Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer

BACKGROUND

Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.

AIM

To identify predictors of rebleeding after endoscopic therapy.

METHODS

Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.

RESULTS

Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57-4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14-2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31-2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98-4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38-10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69-4.86).

CONCLUSIONS

Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.

[Endoscopic treatment of bleeding ulcers: has everything been said and done?]

Endoscopic treatment reduces bleeding recurrence, the need for surgery and mortality in patients with bleeding ulcers. However endoscopic treatment fails in 10-15% of patients, leading to high morbidity and mortality. The therapeutic measures with demonstrated effectiveness in reducing the risk of hemorrhagic recurrence and its complications are combined endoscopic treatment (adrenaline plus a second hemostatic intervention) and proton pump inhibitors. Also useful, although there is less evidence, are immediate resuscitation and <<second look>> endoscopy. Some studies suggest that activated recombinant factor VII infusion or supra-selective arterial embolization can be useful in severe hemorrhage. Further studies are required to determine optimal treatment according to the characteristics of each patient.

[Cecal cytomegalovirus infection following appendicectomy in a patient with ulcerative colitis]

We report a patient who, 3 months after being diagnosed with ulcerative colitis, was admitted to hospital because of malaise and right lower abdominal pain. An open appendectomy was performed. Histological study showed ulcerative colitis affecting the appendix. After surgery, the patient presented a refractory outbreak of ulcerative colitis requiring treatment with steroids and cyclosporin A. Despite this treatment, the patient continued to pass abundant fresh blood associated with severe anemia. Colonoscopy showed only granular and congestive cecal mucosa. Biopsies showed intracytoplasmic inclusion bodies with immunohistochemical stains positive for cytomegalovirus (CMV) infection. Rectorrhagia and anemia quickly disappeared after beginning treatment with ganciclovir. Appendicular ulcerative colitis is not uncommonly associated with distal colitis. In addition, diffuse CMV infection complicating ulcerative colitis treatment is not unusual. By contrast, isolated, segmentary infection by CMV in the proximal colon is extremely rare. Until now, only three patients with localized CMV infection have been described, and all three cases occurred in the context of ileoanal anastomosis.

Diagnosis of Helicobacter pylori infection in dyspeptic patients by stool antigen detection usefulness of a new monoclonal enzyme immunoassay test

BACKGROUND

Helicobacter pylori antigens can be measured in human stools with an enzyme immunoassay, which may prove to be a valuable non-invasive diagnostic tool. Aim. To evaluate the usefulness of a new monoclonal enzyme immunoassay for detecting H. pylori antigens in dyspeptic patients' faeces (FemtoLab H. pylori, Connex, Martinsried, Germany).

PATIENTS

H. pylori infection was determined in 75 patients (49 men, 26 women, mean age 52 + 16.5) for histology and rapid urease test.

METHODS

H. pylori status was established by concordance of the reference tests. FemtoLab H. pylori was measured in triplicate. In addition, two determinations of a polyclonal faecal antigen test (HpSA, Platinum Premier HpSA, Meridian Diagnostic Inc., Cincinnati, USA) were also performed. Sensitivity, specificity, positive and negative predictive values were calculated. Concordance between different measurements was estimated by Kappa statistics.

RESULTS

The sensitivity of the FemtoLab H. pylori immunoassay ranged from 98 to 100% and its specificity was 76%. Positive and negative predictive values were 91 and 94-100%, respectively. Concordance coefficients ranged from 0.81 to 0.92. Corresponding HpSA values were 69, 86, 92 and 53%, respectively. Concordance coefficient was 0.61.

CONCLUSIONS

FemtoLab H. pylori is a very sensitive, specific, highly reproducible and easy-to-perform tool for diagnosis of H. pylori infection.

Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña

INTRODUCTION

The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain).

OBJECTIVE

To evaluate the use of sedation in DEU in Catalonia.

MATERIAL AND METHOD

A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications.

RESULTS

Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation.

CONCLUSIONS

In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.

Evaluación de un test rápido (ImmunoCard STAT! HpSA) para la detección de Helicobacter pylori en heces

INTRODUCTION

The use of a rapid diagnostic technique may be extremely useful for the management of Helicobacter pylori infection. A new immunochromatographic in-office test (ImmunoCard STAT! HpSA, Meridian Diagnosis Inc, Cincinnati, Ohio, USA) for the detection of H. pylori in feces has recently become available. The aim of the present study was to evaluate the diagnostic reliability and reproducibility of the ImmunoCard STAT! HpSA test in patients with dyspepsia.

PATIENTS AND METHODS

Sixty-three dyspeptic patients were enrolled. H. pylori status was determined by CLO-test and Giemsa staining of antral biopsy. Patients with a positive result for both tests were considered infected and those with a negative result for both tests were considered not infected. Fecal H. pylori antigen was tested twice by ImmunoCard STAT! HpSA. The sensitivity, specificity, positive predictive value and negative predictive value of each determination were calculated. The concordance between the two determinations was evaluated using Kappa statistics.

RESULTS

Of the 63 patients, 46 were infected by H. pylori. Sensitivity, specificity and positive and negative predictive values were 89-91%, 86-93%, 96-98% and 72-75%, respectively. The correlation coefficient between determinations was 0.845.

CONCLUSION

The new ImmunoCard STAT! HpSA test shows good sensitivity and reproducibility. Therefore, it could be highly useful in the management of H. pylori infection.

Evaluation of Helicobacter pylori diagnostic methods in patients with liver cirrhosis

BACKGROUND

Helicobacter pylori-associated peptic ulcer is a frequent complication in cirrhotic patients and its morbidity rate is high. In spite of this, diagnostic methods for H. pylori infection have not been fully evaluated in these patients.

AIM

To evaluate H. pylori diagnostic methods in patients with liver cirrhosis.

METHODS

One hundred and one cirrhotic patients were included in the study. Three antral and two corpus biopsies were obtained for rapid urease test of the antral mucosa, and Giemsa stain and immunohistochemistry were performed for both the corpus and antrum. Serology, 13C-urea breath test and faecal H. pylori antigen determination were also carried out.

RESULTS

Sixty-two patients were positive and 35 were negative for H. pylori infection; four were indeterminate. The sensitivity and specificity were 90.4% and 100%, respectively, for antral histology, 100% and 100% for gastric body histology, 90.4% and 100% for antral immunohistochemistry, 96.2% and 96.7% for body immunochemistry, 85.7% and 97% for rapid urease test, 83.6% and 55.9% for serology, 96.4% and 97.1% for 13C-urea breath test and 75.4% and 94.1% for faecal antigen.

CONCLUSION

The most reliable tests for H. pylori infection in cirrhotic patients were the 13C-urea breath test and gastric body histology.

Cleaning and disinfection practices in digestive endoscopy in spain: results of a national survey

BACKGROUND AND STUDY AIMS

Disinfection and surveillance of it are important for ensuring safety in gastrointestinal endoscopy. The aim of this survey was to assess the current status of disinfection in gastrointestinal endoscopy units in Spain.

MATERIALS AND METHODS

An anonymous questionnaire on cleaning and disinfection methods was sent to gastrointestinal endoscopy units at 244 public hospitals in Spain. A minimum standard of disinfection (MSD) was defined to evaluate the appropriateness of disinfection practices.

RESULTS

A total of 144 centers responded (58 %). All units perform manual washing of endoscopes before disinfection. Automatic washers are available in only 23 % of the centers. Selective cleaning of internal channels is systematically performed in 85 % of the centers. Glutaraldehyde-based disinfectants are the most commonly employed (84 % of units). The time of exposure to the disinfectant is at least 10 min in 97 % of units, but 20 min or more in only 36 % of them. Endoscopic accessories are sterilized in 57 % of centers. The MSD was complied with by 79 % of the units evaluated. Compliance with the MSD was significantly lower in small units (P = 0.0005) performing small numbers of examinations per month. Quality control tests on the efficacy of disinfection methods are conducted at 66 % of the centers. Specialized personnel record disinfection procedures in 85 % of the centers and supervise them in 55 % of the centers. Half of the units have inadequate equipment and facilities.

CONCLUSIONS

This survey suggests that cleaning and disinfection practices in gastrointestinal endoscopy units in Spain have improved in recent years, and that there is a good compliance with standard guidelines. Most units should improve their equipment and facilities in order to provide better comfort and safety for patients and staff.

Modified seven-day, quadruple therapy as a first line Helicobacter pylori treatment

BACKGROUND

Cure rates of 7-day triple therapy seem to be decreasing. Quadruple therapies may be an alternative, although their complex administration makes patient acceptance difficult.

OBJECTIVE

To test the usefulness of a thrice a day, quadruple therapy to cure Helicobacter pylori infection.

PATIENTS AND METHODS

A total of 122 consecutive patients with peptic ulcer and Helicobacter pylori infection were treated with omeprazole 20 mg b.d., tetracycline chlorhydrate 500 mg t.d.s., metronidazole 500 mg t.d.s., and bismuth subcitrate 120 mg t.d.s. administered with meals for 7 days. Cure was tested by either endoscopy or breath test after 2 months, and by urea breath test 6 months after therapy.

RESULTS

Seven patients were lost to follow-up. Of the remaining 115, 110 were cured at the first control, giving an intention-to-treat cure rate of 90.2% (95% CI: 83-95%) and a per protocol cure rate of 95.7% (95% CI: 90-98%). One hundred three patients returned for a 6-month breath test; all but one were cured. Side-effects were minimal or minor in 47 patients (40.8%) and moderate in four (3.4%). Compliance was good, 95% of patients taking more than 90% of the pills. Six (5%) patients stopped treatment after 1, 2, 4 (two patients) and 6 (two patients) days.

CONCLUSION

Thrice a day quadruple therapy shows excellent cure rates, far above 90%, is well-tolerated and compliance is easy. Head-to-head comparison with triple therapies as first line Helicobacter pylori treatment seems warranted.

Limited usefulness of a seven-day twice-a-day quadruple therapy

OBJECTIVE

To test the usefulness of a twice-a-day, simplified quadruple therapy to cure Helicobacter pylori infection.

DESIGN

Helicobacter pylori-positive ulcer patients were treated with omeprazole 20 mg twice a day (b.d.), amoxicillin 1 g b.d., tinidazole 500 mg b.d. and bismuth subcitrate 240 mg b.d. for 7 days in an experimental, noncomparative pilot study.

SETTING

The gastroenterology unit of a county hospital.

PARTICIPANTS

Forty-four consecutive patients with peptic ulcer disease and H. pylori infection.

MEASUREMENTS

Cure was tested by either endoscopy or breath test after 2 months, and by urea breath test 6 months after therapy.

RESULTS

One patient was lost to follow-up. Of the remaining 43, 37 were cured at the first control, giving an intention-to-treat cure rate of 84.1% (95% CI 69-93%) and a per protocol cure rate of 86% (95% CI 71-94%). Thirty-three cured patients agreed to return for a six-month breath test. All but one were cured (long-term per protocol cure rate 82.1%; 95% CI 66-92%).

CONCLUSIONS

This particular quadruple therapy is well tolerated and easy to comply with. However, cure rates did not reach 90%.

Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy

BACKGROUND AND STUDY AIMS

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy, but is usually mild and stops spontaneously. We report five cases of life-threatening hemorrhage following this procedure, which were treated successfully by endoscopic injection.

PATIENTS AND METHODS

A total of 550 consecutive patients underwent TRUS-guided prostate biopsy in an outpatient setting. TRUS was performed using a Sonolayer 140 A (Toshiba) unit with a 7-MHz biplane transrectal probe, which was covered with two prophylactic sheaths. Sextant prostatic biopsies were systematically performed with a 16-gauge or 18-gauge needle without antibiotic prophylaxis.

RESULTS

Five patients (1%) presented rectal bleeding with hypovolemic symptoms shortly after the procedure. Emergency colonoscopy revealed active bleeding from biopsy sites in the anterior rectal wall. Endoscopic injection of epinephrine and polidocanol achieved control of bleeding and permanent hemostasis in all cases. The patients required hospitalization and a mean of 4 packed red blood cell units (range 2-7). The patients were discharged, with uneventful recoveries.

CONCLUSIONS

Colonoscopy should be carried out in patients presenting severe rectal bleeding after TRUS-guided prostate biopsy. Endoscopic treatment can be used to deal with this rare complication.

Validation of phone interview for follow-up in clinical trials on dyspepsia: evaluation of the Glasgow Dyspepsia Severity Score and a Likert-scale symptoms test

OBJECTIVE

To validate two widely used dyspepsia scores performed by phone interview.

DESIGN

Spanish translations of the Glasgow Dyspepsia Severity Score and a Likert-scale symptomatic test were evaluated. Responsiveness to the treatment, validity of the tests, and reproducibility of tests performed by phone interview were assessed.

SETTING

Gastroenterology and endoscopy unit of a county hospital.

PARTICIPANTS

Group I consisted of 16 ulcer patients undergoing Helicobacter pylori eradication; Group II consisted of 29 healthy volunteers; and Group III consisted of 95 patients undergoing upper endoscopy.

MEASUREMENTS

Glasgow Severity Dyspepsia Score and Likert test.

RESULTS

Both tests showed adequate improvement (responsiveness) after H. pylori eradication. With regard to validity, the Glasgow and Likert test were significantly higher in 95 patients undergoing endoscopy than in 29 healthy controls. Analysis of reproducibility showed that intraobserver variation was low on both the Glasgow and Likert scores. No differences were found between consecutive tests regardless of whether both were performed by phone (24 patients) or one by phone and the other by clinical interview (40 patients). Interobserver variation analysis showed that the Glasgow test remained highly reproducible even when performed by different observers using different methods (clinical interview 8.83, phone 8.44, P = 0.12). By contrast, Likert-scale tests showed significant differences between observers for all symptoms except abdominal pain.

CONCLUSIONS

(1) The Glasgow score is highly reproducible even when performed by different observers and using different methods. (2) By contrast, Likert tests show greater variability. To be reproducible in different conditions, they need to be performed by the same observer.

Four-day, twice daily, quadruple therapy with amoxicillin, clarithromycin, tinidazole and omeprazole to cure Helicobacter pylori infection: a pilot study

BACKGROUND

The best regimen for the treatment of Helicobacter pylori infection has yet to be defined. Four-day quadruple therapy with tetracycline, metronidazole, bismuth, and a proton pump inhibitor has been shown to obtain a very high cure rate. However, the fact that it must be taken four times daily may interfere with compliance. The objective of the study was to test the efficacy and tolerability of a new 4-day therapy with 4 drugs taken every 12 hours to cure H. pylori infection. Patients and Methods. Fifty-six consecutive patients with peptic ulcer disease and H. pylori infection were treated with an oral 4-day course with omeprazole (20 mg/12 hours), clarithromycin (500 mg/12 hours), amoxicillin (1 g/12 hours) and tinidazole (500 mg/12 hours). Efficacy of the treatment was determined at least 2 months after therapy either by biopsy (in the case of gastric ulcer) or by 13C-urea breath test. A second breath test was performed at least 6 months after therapy.

RESULTS

Two patients were lost to follow-up. Forty-nine of the remaining 54 patients were cured at the first control [intention-to-treat cure rate: 87.5% (CI 95% 75-94%); per protocol cure rate: 90.7% (CI 95% 81-98%)]. Forty-three of these 49 cured patients returned for a second 13C urea breath-test at 6-12 months. Two of them were not cured, giving a long-term cure rate of 85.5% per protocol and 73.2% by intention-to-treat. Compliance was good, although 25 patients had mild side effects.

CONCLUSION

This particular four-day therapy is well tolerated, easy to follow, and achieves an acceptably high cure rate.

Efficacy of low and standard midazolam doses for gastroscopy. A randomized, double-blind study

AIM

To evaluate the efficacy and safety of two different doses of intravenous midazolam (35 and 70 microg/kg) compared to placebo in patients undergoing gastroscopy.

PATIENTS AND METHODS

Sixty patients scheduled for diagnostic gastroscopy were selected according to factors previously reported to affect tolerance (Eur J Gastroenterol Hepatol 1999; 11:201-204) and were randomly assigned to receive premedication with midazolam 35 microg/kg iv, midazolam 70 microg/kg iv or placebo iv. Oxygen saturation was continuously monitored during the procedure. Patients' tolerance, time to discharge and post-sedative inconvenience were evaluated using visual analogue scales and a questionnaire.

RESULTS

Patients receiving either dose of midazolam showed better tolerance of gastroscopy than those receiving the placebo. Fewer patients receiving 70 or 35 microg/kg of midazolam were reluctant to undergo a further gastroscopy compared to those receiving the placebo (2, 1 and 9 patients respectively, P = 0.01). Compared to patients receiving midazolam 70 microg/kg, those receiving midazolam 35 microg/kg were discharged earlier (29.3+/-14.4 versus 43.1+/-12.4 min respectively, P < 0.001), experienced less post-sedative inconvenience (8 versus 15 patients slept for > 1 h at home respectively, P = 0.02), and suffered fewer clinically relevant desaturation episodes (< 90%) (0 versus 5 patients respectively, P = 0.04).

CONCLUSIONS

Low doses of intravenous midazolam (35 microg/kg) are adequate and safe when sedation is indicated for gastroscopy.

Identification of factors that influence tolerance of upper gastrointestinal endoscopy

OBJECTIVE

Unsedated gastroscopy is unpleasant for some patients. The identification of factors related to tolerance would permit the selection of patients for sedation. The aim of the present study was to identify these factors.

METHODS

Five hundred and nine patients underwent diagnostic gastroscopy after the administration of topical pharyngeal anaesthesia, without sedation. Patients were grouped as to whether they had undergone prior examinations or not. Tolerance was assessed with a visual analogue scale and a questionnaire.

RESULTS

Two hundred and seventy-three (54%) patients underwent gastroscopy for the first time, and 236 (46%) patients had prior experience. Patient tolerance was poor in 84 of 273 (31%) patients undergoing gastroscopy for the first time, and in 61 of 236 (26%) patients with prior experience. Logistic regression analysis identified the following variables related to poor tolerance: (a) in patients undergoing gastroscopy for the first time: presence of gag reflex (odds ratio (OR) = 3.42, 95% confidence interval (CI) 1.90-6.17), apprehension (OR = 2.57, CI 1.33-4.95), young age (OR = 0.95, CI 0.93-0.98) and high level of anxiety (OR = 1.91, CI 0.96-3.89); (b) in patients with prior experience: apprehension (OR = 4.21, CI 1.93-9.20), poor tolerance of prior examinations (OR = 4.92, CI 1.93-12.5) and female (OR = 2.23, CI 1.09-4.57).

CONCLUSIONS

The above-mentioned factors are predictive of poor tolerance, and may enable the identification of those patients who might benefit more from sedation for gastroscopy.

Epidemiology of peptic ulcer disease in cirrhotic patients: role of Helicobacter pylori infection

OBJECTIVE

The aim of this study was to investigate the clinical and epidemiological factors associated with the appearance of peptic ulcer in patients with cirrhosis and, in particular, the role of Helicobacter pylori infection.

METHODS

A total of 201 of 220 consecutive patients included in a prospective study that aimed to evaluate the effect of dietary intervention on cirrhotic complications and survival underwent upper gastrointestinal endoscopy. At entry, an epidemiological and clinical questionnaire was completed and the presence of peptic ulcer disease or esophageal varices at endoscopy was prospectively collected. Sera were obtained and stored at -70 degrees C until analyzed, being tested afterward for Helicobacter pylori antibodies using a commercial ELISA kit.

RESULTS

Eleven of 201 patients had borderline anti-Helicobacter pylori IgG titers and were excluded from further analysis. In the remaining 190 patients, point prevalence of peptic ulcer was 10.5% and lifetime prevalence 24.7%. Multivariate analysis selected male sex (OR 2.3; 95%CI 1.09-4.89) and Helicobacter pylori seropositivity (OR: 1.7, 95%CI 1.02-2.81) as the variables independently related to peptic ulcer disease.

CONCLUSIONS

Male sex and seropositivity for Helicobacter pylori are the major risk factors for peptic ulcer in cirrhosis.

Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance

BACKGROUND AND STUDY AIMS

Gastroscopy is often an unpleasant procedure for the patient. Sedation improves the tolerance, but it causes inconvenience both for patients and for endoscopy units. The aim of the present study was to compare the feasibility, safety, and tolerance of transnasal gastroscopy using a thin endoscope with conventional oral gastroscopy.

PATIENTS AND METHODS

One hundred eighty-one consecutive outpatients referred for diagnostic gastroscopy were randomized to undergo transnasal or oral conventional gastroscopy. The tolerance (discomfort, retching, throat pain, and desire for sedation in any further procedures) and examination difficulty (intubation, examination, aspiration, and visibility) were assessed by the patients and the endoscopists, respectively, using visual analogue scales and a questionnaire.

RESULTS

Endoscope insertion failed in six patients (four transnasal, two conventional). The tolerance was significantly better with transnasal gastroscopy in comparison to conventional oral gastroscopy. Only 3% of patients undergoing transnasal gastroscopy desired sedation in any further examinations, compared to 15% in the conventional oral gastroscopy group (P = 0.01). The examination time was longer in the transnasal group (5 min 25 sec +/- 1 min 46 sec vs. 3 min 22 sec +/- 1 min 9 sec, P < 0.001). Visualization capability and aspiration using the thin endoscope were considered more difficult by the endoscopists.

CONCLUSIONS

Nasal introduction of thin endoscopes is better tolerated by patients than conventional gastroscopy, minimizing the need for sedation. However, technical improvements in thin endoscopes (a wider working channel, increased length and better image quality) would increase their usefulness.

Two-day quadruple therapy for cure of Helicobacter pylori infection: a comparative, randomized trial

OBJECTIVE

We sought to compare a 2-day quadruple therapy with a 14-day triple therapy in the treatment of Helicobacter pylori infection.

METHODS

Eighty-one consecutive patients with an endoscopically diagnosed peptic ulcer and demonstrated infection by H. pylori were included in the study. Patients were randomized to receive omeprazole 40 mg b.i.d., amoxicillin 2.5 g once daily, metronidazole 500 mg t.i.d., and bismuth subcitrate 360 mg t.i.d. for 2 days, followed by omeprazole 20 mg once daily for 6 additional days (Group 1) or a 14-day course of omeprazole 20 mg b.i.d., amoxicillin 1 g t.i.d., and metronidazole 500 mg t.i.d. (Group 2). Eradication was evaluated by antral biopsy and rapid urease test at 2 months after therapy and by C13-urea breath test after a year.

RESULTS

Two patients were lost to follow-up at 2 months. Intention-to-treat analysis showed that H. pylori infection was cured in 29 of 42 patients (69%; 95% CI: 53-82%) in Group 1 versus 36 of 39 (92%; 95% CI: 78-98%) of patients in Group 2 (p = 0.009). Per-protocol analysis showed a cure rate of 71% (95% CI: 55-84%) (29/41 patients) and 95% (95% CI: 81-99%) (36/38 patients), respectively (p = 0.007). Fifty-five of 65 cured patients returned 1 year after treatment (26 in Group 1, 29 in Group 2). All but one in Group 2 remained cured. There were no significant differences in compliance (88% in Group 1 versus 92% in Group 2) or in the presence of side effects (27%; 95% CI: 15-43% versus 41%; 95% CI: 26-58%; ns).

CONCLUSION

Two-day quadruple therapy is significantly less effective than 2-wk triple treatment.

[Epidemiological study on the incidence of inflammatory bowel disease in 4 Spanish areas. Spanish Group on the Epidemiological Study of Inflammatory Bowel Disease]

BACKGROUND

The incidence of inflammatory bowel disease (IBD) shows marked geographical variations. The aim of this study was to determine and compare the incidence of IBD in four Spanish areas: Sabadell (Northeast), Vigo (Northwest), Mallorca island and Motril (South).

PATIENTS AND METHODS

Prospective survey based on inception cohorts over a two-years period (1 October 1991 to September 1993). Subjects were the patients resident in these areas and diagnosed of IBD according to a standard protocol for case ascertainment and definition.

RESULTS

Altogether 328 cases were identified, of whom 191 were diagnosed as ulcerative colitis (UC), 135 as Crohn's disease (CD) and 2 as indeterminate colitis. The overall adjusted incidence rate per 100,000 persons between ages 15-64 years of UC and CD were respectively 9.8 and 5.2 in Sabadell, 7.7 and 5.0 in Vigo, 7.8 and 5.8 in Mallorca and 4.3 and 6.5 in Motril. The Incidence rate ratio showed no significant differences for either conditions among these areas. The global adjusted incidence rate of UC in Spanish areas (8.0; IC 95%: 6.3-9.7) was significantly lower to that of Northern European countries while that of CD (5.5; IC 95%: 4.1-6.9) was between that of Northern and Southern Europe with no significant differences.

CONCLUSIONS

The incidence of IBD did not show differences among the Spanish areas, and rates are between 2 and 6 times higher than those previously reported. The incidence of UC is significantly lower than that observed in the North of Europe, while for CD the incidence is between that of Northern and Southern Europe.

Seroprevalence and epidemiology of Helicobacter pylori infection in patients with cirrhosis

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer

BACKGROUND

Although endoscopic injection therapy is effective in controlling initial haemorrhage from peptic ulcer, between 10% to 30% of patients suffer rebleeding.

AIM

To assess the factors that may predict the failure of endoscopic injection in patients bleeding from high risk gastric ulcer.

SUBJECTS

One hundred and seventy eight patients admitted for a gastric ulcer with a bleeding or a non-bleeding visible vessel were included.

METHODS

Patients received endoscopic therapy by injection for adrenaline and polidocanol. Twelve clinical and endoscopic variables were entered into a multivariate logistic regression model to ascertain their significance as predictive factor of therapeutic failure.

RESULTS

Eighty seven per cent (155 of 178) of patients had no further bleeding after endoscopic therapy. Endoscopic injection failed in 23 (13%) patients: 20 (12%) continued to bleed or rebleed, and three (1%) patients could not be treated because of inaccessibility of the lesion. Logistic regression analysis showed that therapeutic failure was significantly related to: (1) the presence of hypovolaemic shock (p = 0.09, OR 2.38, 95% CI: 0.86, 6.56), (2) the presence of active bleeding at endoscopy (p = 0.02, OR 2.98, 95% CI: 1.12, 7.91), (3) ulcer location high on the lesser curvature (p = 0.04, OR 2.79, 95% CI: 1.01, 7.69), and (4) ulcer size larger than 2 cm (p = 0.01, OR 3.64, 95% CI: 1.34, 9.89).

CONCLUSION

These variables may enable identification of those patients bleeding from gastric ulcer who would not benefit from injection therapy.

[Endoscopic ligation with elastic bands in the prevention of hemorrhage recurrence caused by esophageal varices. Study of 45 patients]

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence by esophageal varices. Forty-five patients without known hepatocarcinoma who had survived a hemorrhagic variceal episode were included in the study. Seventeen patients (38%) were Child-Pugh A, 22 (49%) B, and 6 (13%) C, with the hepatitis C virus and alcohol being the etiology of cirrosis in 55 and 20% of the cases, respectively. The first ligation session was performed between the third and fifth days after the hemorrhagic episode and the posterior sessions were carried out at intervals of 2-4 weeks. The ligation sessions were performed without antibiotic prophylaxis and with placement of an overtube. A mean of 4 +/- 2 bands were placed per session (range, 1-8) and the mean number of sessions required per patient to achieve erradication of the varices was 3.5 +/- 1.5 (range, 2-8). The rate of bleeding recurrence was 17.7% (9 episodes, five by variceal rupture and four by ulcer secondary to ligation). All the episodes of bleeding recurrence occurred between the sessions, with the mortality being 11% (5/45 patients). In the 40 remaining patients the varices were erradicated although 19 (47.5%) required one or two additional sessions of sclerotherapy. The accumulated percentage of patients free of bleeding recurrence was 82% during a mean follow-up of 10.2 +/- 6.7 months. Ten lesions of dislaceration of the esophageal mucosa caused by placement of the were observed overtube. In conclusion, endoscopic elastic band ligation is a useful technique for the erradication of esophageal varices an in the prevention of bleeding recurrence.

[Prognostic factors of early mortality in the 1st episode of hemorrhage caused by esophageal varices]

AIM

To assess the prognostic factors of early mortality in cirrhotic patients with the first variceal bleeding episode.

PATIENTS AND METHODS

Fifty-five cirrhotic patients with endoscopic evidence of variceal bleeding treated with sclerotherapy during emergent endoscopy were included.

RESULTS

Permanent hemostasis was obtained in 36 patients (65.5%). Fourteen (25.4%) patients died within six weeks of the bleeding episode. Twenty-four variables obtained at admission and in the following days were compared between patients who survived (n = 41), and died (n = 14). In the univariate analysis the following variables were related to early mortality: prothrombin ratio (p = 0.04), the presence of ascites (p = 0.004) and encephalopathy (p = 0.06), albumin (p = 0.01), Child-Pugh score (p = 0.0003), hemostasis during endoscopy (p = 0.002), absence of rebleeding at 24 hours (p = 0.01) and early rebleeding (within five days after the bleeding episode) (p = 0.006). Multiple logistic regression identified the Child-Pugh score (OR 11.86, CI 95% 2.54-55.48; p = 0.001) and early rebleeding (OR 6.27, CI 95% 1.29-30.44; p = 0.02) as prognostic independent factors of early mortality.

CONCLUSIONS

The degree of hepatic failure and early rebleeding are prognostic independent factors of early mortality in cirrhotic patients after the first variceal bleeding episode.

Gastric ulcer perforation into the heart

Penetration of the pericardium and heart is a very rare complication of benign peptic ulcer. The case is reported here of a 76-year-old woman with advanced senile dementia, who was admitted due to melena. Endoscopy revealed a large gastric ulcer located in a giant hiatal hernia. The ulcer base was protruding and strongly pulsatile, and seemed to be mobile and free in relation to the ulcer margins. This effect was particularly obvious during the pulsatile movements. Endoscopic findings suggested ulcer perforation to the pericardium. The patient's relatives denied consent to surgery. She was therefore treated with conservative measures, including parenteral nutrition, ranitidine, and antibiotics. The patient remained in a relatively stable condition, and she was discharged three weeks later. One month later, however, she was admitted with massive bleeding and hypovolemic shock. In spite of resuscitation measures, she died. The autopsy study showed a gastric ulcer penetrating through the pericardium and myocardium into the left ventricle.

Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer

BACKGROUND

The aim of this study was to assess the factors that may cause failure of endoscopic injection in patients bleeding from a duodenal ulcer.

METHODS

One hundred twenty patients admitted for a bleeding duodenal ulcer with active arterial hemorrhage or a nonbleeding visible vessel were included.

RESULTS

Endoscopic injection was not feasible in 14 of 120 (11.6%) patients because of inaccessibility or massive hemorrhage. The remaining 106 patients underwent endoscopic therapy by injection of adrenaline and polidocanol. The efficacy (achievement of definitive hemostasis) of endoscopy therapy was 83% (88 of 106). Univariate analysis showed that failure of endoscopic injection was related to age, presence of shock, ulcer size greater than 2 cm, and hemoglobin level. Multivariate analysis showed that ulcer size greater than 2 cm (p = 0.005) and the presence of shock (p = 0.03) were factors predictive of endoscopic treatment failure. Failure to achieve hemostasis (p < 0.001) and poor physical status measured by American Society of Anesthesiology classification (p = 0.02) were significantly related to mortality.

CONCLUSIONS

Ulcer size and severity of hemorrhage are predictive of endoscopic injection failure in patients bleeding from high-risk duodenal ulcers. Survival is determined by clinical status and associated diseases.

Topical pharyngeal anesthesia improves tolerance of upper gastrointestinal endoscopy: a randomized double-blind study

BACKGROUND AND STUDY AIMS

The usefulness of topical pharyngeal anesthesia is not well established. The aim of the present study was to determine its benefits in relation to patient tolerance and facilitation of the procedure in unsedated patients undergoing upper gastrointestinal endoscopy.

PATIENTS AND METHODS

A randomized double-blind study comparing Topicaina spray - a mixture of benzocaine butyl aminobenzoate (butoforme), amethocaine, and butacaine - and a placebo was carried out on 256 outpatients referred for diagnostic endoscopy. No additional premedication was used. After the examination, both the tolerance to and difficulty of the intubation and examination were evaluated by patients and endoscopists respectively, using visual analogue scales and a questionnaire.

RESULTS

Three patients (1.2%) did not tolerate the endoscopy. One patient was excluded for unexpected therapeutic endoscopy. One hundred twenty-five patients received the active spray and 127 received the placebo. The two groups were similar with respect to patient characteristics. Both intubation and examination, assessed with visual analogue scales, were better tolerated (both p = 0.0001) and more easily performed (p = 0.02 and p = 0.0001 respectively) in the active treatment group. Patients receiving the active spray had a better tolerance for the procedure, according to questionnaire replies.

CONCLUSIONS

Topical pharyngeal anesthesia in unsedated patients undergoing diagnostic upper gastrointestinal endoscopy improves tolerance and makes examination easier.

Endoscopic sclerotherapy in upper gastrointestinal bleeding due to the Mallory-Weiss syndrome

OBJECTIVES

Therapeutic endoscopic techniques have changed the need for emergency surgery in gastrointestinal bleeding episodes. However, there is only little information about endoscopic therapies in severe gastrointestinal bleeding due to the Mallory-Weiss syndrome. The aim of this clinical study was to assess the usefulness of early endoscopic examination and sclerotherapy for severe or recurrent bleeding due to the Mallory-Weiss syndrome.

METHODS

We studied all 50 cases of gastrointestinal bleeding secondary to the Mallory-Weiss syndrome seen in 2175 consecutive emergency endoscopic examinations performed in a University Hospital over a 3-year period. Endoscopic sclerotherapy (1/10000 adrenaline + 1% polidocanol) was performed in all patients with active bleeding or visible vessel at endoscopic examination. The remaining patients were medically treated.

RESULTS

Active bleeding or a visible vessel were found in 13 patients; definitive hemostasis was obtained in all cases with sclerotherapy. The remaining 37 patients were successfully treated by conservative therapy. On admission, the severity of the hemorrhagic episodes was significantly higher in patients treated with sclerotherapy than in those who did not require this procedure. An esophageal perforation, successfully managed by conservative means, was the only complication recorded in the subset of patients undergoing sclerotherapy.

CONCLUSIONS

Severe bleeding due to Mallory-Weiss syndrome can be successfully treated by sclerotherapy. Early endoscopic examination is an accurate procedure in identifying patients who do not require sclerotherapy.