 19107, USA.
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Sharma VK, Komanduri S, Nayyar S, Headly A, Modlinger P, Metz DC, Verghese VJ, Wanahita A, Go MF, Howden CW. An audit of the utility of in-patient fecal occult blood testing. Am J Gastroenterol 2001; 96:1256-60. [PMID: 11316179 DOI: 10.1111/j.1572-0241.2001.03709.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Recent surveys of physician practice have suggested the existence of excessive, inappropriate use of the fecal occult blood test (FOBT). We studied the implementation of this test in hospitalized patients. METHODS We performed a retrospective chart review of 1000 randomly selected patients who had been discharged from the Medicine service at four teaching hospitals. Patient demographics, clinical presentation, presence or absence of overt GI bleeding, and use of medications that might affect the FOBT were recorded. Reviewers assessed whether patients who had FOBT would have been candidates for colon resection if asymptomatic colon cancer had been found. RESULTS Digital rectal examination was documented in 44.8% of patients; the findings were recorded in only 9%. A total of 421 patients had FOBT on admission, usually on stool obtained at digital rectal examination. Of the patients with a positive FOBT, 17% had active GI bleeding. Only 41.1% of patients with a positive FOBT were referred to the gastroenterology service. In 70.5% of patients, FOBT could be considered inappropriate because of factors such as age, active GI bleeding, or use of aspirin or other nonsteroidal anti-inflammatory drugs. CONCLUSIONS The FOBT, which is validated only for colorectal cancer screening, is often performed inappropriately in patients admitted to the hospital. This test should be restricted in hospital practice. It would be preferable to identify patients who are appropriate candidates for colorectal cancer screening at the time of hospital discharge and to advise them about the appropriate performance of the FOBT at home.
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Affiliation(s)
- V K Sharma
- University of Arkansas for Medical Sciences, Little Rock, USA
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Abstract
Proton pump inhibitors are the most effective agents for suppressing gastric acidity and are the preferred therapy for many acid-related conditions. While proton pump inhibitors have been accessible in intravenous formulations in several European countries, they have been available only as oral drugs in the United States. In the near future, the proton pump inhibitor pantoprazole is likely to become available in an intravenous formulation for American patients. Potential uses for intravenous proton pump inhibitors include treatment of Zollinger-Ellison syndrome and peptic ulcers complicated by bleeding or gastric outlet obstruction, as well as prevention of stress ulcers and acid-induced lung injury. These intravenous proton pump inhibitors are also likely to be beneficial to patients undergoing long-term maintenance with oral proton pump inhibitors who cannot take oral therapy for a period of time. Intravenous pantoprazole is especially distinguished in its lack of clinically relevant drug interactions, and it requires no dosage adjustment for patients with renal insufficiency or with mild to moderate hepatic dysfunction. Both omeprazole and pantoprazole are well tolerated in both oral and intravenous forms. Although further studies are needed to define their roles clearly, the availability of intravenous formulations of proton pump inhibitors will certainly assist with the treatment of gastric acid-related disorders.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, PA 19104, USA.
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Affiliation(s)
- M E Blam
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sharma VK, Bailey DM, Raufman JP, Elraie K, Metz DC, Go MF, Schoenfeld P, Smoot DT, Howden CW. A survey of internal medicine residents' knowledge about Helicobacter pylori infection. Am J Gastroenterol 2000; 95:1914-9. [PMID: 10950035 DOI: 10.1111/j.1572-0241.2000.02247.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Despite recently published national guidelines, many physicians have only limited knowledge about Helicobacter pylori infection. We conducted this study to assess internal medicine residents' knowledge about H. pylori. METHODS Two hundred and nineteen residents in seven accredited internal medicine training programs completed a self-administered questionnaire on personal demographics and practices related to testing for-and treating-H. pylori infection. RESULTS Noon conferences (82%), ward teaching (66%), journals (70%), and sponsored symposia (27%) were their major sources of H. pylori-related information. Forty-eight percent had used office-based tests for the infection. Testing for (and treatment of) Helicobacter pylori infection was recommended by 97% (97%) for newly diagnosed duodenal ulcer, but by only 61% (63%) for a past history of duodenal ulcer. Many recommended testing in unproven conditions and might not have offered treatment to an infected patient. A proton pump inhibitor-based triple-drug regimen was the treatment of first choice of 55%; 20% recommended proton pump inhibitor-based dual regimens. Sixty-six percent and 80%, respectively, underestimated the rates of resistance to clarithromycin and metronidazole. In the absence of gastrointestinal symptoms, 22% would have ordered Helicobacter pylori testing but only 33% of these would undergo treatment if positive. CONCLUSIONS Internal medicine residents usually test for Helicobacter pylori infection in appropriate conditions, but may not always treat the infection when the result is positive. Most use efficacious treatment regimens although many have inaccurate knowledge of resistance rates, which may adversely influence prescribing. Education should focus on practical issues surrounding Helicobacter pylori testing and treatment such as those contained in the American College of Gastroenterology's 1998 practice guidelines.
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Affiliation(s)
- V K Sharma
- Division of Digestive Diseases, University of Arkansas for Medical Sciences, Little Rock 72205-7199, USA
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Abstract
OBJECTIVE The aim of this study was to determine the performance characteristics of the 14C-urea breath test (UBT) performed 2 wk after the completion of therapy for Helicobacter pylori using a 4 to 6 wk study as the gold standard. METHODS Patients with active Helicobacter pylori infection at four medical centers received proton pump inhibitor-based triple or quadruple therapy for 10-14 days. Patients underwent the 14C-UBT 2 and 4-6 wk after the completion of therapy. A positive test was defined as 14CO2 excretion of >200 dpm, a negative test as <50 dpm, and an equivocal test as >50 but <200 dpm. Performance characteristics of the 2-wk UBT were calculated using the 4 to 6-wk result as a gold standard. RESULTS Eighty-five patients were enrolled and 82 patients (mean +/- SD age, 62 +/- 15 yr; 15 women) completed the protocol. Four patients had equivocal UBT results and were excluded from the analysis. Of the 78 patients, 68 (87%) had a negative 4 to 6-wk UBT. The 2-week UBT yielded a sensitivity of 90% (95% confidence interval 72-100%), specificity of 99% (97-100%), and accuracy of 97% (93-100%). In patients with a persistently positive UBT, 14CO2 excretion at 2 wk was significantly lower than at 4-6 wk after therapy (p = 0.03). CONCLUSIONS A UBT performed 2 wk after therapy yielded results comparable to 4 to 6 wk testing. Further studies to evaluate the optimal time of confirmatory testing in the age of more effective proton pump inhibitor-based triple therapies are warranted.
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Affiliation(s)
- W D Chey
- University of Michigan Medical Center, Ann Arbor, USA
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Lew EA, Pisegna JR, Starr JA, Soffer EF, Forsmark C, Modlin IM, Walsh JH, Beg M, Bochenek W, Metz DC. Intravenous pantoprazole rapidly controls gastric acid hypersecretion in patients with Zollinger-Ellison syndrome. Gastroenterology 2000; 118:696-704. [PMID: 10734021 PMCID: PMC6736552 DOI: 10.1016/s0016-5085(00)70139-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Parenteral control of gastric acid hypersecretion in conditions such as Zollinger-Ellison syndrome (ZES) or idiopathic gastric acid hypersecretion is necessary perioperatively or when oral medications cannot be taken for other reasons (e.g., during chemotherapy, acute upper gastrointestinal bleeding, or in intensive care unit settings). METHODS We evaluated the efficacy and safety of 15-minute infusions of the proton pump inhibitor pantoprazole (80-120 mg every 8-12 hours) in controlling acid output for up to 7 days. Effective control was defined as acid output >10 milliequivalents per hour (mEq/h) (<5 mEq/h in patients with prior acid-reducing surgery) for 24 hours. RESULTS The 21 patients enrolled had a mean age of 51.9 years (range, 29-75) and a mean disease duration of 8.1 years (range, <0.5-21); 13 were male, 7 had multiple endocrine neoplasia syndrome type I, 4 had undergone acid-reducing surgery, 2 had received chemotherapy, and 13 had undergone gastrinoma resections without cure. Basal acid output (mean +/- SD) was 40.2 +/- 27.9 mEq/h (range, 11.2-117.9). In all patients, acid output was controlled within the first hour (mean onset of effective control, 41 minutes) after an initial 80-mg intravenous pantoprazole dose. Pantoprazole, 80 mg every 12 hours, was effective in 17 of 21 patients (81%) for up to 7 days. Four patients required upward dose titration, 2 required 120 mg pantoprazole every 12 hours, and 2 required 80 mg every 8 hours. At study end, acid output remained controlled for 6 hours beyond the next expected dose in 71% of patients (n = 15); mean acid output increased to 4.0 mEq/h (range, 0-9.7). No serious or unexpected adverse events were observed. CONCLUSIONS Intravenous pantoprazole, 160-240 mg/day administered in divided doses by 15-minute infusion, rapidly and effectively controlled acid output within 1 hour and maintained control for up to 7 days in all ZES patients.
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Affiliation(s)
- E A Lew
- CURE/UCLA Digestive Diseases Research Center, Division of Digestive Diseases, Department of Medicine, West Los Angeles VA Medical Center, Los Angeles, California, USA
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Metz DC, Pratha V, Martin P, Paul J, Maton PN, Lew E, Pisegna JR. Oral and intravenous dosage forms of pantoprazole are equivalent in their ability to suppress gastric acid secretion in patients with gastroesophageal reflux disease. Am J Gastroenterol 2000; 95:626-33. [PMID: 10710049 DOI: 10.1111/j.1572-0241.2000.01834.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to assess the ability of pantoprazole to maintain gastric acid suppression in patients with gastroesophageal reflux disease who are switched from an oral (p.o.) to an intravenous (i.v.) dosage form. METHODS A total of 65 patients with gastroesophageal reflux disease were administered either 40 or 20 mg of p.o. pantoprazole daily for 10 days, then were switched to either a matching dose of i.v. pantoprazole or to placebo for 7 days. Acid output (basal and maximal) was measured at the end of the p.o. treatment period and on the first and last days of i.v. therapy. In the primary efficacy analysis, the acid output values at the end of the p.o. pantoprazole treatment were compared with those at the end of the i.v. treatment. Safety was monitored by periodic vital sign measurements, clinical laboratory evaluations, ophthalmic examinations, electrocardiograms, and reports of adverse events. The data were tested by an analysis of covariance and by Wilcoxon signed rank and t tests. RESULTS Maximal acid output (mean +/- SD) in the 40 mg and 20 mg pantoprazole group after p.o. treatment was 6.5 +/- 5.6 mEq/h and 14.5 +/- 15.5 mEq/h, respectively; whereas, at the end of the i.v. treatment period, the values were 6.6 +/- 6.3 mEq/h and 11.1 +/- 10.2 mEq/h, respectively. In patients given i.v. placebo, acid output was significantly (p < 0.05) increased to 29.2 +/- 13.0 mEq/h by day 7. Both p.o. and i.v. pantoprazole dosage forms had similar favorable safety and tolerability profiles. CONCLUSIONS The p.o. and i.v. formulations of pantoprazole (40 and 20 mg) are equivalent in their ability to suppress gastric acid output. The i.v. form of pantoprazole offers an alternative for gastroesophageal reflux disease patients who are unable to take the p.o. formulation.
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Affiliation(s)
- D C Metz
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
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Metz DC. Stool testing for Helicobacter pylori infection: yet another noninvasive alternative. Am J Gastroenterol 2000; 95:546-8. [PMID: 10685767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A prospective, multicenter study was performed in 11 European centers to evaluate the accuracy of stool testing for active Helicobacter pylori (H. pylori) infection, using the HpSA ELISA antigen assay. The accuracy of this test was assessed in a large number of patients both before and after treatment by comparing results with a rigidly defined gold standard consisting of gastric antral and body biopsies with normal and special stains, as well as culture and rapid urease testing. The accuracy of the stool test was also compared with the currently accepted best noninvasive test, the carbon-13 urea breath test. Five hundred and one treatment naive patients (276 men, mean age 52 yr) were tested after endoscopy (491 patients had evaluable results). The sensitivity and specificity of the stool test were 94.1% (the 95% confidence interval was 90.6-96.6%) and 91.8% (87.3-95.1%), respectively. Pretreatment sensitivity and specificity for breath testing were similar (95.3% [92.2-97.5%] and 97.7% [94.8-99.3%], respectively). One hundred and seven infected patients were reassessed 4 wk after undergoing therapy for H. pylori infection. The posttreatment sensitivity and specificity of the HpSA assay was also excellent, although the confidence intervals were significantly wider because of the smaller number of patients (90% [68.3-98.9%], and 95.3% [88.5-98.7%], respectively). Posttreatment sensitivity and specificity for urea breath testing were also similar (90% [68.3-98.8%] and 98.9% [93.8-100%], respectively). Intercenter variability of test results did not reach statistical significance with either testing method. The authors concluded that HpSA stool testing is a reliable and easy-to-use method for diagnosing H. pylori infection in both treatment naïve and posttreatment patients that compares well with carbon-13 urea breath testing. They site specific advantages of the HpSA assay to include: 1) a more simple sampling method (only one stool specimen is required); 2) the lack of a requirement for trained personnel at the testing site; and 3) there is no need for expensive equipment.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA
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Abstract
BACKGROUND Gastric analysis is useful for diagnosing and monitoring the control of hypersecretory conditions and to distinguish appropriate from inappropriate causes of hypergastrinaemia. Pentagastrin, used to measure maximal acid output (MAO), is no longer available in the USA. METHODS We examined the University of Pennsylvania Health System gastric analysis database, which includes demographic data, study indications, gastric analysis, and serum gastrin and secretin testing results according to referral indications, paying specific attention to discordant basal acid output (BAO) and MAO measurements. RESULTS One hundred and twenty-four gastric analyses were performed in 103 patients (42 males, mean age 47.5 years, 14 with prior acid-decreasing surgery). Recurrent ulceration or pain unresponsive to antisecretory therapy was the indication in 42 patients. Twelve were hypersecretory, including three each with isolated elevations of BAO or MAO. Hypergastrinaemia was the indication in 35 patients. Five were hypersecretory (four with Zollinger-Ellison syndrome), three had isolated MAO elevations and 16 were hypo- or achlorhydric, indicating appropriate hypergastrinaemia. Of the seven patients with isolated MAO elevations, two had clear benefit from the stimulated portion of the study (four additional patients had equivocal benefit). CONCLUSIONS Gastrin concentrations cannot be interpreted without knowledge of acid secretory capacity. MAO measurement has a small but significant benefit over measuring BAO alone.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE Congenital esophageal stenosis is thought to be a rare disease confined to infancy and childhood with only a few case reports in adults described. METHODS We report five patients between the ages of 19 and 46 yr who presented with this disorder over a 2-yr period. RESULTS Patients had been labeled with reflux strictures, webs, or as idiopathic in the past. All patients had chronic solid food dysphagia, some since early childhood. The location of the stricture varied, occurring in the mid or proximal esophagus in four, but throughout the esophagus in one. Radiographic and endoscopic appearance was a smooth concentric stricture or multiple rings, sometimes tracheal in appearance. Endosonography was performed in two patients, both of whom had focal circumferential hypoechoic wall thickening with disruption of the normal layer pattern corresponding to the areas of luminal narrowing. All patients dilated had good symptomatic response, with resolution of symptoms up to 6 months in follow-up. CONCLUSIONS We suggest that congenital esophageal stenosis does occur in adults and may be underrecognized. Its endosonographic appearance is described.
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Affiliation(s)
- D A Katzka
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Abstract
OBJECTIVE To characterize the source of bleeding and the prognosis in critically ill patients with upper gastrointestinal hemorrhage that developed while in the hospital. SETTING Intensive care units of a large academic tertiary-care center. DESIGN Retrospective cohort study. SUBJECTS Patients undergoing endoscopy in intensive care units for gastrointestinal bleeding that developed while in the hospital. MEASUREMENTS AND MAIN RESULTS Medical records were available for 142 patients. Of these, 66 met the criteria for in-hospital bleeding. Peptic ulcer disease, present in 56% of patients, was the most common bleeding source identified. Of patients with peptic ulcer disease, nine of 37 (24%) had stigmata of recent hemorrhage. Ten patients (15%) received endoscopic hemostasis interventions (eight receiving therapy for bleeding ulcers, two receiving therapy for esophageal varices). The in-hospital mortality rate was 42%. The cause of death was sepsis and/or multiple system organ failure in 21 patients (75%); the gastrointestinal bleeding may have contributed to the onset of sepsis in one of these patients. No patients died directly of gastrointestinal bleeding. CONCLUSIONS Critically ill patients who bleed while in the hospital have similar sources of bleeding and rates of endoscopically directed therapy as patients admitted to hospital with bleeding. The mortality rate is very high in patients with bleeding that develops in the hospital, and this is usually a result of systemic disease. These data may help clinicians and patients to estimate the potential benefit of urgent endoscopy in critically ill patients.
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Affiliation(s)
- J D Lewis
- Department of Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, University of Pennsylvania Health Science Center, Philadelphia, USA
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Abstract
The nature of the relationship between Helicobacter pylori (Hp) infection and gastroesophageal reflux disease (GERD) remains unclear. This article reviews the current body of knowledge regarding the association between these two common entities. The authors examine the potential interactions of Hp and GERD from epidemiologic and pathophysiologic viewpoints and summarize and critique the prevalence and eradication studies that have been performed to date. Special consideration is given to the possible effects that long-term use of proton pump inhibitors may have on Hp gastritis.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA
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Metz DC. Diagnosis of non-Zollinger-Ellison syndrome, non-carcinoid syndrome, enteropancreatic neuroendocrine tumours. Ital J Gastroenterol Hepatol 1999; 31 Suppl 2:S153-9. [PMID: 10604121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
The diagnosis of entero-neuropancreatic tumours different from Zollinger-Ellison syndrome and carcinoid syndrome require an high index of suspicion and even when they are associated to virulent syndromes such as VIPoma or insulinoma syndrome the mean delay in diagnosis is of 4 years. Symptomatic hypoglycaemia due to inappropriate insulin release from insulinoma and watery diarrhoea leading to dehydration caused by elevated circulant vaso-intestinal peptide levels are present in the 90% and 100% of the patients at presentation of the respective syndrome. Somatostatinoma syndrome has a far more subtle presentation and it tends to present much later during the disease course. The diagnosis is based on the presence of gallstones, diabetes, weight loss, diarrhoea and steatorrhoea. Growth hormone releasing factor neuroendocrine tumours (GRFoma) present with acromegaly and account for less than 2% of the acromegalic patients in which the growth hormone is from an ectopic source located in the pancreas. The Cushing's syndrome diagnosis due to rare ectopic neuroendocrine tumour adrenocorticotropic hormone secretion can be made only with selective angiography, whereas non-functional and pancreatic polypeptide producing neuroendocrine tumours (PPoma) present without any symptoms. Finally, multiple endocrine neoplasia type one occurs more commonly with somatostatinoma or GRFoma, conversely patients with multiple endocrine neoplasia type one can develop insulinoma (20%) or PPoma (60%).
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Affiliation(s)
- D C Metz
- GI Physiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Ahmad NA, Furth EE, Schwartz SS, Vaughn D, Metz DC. Sporadic Zollinger-Ellison Syndrome With Ectopic Production Of Corticotropin: Surgical Management. Endocr Pract 1999; 5:261-5. [PMID: 15251664 DOI: 10.4158/ep.5.5.261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe two patients with concurrent Zollinger-Ellison syndrome and ectopic production of corticotropin in whom Cushing's syndrome was managed surgically. METHODS Two case vignettes are presented, and a general approach is discussed for determining a management strategy for optimal potential for survival. RESULTS The prognosis associated with medical management of patients with sporadic Zollinger-Ellison syndrome and Cushing's syndrome attributable to ectopic production of adrenocorticotropic hormone (corticotropin) is dismal. Two surgical options may yield improved outcomes. The first approach is bilateral adrenalectomy followed by replacement therapy with corticosteroids and mineralocorticoids. The second surgical approach consists of removal of the organ producing the corticotropin (the liver) and performance of hepatic transplantation. These two treatment strategies were used in our two patients, both of whom had widely metastatic disease at the time of initial assessment. The patient who underwent bilateral adrenalectomy continued to do well 4 years postoperatively. CONCLUSION Treatment of patients with Zollinger-Ellison syndrome and ectopic production of corticotropin presents a challenge. Because results with medical therapy have been suboptimal, aggressive surgical intervention seems warranted.
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Affiliation(s)
- N A Ahmad
- Department of Medicine, Division of Gastroenterology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pfau PR, Metz DC. Helicobacter pylori and nonulcer dyspepsia: more confusion? Am J Gastroenterol 1999; 94:2563-5. [PMID: 10484030 DOI: 10.1111/j.1572-0241.1999.02563.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- P R Pfau
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA
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Abstract
Dyspepsia and heartburn are the two cardinal symptoms of foregut dysfunction. When confronting such a problem, that physician must first learn to discern between the two, because treatment can be quite different for the conditions presenting with these symptoms. This article details the approach to work-up and treatment of patients presenting with dyspepsia or heartburn.
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Affiliation(s)
- N A Ahmad
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, USA
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Affiliation(s)
- D C Metz
- University of Pennsylvania Health System, Philadelphia, USA
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA
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Barrett DM, Faigel DO, Metz DC, Montone K, Furth EE. In situ hybridization for Helicobacter pylori in gastric mucosal biopsy specimens: quantitative evaluation of test performance in comparison with the CLOtest and thiazine stain. J Clin Lab Anal 1998; 11:374-9. [PMID: 9406060 PMCID: PMC6760720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Numerous detection methods for Helicobacter Pylori (H. pylori) have been developed with varying degrees of purported diagnostic utility. We have developed a rapid nonradioactive in situ hybridization (ISH) method for H. pylori detection in paraffin-embedded tissue and assessed its relative diagnostic performance by receiver operator characteristics (ROC) in comparison to the thiazine stain and CLOtest. Forty-five patients undergoing endoscopy had antral biopsies and concomitant CLOtest performed. ISH for H. pylori was done using a 22-base, biotin-labeled oligonucleotide probe complementary to a portion of H. pylori 16s rRNA with the following sequence: 5'-GGACATAGGCTGATCTTAGC-3'. ISH using this probe was specific for H. pylori with no crossreactivity with other bacterial or fungal organisms. Receiver operator characteristic analysis was used to assess the diagnostic performance of ISH and thiazine techniques. ISH and thiazine stains were done on serial sections, reviewed independently, and scored on a graded scale from 1-5 based upon the degree of assurance of H. pylori presence. Diagnostic performance was assessed in "expert" and "nonexpert" pathologist groups with the CLOtest serving as the invariant test for relative test comparison. The ISH test performed slightly better (ROC area 0.9) than the thiazine (ROC area 0.8) in the nonexpert population, but equally well in the "expert" group (ROC area 0.95, 0.95). ISH followed by routine hematoxylin and eosin staining showed detailed mucosal histology with a dramatic visualization of H. pylori along the surface of the foveolar cells with no evidence of lamina propria invasion. In summary, ISH for H. pylori is an excellent test that is specific, easily read, and allows concomitant detailed histologic mucosal examination.
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Affiliation(s)
- D M Barrett
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia 19104-4283, USA
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Abstract
The authors hypothesized that Helicobacter species may be present in the bile and gallbladder wall of patients with chronic cholecystitis who live in a region with a high prevalence of gallbladder cancer. They attempted to identify such species by obtaining both bile and resected gallbladder tissue from 46 patients who underwent cholecystectomy. Tissue specimens were stained with hematoxylin and eosin as well as other stains used specifically for the identification of Helicobacter species, and culture was attempted using specialized media on samples from tissue and bile. Unfortunately, the authors were unable to culture any Helicobacter species, and the yield from histopathology was also poor with silver stains identifying curved bacteria suggestive, but not diagnostic, of Helicobacter species in only two cases. Molecular techniques were more successful. DNA was extracted from both tissue and bile and amplified by polymerase chain reaction (PCR) using a specific primer. The amplicons they identified were then compared with known Helicobacter proteins using a Southern blot approach. PCR amplification was relatively successful with 9 of 23 gallbladder samples and 13 of the 23 bile samples coming up positive for Helicobacter species using two specific primers. These specimens were also positive by Southern blot hybridization. The cloning and sequencing of the 16S ribosomal RNA amplicons in eight cases verified true Helicobacter origin with a phylogenetic analysis showing greater than 99.3% similarity. Five of the amplicons clustered with H. bilis, two with Flexispira rappini, and one with H. pullorum. The authors concluded that despite their being unable to identify organisms directly, the stringent PCR technique with amplicon sequencing confirmed that Helicobacter species could be identified within the bile and gallbladder tissue of patients with chronic cholecystitis in a region with high incidence of gallbladder cancer. They indicated that further studies are needed to ascertain whether similar species have a causative role in the development of gallbladder cancer.
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA
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Abstract
Helicobacter pylori antibody testing is accurate for diagnosing untreated patients. Rapid serum testing is as accurate as formal enzyme-linked immunosorbent assay (ELISA) testing. As whole blood fingerstick tests may become the diagnostic method of choice if they are of similar accuracy, 51 patients were studied who had not taken antibiotics, bismuth, sucralfate, or proton pump inhibitors. Concordance between C-14 Urea Breath Testing and HM-CAP ELISA testing served as the study standard for H. pylori diagnosis. Rapid antibody testing was performed with the AccuStat whole blood (Boehringer Mannheim, Mannheim, Germany) and FlexSure HP (Smith Kline Diagnostics, San Jose, CA) serum tests. Antral biopsy for CLO testing and histological evaluation with thiazine staining were available for 18 (35.3%) and 20 patients (39.2%), respectively. Nineteen of 50 patients (38%) were infected. (One patient had discordant tests and was excluded.) FlexSure HP and AccuStat were each positive in 18 (36%) and 19 patients (38%) with sensitivity, specificity, and positive and negative predictive values of 89.5% and 89.5%, 96.8% and 93.5%, 94.4% and 89.5%, and 93.8% and 93.5%, respectively. There were two false-negative FlexSure HP and AccuStat tests and three false-positive tests--1 FlexSure and 2 AccuStat results. CLO test and histology concurred in every case tested. We conclude that both rapid antibody tests are accurate and suitable for screening patients not previously treated for H. pylori infection. Since the AccuStat has preserved diagnostic strength, is less costly, takes less time, and is less labor intensive, whole blood testing is the screening test of choice.
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Affiliation(s)
- J R Harrison
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA
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Lipson DA, Berlin JA, Palevsky HI, Kotloff RM, Tino G, Bavaria J, Kaiser L, Long WB, Metz DC, Lichtenstein GR. Giant gastric ulcers and risk factors for gastroduodenal mucosal disease in orthotopic lung transplant patients. Dig Dis Sci 1998; 43:1177-85. [PMID: 9635604 DOI: 10.1023/a:1018835219474] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Giant gastric ulcers are defined as ulcers with a diameter greater than 3 cm. Previously they have not been described in lung transplant recipients. We report a high incidence of symptomatic giant gastric ulcers and identify the risk factors for ulcer development in these patients. We examined the records of all 95 patients who had undergone lung transplantation at our institution from November 1991 to July 1995. Fourteen of the patients who underwent lung transplantation developed symptoms that required esophagogastroduodenoscopy. Three of these patients (21%) were found to have giant gastric ulcers. The relative risk of giant gastric ulcer in symptomatic patients undergoing endoscopy after lung transplantation is over 40 times that of population controls. The patients who developed giant gastric ulcers, despite H2 antagonist use, had all received bilateral lung transplantation and had received nonsteroidal antiinflammatory drugs, cyclosporine, and high-dose intravenous corticosteroids. The risk of developing giant gastric ulcers is significantly increased in patients who have undergone bilateral orthotopic lung transplantation. Clinicians should be made aware of this complication in order to avoid use of ulcerogenic medications in this population. Avoidance of these medications could potentially minimize the risk of this complication.
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Affiliation(s)
- D A Lipson
- Department of Internal Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
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Affiliation(s)
- D C Metz
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, USA
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Metz DC, Furth EE, Faigel DO, Kroser JA, Alavi A, Barrett DM, Montone K. Realities of diagnosing Helicobacter pylori infection in clinical practice: a case for non-invasive indirect methodologies. Yale J Biol Med 1998; 71:81-90. [PMID: 10378353 PMCID: PMC2578895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The current, arbitrarily defined gold standard for the diagnosis of H. pylori infection requires histologic examination of two specially stained antral biopsy specimens. However, routine histology is potentially limited in general clinical practice by both sampling and observer error. The current study was designed to examine the diagnostic performance of invasive and non-invasive H. pylori detection methods that would likely be available in general clinical practice. METHODS The diagnostic performance of rotating clinical pathology faculty using thiazine staining was compared with that of an expert gastrointestinal pathologist in 38 patients. In situ hybridization stains of adjacent biopsy cuts were also examined by the expert pathologist for further comparison. Receiver operator characteristic (ROC) analysis was performed to evaluate whether the diagnostic performance of the expert pathologist differed depending upon the histologic method employed. A similar analysis was made to evaluate the diagnostic performance of pathology trainees relative to the expert. In the absence of an established invasive gold standard, non-invasive testing methods (rapid serum antibodies, formal Elisa antibodies and carbon-14 urea breath testing) were evaluated in 74 patients by comparison with a gold standard defined using a combination of diagnostic tests. RESULTS Using either rapid urease testing of biopsy specimens or urea breath testing as the gold standard for comparison, the diagnostic performance of the rotating clinical pathology faculty was inferior to that of the expert gastrointestinal pathologist especially with regard to specificity (e.g., 69 percent for the former versus 88 percent, with the latter relative to rapid urease testing). Although interpretation of in situ hybridization staining by the expert appeared to have an even higher specificity, ROC analysis failed to show a difference. The mean ROC areas for thiazine and in situ hybridization staining for trainee pathologists relative to the expert were 0.88 and 0.94, respectively. In untreated patients, urea breath testing had a sensitivity and specificity of 100 percent as compared with thiazine staining with a sensitivity of 83 percent and a specificity of 97 percent. Post-therapy, breath testing had a sensitivity of 100 percent but a specificity of only 86 percent as compared with invasive testing with a sensitivity and specificity of 100 percent. Rapid serum antibody testing and formal Elisa antibody testing agreed in 93 percent of cases (Kappa 0.78) with the rapid test being correct in three of the four disagreements. CONCLUSIONS The current study illustrates a number of realities regarding H. pylori diagnosis. There is no diagnostic gold standard in general clinical practice. Accurate interpretation of specially stained slides is a learned activity with a tendency towards overdiagnosis early on. Urea breath testing is likely to be the diagnostic method of choice for untreated patients in general clinical practice although antibody testing is almost as accurate. Rapid antibody tests are at least as accurate as formal Elisa antibody tests. Urea breath testing is useful for confirming cure after therapy, but false-positive results may occur in some patients.
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Affiliation(s)
- D C Metz
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia 19104, USA.
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Kroser JA, Faigel DO, Furth EE, Metz DC. Comparison of rapid office-based serology with formal laboratory-based ELISA testing for diagnosis of Helicobacter pylori gastritis. Dig Dis Sci 1998; 43:103-8. [PMID: 9508510 DOI: 10.1023/a:1018832306135] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Accurate and cost-effective diagnosis of Helicobacter pylori gastritis has taken on major importance. Several serologic tests for the diagnosis of H. pylori infection are commercially available. We compared the performance of the FlexSure HP rapid IgG antibody test with the conventional HM-CAP ELISA to evaluate whether qualitative office-based serology is reliable enough to replace formal laboratory-based testing. We assessed H. pylori status by concordance in 100 consecutive patients with antral biopsy, rapid urease, and 1 microCi[14C]urea breath tests. Both antibody tests had good sensitivity and specificity (>86%). Concordance between the two antibody tests occurred in 87/93 patients (94%). Based on our data, the office-based FlexSure HP performed equally well as the laboratory-based formal ELISA and may be a better choice for initial serologic diagnosis in untreated patients.
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Affiliation(s)
- J A Kroser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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