Association of vagus nerve severance and decreased risk of subsequent type 2 diabetes in peptic ulcer patients: An Asian population cohort study

Vagus nerve may play a role in serum glucose modulation. The complicated peptic ulcer patients (with perforation or/and bleeding) who received surgical procedures with or without vagotomy provided 2 patient populations for studying the impact of vagus nerve integrity. We assessed the risk of developing type 2 diabetes in peptic ulcer patients without and with complications by surgical treatment received in a retrospective population study using the National Health Insurance database in Taiwan.A cohort of 163,385 patients with peptic ulcer and without Helicobacter pylori infection in 2000 to 2003 was established. A randomly selected cohort of 163,385 persons without peptic ulcer matched by age, sex, hypertension, hyperlipidemia, Charlson comorbidity index score, and index year was utilized for comparison. The risks of developing diabetes in both cohorts and in the complicated peptic ulcer patients who received truncal vagotomy or simple suture/hemostasis (SSH) were assessed at the end of 2011.The overall diabetes incidence was higher in patients with peptic ulcer than those without peptic ulcer (15.87 vs 12.60 per 1000 person-years) by an adjusted hazard ratio (aHR) of 1.43 (95% confidence interval [CI] = 1.40-1.47) based on the multivariable Cox proportional hazards regression analysis (competing risk). Comparing ulcer patients with truncal vagotomy and SSH or those without surgical treatment, the aHR was the lowest in the vagotomy group (0.48, 95% CI = 0.41-0.56).Peptic ulcer patients have an elevated risk of developing type 2 diabetes. Moreover, there were associations of vagus nerve severance and decreased risk of subsequent type 2 diabetes in complicated peptic ulcer patients.

Clinical characteristics of Helicobacter pylori-negative drug-negative peptic ulcer bleeding

AIM: To investigate the clinical characteristics and outcomes of idiopathic Helicobacter pylori (H. pylori)-negative and drug-negative] peptic ulcer bleeding (PUB).

METHODS: A consecutive series of patients who experienced PUB between 2006 and 2012 was retrospectively analyzed. A total of 232 patients were enrolled in this study. The patients were divided into four groups according to the etiologies of PUB: idiopathic, H. pylori-associated, drug-induced and combined (H. pylori-associated and drug-induced) types. We compared the clinical characteristics and outcomes between the groups. When the silver stain or rapid urease tests were H. pylori-negative, we obtained an additional biopsy specimen by endoscopic re-examination and performed an H. pylori antibody test 6-8 wk after the initial endoscopic examination. For a diagnosis of idiopathic PUB, a negative result of an H. pylori antibody test was confirmed. In all cases, re-bleeding was confirmed by endoscopic examination. For the risk assessment, the Blatchford and the Rockall scores were calculated for all patients.

RESULTS: For PUB, the frequency of H. pylori infection was 59.5% (138/232), whereas the frequency of idiopathic cases was 8.6% (20/232). When idiopathic PUB was compared to H. pylori-associated PUB, the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis during the hospital stay (30% vs 7.4%, P = 0.02). When idiopathic PUB was compared to drug-induced PUB, the patients in the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis upon admission (30% vs 2.7%, P < 0.01). When drug-induced PUB was compared to H. pylori-associated PUB, the patients in the drug-induced PUB were older (68.49 ± 14.76 years vs 47.83 ± 15.15 years, P < 0.01) and showed a higher proportion of gastric ulcer (77% vs 49%, P < 0.01). However, the Blatchford and the Rockall scores were not significantly different between the two groups. Among the patients who experienced drug-induced PUB, no significant differences were found with respect to clinical characteristics, irrespective of H. pylori infection.

CONCLUSION: Idiopathic PUB has unique clinical characteristics such as re-bleeding after initial hemostasis upon admission. Therefore, these patients need to undergo close surveillance upon admission.

Optimal initiation of Helicobacter pylori eradication in patients with peptic ulcer bleeding

AIM: To evaluate when Helicobacter pylori (H. pylori) eradication therapy (ET) should be started in patients with peptic ulcer bleeding (PUB).

METHODS: Clinical data concerning adults hospitalized with PUB were retrospectively collected and analyzed. Age, sex, type and stage of peptic ulcer, whether endoscopic therapy was performed or not, methods of H. pylori detection, duration of hospitalization, and specialty of the attending physician were investigated. Factors influencing the confirmation of H. pylori infection prior to discharge were determined using multiple logistic regression analysis. The H. pylori eradication rates of patients who received ET during hospitalization and those who commenced ET as outpatients were compared.

RESULTS: A total of 232 patients with PUB were evaluated for H. pylori infection by histology and/or rapid urease testing. Of these patients, 53.7% (127/232) had confirmed results of H. pylori infection prior to discharge. In multivariate analysis, duration of hospitalization and ulcer stage were factors independently influencing whether H. pylori infection was confirmed before or after discharge. Among the patients discharged before confirmation of H. pylori infection, 13.3% (14/105) were lost to follow-up. Among the patients found to be H. pylori-positive after discharge, 41.4% (12/29) did not receive ET. There was no significant difference in the H. pylori eradication rate between patients who received ET during hospitalization and those who commenced ET as outpatients [intention-to-treat: 68.8% (53/77) vs 60% (12/20), P = 0.594; per-protocol: 82.8% (53/64) vs 80% (12/15), P = 0.723].

CONCLUSION: Because many patients with PUB who were discharged before H. pylori infection status was confirmed lost an opportunity to receive ET, we should confirm H. pylori infection and start ET prior to discharge.

[Remote results of conservative and operative treatment of patients with duodenal ulcer complicated by bleeding]

Analyzed long-term outcomes of 690 patients with duodenal ulcer, complicated by bleeding in Kyiv City Centre gastrointestinal bleeding for the periods 1994-1996 (control group) and 2004-2008 (main group). In the late period of patients who were found giperhlorgidry (moderate and severe), increased by 1.4 tImes, indicating a higher voltage continuous acid production In the main group. With the introduction of modern circuits Helicobacter therapy incidence of H. pylori reduced by half. Improving modern tactical approaches to conservative treatment helped to reduce the frequency of relapses in duodenal ulcer remote period by 2.2 times, acute bleeding--in 1.9 times, increase the frequency of excellent results--in 2.8 times.

[Dynamics of the main immunological indices in patients, suffering gastroduodenal ulcers, complicated by hemorrhage]

A deep clinical, immunological, microbiological analysis was performed in patients, suffering gastroduodenal ulcer, complicated by hemorrhage. Immunodeficiency state with the signs of autoimmunization was noted in the patients. These changes were most severe in a severe blood loss, the local endoscopic hemostasis instability, high risk of the hemorrhage recurrence occurrence, presence in a periulcer zone mucosa of a conditionally pathogenic and pathogenic microflora with a Klebsiella pneumoniae and Streptococcus beta-haemoliticus predominance. The analysis of the data obtained permits to prognosticate the pathologic process severity course and to improve the program of treatment.

[Application of antihelicobacter therapy in patients, suffering pyloroduodenal zone ulcers, complicated by hemorrhage]

There were examined 113 patients, suffering pyloroduodenal zone ulcers, complicated by an acute hemorrhage. H. pylori was revealed in 108 (96%) patients. To escape a false-negative results a serological method was applied, which was used to determine a content of IgG antibodies to H. pylori with the help of diagnostic panel GastroPanel (Biohit PLc firm, Finland). The H. pylori presence in patients must be considered as a risk factor for the early recurrent hemorrhage occurrence. A timely conducted examination, determination of H. pylori and timely prescription of antihelicobacter therapy promote the improvement of the treatment results in patients, suffering gastroduodenal ulcers, complicated by an acute hemorrhage due to reduction of the occurrence rate of early recurrence of hemorrhage.

Helicobacter pylori related and non-related lesions in the stomach

Gastric lesions may arise in gastric mucosa of patients with gastritis or gastropathies due to different etiopathogenic factors. As most lesions of the stomach result from a chronic infection of gastric mucosa with Helicobacter pylori (H. pylori), a possible classification of gastric lesions based on etiology may distinguish H. pylori-related lesions from those arising in a gastric mucosa not colonized from the bacterium. The repertoire of lesions one may find in the stomach is limited and different pathologies may present with a similar macroscopic aspect. Clinically relevant lesions of the stomach that are or are not associated with H. pylori infection include gastric ulcer, gastric atrophy, gastric neoplasia, and metastasis from other cancers. The detection or exclusion of an H. pylori infection in patients with gastric lesions has important consequences for the clinical management. In the present review we focus on H. pylori-related and non-related peptic lesions in the stomach.

13C-urea breath test for the diagnosis of Helicobacter pylori infection in bleeding duodenal ulcer

Helicobacter pylori (H. pylori) is the main etiologic factor for duodenal ulcer (DU). Bleeding is still a frequent and sometimes severe complication, with unacceptable mortality despite modern therapeutic modalities. The importance of diagnosing and treating H. pylori infection in bleeding DU is underlined by the fact that eradication therapy is effective in preventing recurrent bleeding. The aim of this study was to evaluate the prevalence of H. pylori infection by means of 13C urea breath test (13C-UBT) in patients with bleeding DU.

MATERIAL AND METHOD

Thirty-nine patients (25 men, 14 women) hospitalized with bleeding DU underwent emergency endoscopy and treated with intravenous proton pump inhibitors (PPIs), and a 13C-UBT was performed the day after the resuming oral feeding.

RESULTS

Twenty-seven patients (19 men, 8 women) (69.3%) had a positive 13C-UBT. All patients received intravenous PPIs (22 pantoprazole, 17 esomeprazole) after emergency endoscopy (80 mg bolus + 8 mg/hour infusion/day) for 3-4 days. The time elapsed between admission and performance of 13C-UBT did not differ significantly between patients having a positive or negative 3C-UBT (5.6 vs 6.1 days). Eight of the twelve patients (66.6%) with a negative 13C-UBT had a repeated test two month later, and five of them became positive; therefore, H. pylori infection was finally detected in 32 (82%) out of 39 patients with bleeding DU.

CONCLUSION

Most patients with bleeding DU have a positive 13C-UBT although they were taking PPIs.

Risk factors involved in patients with bleeding peptic ulcers: a case-control study

Our objectives were to (1) identify the risk factors involved in patients with peptic ulcer disease and determine if they predict bleeding in these patients, (2) determine the association between these risk factors, and (3) analyze the cost effectiveness of various tests for Helicobacter pylori (H. pylori). Two-hundred and thirty patients were included in our study between January 2004 and June 2005 (128 bleeding peptic ulcer disease patients constituted the cases, 102 nonbleeding ulcer patients constituted the controls). H. pylori infection was assessed by urease test and biopsy from gastric antrum. There was no statistically significant difference between these groups regarding sex, age, or location of ulcer. Nonsteroidal anti-inflammatory drug (NSAID) use was higher in the case group (P < 0.001), and the rate of H. pylori infection was lower in these patients (P < 0.05). There was no interaction between NSAID use and H. pylori infection in predicting bleeding ulcer risk (P = 0.08). Sensitivity and specificity for urease test in detecting H. pylori was 75% and 99.7%, respectively. So a positive urease test does not need confirmation with biopsy, which is cost effective.

[Bleeding peptic ulcer. Prevalence of Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs/acetylsalicylic acid]

INTRODUCTION

Helicobacter pylori (HP) infection and use of nonsteroidal anti-inflammatory drugs (NSAIDs)/acetyl salicylic acid (ASA) are risk factors for bleeding peptic ulcer. HP eradication reduces the risk of rebleeding. Antibiotics, proton pump inhibitors (PPI) and presence of blood in the stomach can affect the HP test. The objectives of this study were to determine the HP prevalence and NSAID/ASA use in patients with bleeding ulcer in a low-prevalence HP area, to determine the proportion of idiopathic ulcers and to estimate the proportion of initially false negative HP tests. In addition, the objective was to describe changes in the characteristics of the patients who were admitted with ulcer bleeding during the last two decades.

MATERIAL AND METHODS

Retrospective review of the records of patients who were admitted with a bleeding ulcer in 2003 to 2006 at The Department of Medical Gastroenterology S, Odense University Hospital. Patients with initially negative or missing HP tests were offered a urea breath test. This population was compared with prospective registrations for the periods 1990-1992 and 2000.

RESULTS

A total of 264 patients were admitted in 2003-2006. The mean age was 72 years. The HP-prevalence was 34%, and 81% had used NSAID/ASA, as compared with 55% in 1990-1992. The proportion of idiopathic peptic ulcer disease was 6.6%. At admission, 19% and 17% of the patients were in treatment with PPI and antibiotics, respectively. Thirteen percent of the initially HP-negative patients were later found to be HP-positive.

CONCLUSION

Compared to previous studies, we found a lower HP prevalence (34%) and a higher proportion of NSAID/ASA usage (81%) in 2003-2006. As we found 13% false negative HP-tests when factors that may affect the HP test were present, we advise that a retest be made where these factors are present and the initial HP test is negative.

[Characteristics of outpatient rehabilitation of patients with duodenal ulcer complicated by bleeding]

Now current of a stomach ulcer differs special aggression. Treatment of patients with complicated current gastroduodenal ulcer remains the big problem. The method argon plasma coagulations (APC) now finds primary application for a stop extensive [Russian characters: see text] bleedings. At the same time, the important factor of favorable current of the complicated stomach ulcer is the continuity in treatment of patients and carrying out of adequate therapy from the moment of receipt in a surgical hospital and its continuation at an outpatient stage.

[Prevalence and role of Helicobacter pylori infection in some gastroduodenal and hepatic complications in cirrhotic patients]

It has been clearly established that Helicobacter pylori (H. pylori) infection plays a pivotal role in the pathogenesis of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and gastric lymphoma MALT (mucosa-associated lymphoid tissue) in the general population, but data regarding the prevalence and the role of H. pylori infection in liver cirrhosis are conflicting. Most serological studies estimated a high prevalence of H. pylori infection in patients with liver cirrhosis; however, when other methods (urea breath test, histology, culture, rapid urease test) were used, the overall H. pylori prevalence was similar to that in controls. Although the prevalence of both gastric ulcer (GU) and duodenal ulcer (DU) is higher in cirrhotic patients than in general population, the relationship between H. pylori infection and peptic ulcer in cirrhosis remains controversial. Our data regarding peptic ulcer prevalence in cirrhotic patients are in agreement with previous studies that suggest an increased prevalence of both GU and DU. The incidence of bleeding peptic ulcer is high in cirrhotic patients and carries an increased risk of complications or death in these patients and therefore eradication of H. pylori infection might be as effective in preventing ulcer relapse and bleeding as it is in noncirrhotic ulcer patients. Hepatic encephalopathy is a frecquent complication of liver cirrhosis, and it is widely accepted that ammonia plays a major role in its pathogenesis. The ammonia production by H. pylori urease does not increase blood ammonia levels during cirrhosis, and eradication of H. pylori infection does not affect hepatic encephalopathy status.

Bleeding peptic ulcer in the elderly: risk factors and prevention strategies

Peptic ulcer bleeding is a frequent and dramatic event with both a high mortality rate and a substantial cost for healthcare systems worldwide. It has been found that age is an independent predisposing factor for gastrointestinal bleeding, with the risk increasing significantly in individuals aged>65 years and increasing further in those aged>75 years. Indeed, bleeding incidence and mortality are distinctly higher in elderly patients, especially in those with co-morbidities. NSAID therapy and Helicobacter pylori infection are the most prevalent aetiopathogenetic factors involved in peptic ulcer bleeding. The risk of bleeding seems to be higher for NSAID- than for H. pylori-related ulcers, most likely because the antiplatelet action of NSAIDs impairs the clotting process. NSAID users may be classified as low or high risk, according to the absence or presence of one or more of the following factors associated with an increased risk of bleeding: co-morbidities; corticosteroid or anticoagulant co-therapy; previous dyspepsia, peptic ulcer or ulcer bleeding; and alcohol consumption. Different types of NSAIDs have been associated with different bleeding risk, but no anti-inflammatory drug, including selective cyclo-oxygenase (COX)-2 inhibitors, is completely safe for the stomach. Furthermore, even low-dose aspirin (acetylsalicylic acid) [<325 mg/day] and a standard dose of non-aspirin antiplatelet treatment (clopidogrel or ticlopidine) have been found to cause bleeding and mortality. No clear risk factor favouring H. pylori-related ulcer bleeding has been identified. Peptic ulcer bleeding prevention remains a challenge for the physician, but data are now available on use of a safer and cheaper strategy for both low- and high-risk patients. Unfortunately, despite the fact that several society and national guidelines have been formulated, these are poorly followed in clinical practice. Proton pump inhibitor (PPI) or misoprostol therapy and H. pylori eradication in NSAID-naive patients are the most commonly proposed strategies. Selective COX-2 inhibitor therapy in high-risk patients has also been suggested, but concerns over the possible cardiovascular adverse effects of some of these agents should be taken into account. Moreover, switching to selective COX-2 inhibitors in patients with previous bleeding is not completely risk free, and concomitant PPI therapy is also needed. H. pylori eradication is mandatory in all patients with peptic ulcer, and such an approach has been found to be significantly superior to PPI maintenance therapy. H. pylori eradication is frequently achieved with sequential therapy in elderly patients with peptic ulcer. In conclusion, upper gastrointestinal bleeding is a dramatic event with a high mortality rate, particularly in the elderly. Some effective preventative strategies are now available that should be implemented in clinical practice.

[Helicobacter pylori in patients with bleeding ulcer]

The diagnostic sensitivity of the polymerase chain reaction (PCR) and urease respiratory test (URT) in H. pylori infection are compared. The efficacy of H. pylori eradication in patients with a bleeding peptic ulcer using three-component scheme (De-nol, Clarythromycin, Furazolidon) and a complex medication Pylobact is also compared. Thus, URT, performed within 24 hours after the admission is more effective in patients with bleeding ulcer, then PCR. H. pylori eradication is more successful with Pylobact (93,8%) and has less side-effects in such patients, then the used three-component eradication scheme.

[Significance of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs in patients with bleeding from upper part of the gastrointestinal tract]

BACKGROUND/AIM

Helicobacter pylori (H. pylori) infection and nonsteroidal anti-inflammatory drugs (NSAIDs) use are considered to be the most important risk factors having influence on the onset of bleeding gastroduodenal lesions. Whether there is an interaction between H. pylori infection and the use of NSAIDs in the development of peptic ulcer disease is still controversial. The aim of the present study was to evaluate the prevalence of NSAIDs use and H. pylori infection in patients presented with bleeding gastroduodenal lesions.

METHODS

During the period from January 2003 December 2003 we prospectively obtained data of all the patients (n=106) presented with signs of upper gastrointestinal bleeding. All the patients were admitted to the intensive care unit, with the endoscopy performed within 12 hours after admission. Histologic analysis was used for the detection of H. pylori infection. The NSAIDs and aspirin use data were obtained by anamnesis.

RESULTS

The results of our study revealed that the most common sources of upper gastrointestinal bleeding were duodenal (57 patients, 53.77%) and ventricular (36 patients, 33.96%) ulcers. The majority of the examined cases were associated with both H. pylori infection and NSAIDs use. A statistically significant difference among the studied groups of patients was proven.

CONCLUSION

The majority of bleeding gastroduodenal lesions were associated with the coexistance of H. pylori infection and NSAIDs use, while their independent influences were statistically less important. Eradication of H. pylori infection in patients using NSAIDs might prevent upper gastrointestinal hemorrhage and reduce peptic ulcer bleeding risk.

[Role of Helicobacter pylori infection and use of NSAIDs in the etiopathogenesis of upper gastrointestinal bleeding]

INTRODUCTION

Non-steroid antiinflammatory drugs (NSAIDs) and Helicobacter pylori (Hp) infection are two most important independent risk factors involved in the etiopathogenesis of gastroduodenal mucosal injury with a clear and critical role in both uncomplicated and complicated peptic ulcer disease. It is estimated that upto 90% of all peptic ulcers result from the effect of one or both of these factors.

AIM

To determine the frequency of NSAIDs use and Hp infection in patients with acute upper gastrointestinal bleeding.

PATIENTS AND METHODS

Study evaluated data from 500 patients in whom esophagogastroduodenoscopy was performed following presentation in emergency unit with acute upper gastrointestinal bleeding. Anamnestic data was collected together with detailed information on previous salicilates and/or NSAIDs use. Hp status was determined and anatomic localisation of bleeding lesion was also registered.

RESULTS

Acute upper GIT bleading was caused solely by NSAIDs in 55 (11%), by aspirin in 66 (13.2%), while combined NSAID/aspirin therapy was identified in 19 (3.8%) of patients. In total NSAID and/or aspirin use were diagnosed in 139 (27.8%). while in 122 (24.4%) only Hp infection was diagnosed. Both risk factors were identified in 144 (28.8%) patients (Hp+NSAIDs in 12.2%, Hp+aspirin in 10.8% and Hp+aspirin+NSAIDs in 5.8%). In 19.8% of the cases (14% of males and 27% of females) neither NSAID/aspirin use nor presence of Hp infection was noted. Out of 500 patients enrolled, 63% were mails. In females, bleeding lesion was most frequently localized in gastric mucosa, while males had equal chance of bleeding from either gastric or duodenal mucosa. Fortunatelly, only 5 to 7% of patients were bleeding from both gastric and duodenal lesion.

CONCLUSION

Prevention of acute upper gastrointestinal bleeding can be achieved trough strict and limited use of aspirin and NSAIDs, eradication of Hp infection and use of gastroprotective therapy in well-defined risk patients that need chronic NSAIDs and/or aspirin therapy. In all patients starting long-term NSAID and/or aspirin therapy and all patients already on long-term aspirin therapy test and treat strategy for Hp infection should be used. On the other hand, only in high risk patients (more than 65 years, history of peptic ulcer disease, concomitant corticosteroid, aspirin, clopidogrel or warfarin therapy) already on chronic NSAID therapy long-term PPI therapy should be prescribed after testing and treating of Hp infection.

Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding

AIM

To evaluate the effect of Helicobacter pylori eradication on ulcer bleeding recurrence in a prospective, long-term study including more than 400 patients.

METHODS

Patients with peptic ulcer bleeding were prospectively included. H. pylori infection was confirmed by rapid urease test, histology or (13)C-urea breath test. Several eradication regimens were used. Ranitidine 150 mg was administered daily until eradication was confirmed by breath test 8 weeks after completing eradication therapy. Patients with therapy failure received a second or third course of therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy, and were controlled yearly with a repeated breath test.

RESULTS

Four hundred and twenty-two patients were followed up for at least 12 months, with a total of 906 patient-years of follow up. Mean age was 59 years, and 35% were previous nonsteroidal anti-inflammatory drug (NSAID) users. Sixty-nine percent had duodenal, 24% gastric, and 7% pyloric ulcer. Recurrence of bleeding was demonstrated in two patients at 1 year (incidence: 0.22% per patient-year of follow up), which occurred after NSAID use in both cases.

CONCLUSION

Peptic ulcer rebleeding does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved.

Endoscopic diagnosis of Helicobacter pylori in patients with bleeding peptic ulcers

Helicobacter pylori (H. pylori) is the main etiologic factor for peptic ulcers (PU), and it has been shown that H. pylori eradication therapy is effective in preventing recurrent bleeding from PU.

AIM

The aim of this study was to establish the prevalence of H. pylori infection in patients with bleeding PU using two endoscopic-based methods--rapid urease test (RUT) and histology--and to compare their diagnostic accuracy.

METHODS

All patients underwent emergency endoscopy during which a biopsy specimen from the pre-pyloric antrum for RUT and two other specimens from the antrum and gastric corpus for histological assessment were taken.

RESULTS

Ninety-one patients (52 men, 39 women, aged 18-78 years) were included; 69 patients had duodenal ulcer (DU), 18 had gastric ulcer (GU) and four had both duodenal and gastric ulcers. The most frequent presentation was melena (72.5%). Hemoglobin concentration ranged from 3.9 to 14.8 g/dL, and blood in the stomach was present in 59 (64.8%) of patients. Sixty-two patients (68.9%) were diagnosed by RUT as H. pylori-positive, while 81 patients (89.0%) were found to be positive by histology, the difference being statistically significant (p = 0.0048, 95% CI) The sensitivity and specificity of RUT were 76.5% and 100%, respectively. The presence of blood in the stomach did not influence the results of both RUT and histology. The study confirmed the high prevalence of H. pylori infection in patients with bleeding DU.

CONCLUSION

RUT has a low sensitivity, and thus it is unreliable for the diagnosis of H. pylori infection in patients with bleeding PU; however, RUT has a high specificity and therefore, it should be used as the first choice test for the diagnosis of H. pylori in such patients undergoing emergency endoscopy. Additional biopsies should be taken during endoscopy and proceeded with histological examination when RUT is negative.

Accuracy of Helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and a meta-analysis of diagnostic accuracy of the different tests aimed to detect Helicobacter pylori infection in patients with upper gastrointestinal bleeding (UGIB).

SELECTION OF STUDIES

assessing the accuracy of H. pylori diagnostic methods in patients with UGIB.

SEARCH STRATEGY

electronic bibliographical searches.

DATA EXTRACTION

independently done by two reviewers.

DATA SYNTHESIS

meta-analyses of the different tests were performed combining the sensitivities, specificities, and likelihood ratios (LRs) of the individual studies.

RESULTS

Studies showed a high degree of heterogeneity. Pooled sensitivity, specificity, LR+ and LR- (95% confidence interval (CI)) for the different methods were: Rapid urease test (16 studies/1,417 patients): 0.67 (0.64-0.70), 0.93 (0.90-0.96), 9.6 (5.1-18.1), and 0.31 (0.22-0.44). Histology (10 studies/827 patients): 0.70 (0.66-0.74), 0.90 (0.85-0.94), 6.7 (2.5-18.4), and 0.23 (0.12-0.46). Culture (3 studies/314 patients): 0.45 (0.39-0.51), 0.98 (0.92-1.00), 19.6 (4-96), and 0.31 (0.05-1.9). Urea breath test (8 studies/520 patients): 0.93 (0.90-0.95), 0.92 (0.87-0.96), 9.5 (3.9-23.3), and 0.11 (0.07-0.16). Stool antigen test (6 studies/377 patients): 0.87 (0.82-0.91), 0.70 (0.62-0.78), 2.3 (1.4-4), and 0.2 (0.13-0.3). Serology (9 studies/803 patients): 0.88 (0.85-0.90), 0.69 (0.62-0.75), 2.5 (1.6-4.1), and 0.25 (0.19-0.33).

CONCLUSION

Biopsy-based methods, such as rapid urease test, histology, and culture, have a low sensitivity, but a high specificity, in patients with UGIB. The accuracy of 13C-urea breath test remains very high in these patients. Stool antigen test is less accurate in UGIB. Although serology seems not to be influenced by UGIB, it cannot be recommended as the first diagnostic test for H. pylori infection in this setting.

Role of Helicobacter pylori infection in peptic ulcer haemorrhage

AIM

In spite of the diffusion of endoscopic treatment, mortality rate due to peptic ulcer haemorrhage (PUH) remains high. Helicobacter pylori (H. pylori) infection and nonsteroidal anti-inflammatory drugs (NSAIDs) are the 2 main aetiological factors, but their interactive role is controversial. The aim of this study was to determine both the prevalence of H. pylori infection and NSAIDs consumption in PUH and their prognostic importance.

METHODS

In a prospective study, 41 consecutive patients (33 males, 8 females) admitted for PUH were recruited. H. pylori status was investigated both by measuring specific antibodies in serum and by histological detection on gastric biopsies obtained after one month from bleeding. In case of doubt, either a 13C urea breath test, or a stool antigen test were associated. All patients were treated with medical therapy associated to endoscopic treatment in most severe cases.

RESULTS

Sixteen patients were infected from H. pylori (group A), 12 had a history of NSAIDs consumption (group B), and 13 had both risk factors (group C). The median duration of hospitalisation was 7 days for each group and correlated with age (P<0.04). Severity of PUH (high risk of rebleeding) was higher in group A (13/16; 81%) and group C (9/13; 69%), with respect to group B (6/12; 50%). This difference was not significant.

CONCLUSIONS

H. pylori infection has a predominant role in causing PUH as well as in the prognosis and clinical course of this condition. Hence, it is important to determine H. pylori status in every patient with PUH.

Usefulness of a delayed test for the diagnosis of Helicobacter pylori infection in bleeding peptic ulcer

AIM

To evaluate (i) the diagnostic usefulness of a delayed test in initially negative patients; and (ii) the reliability of the rapid urease test, histology or a combination of the two to diagnose Helicobacter pylori during emergency endoscopy in a large clinical practice series.

PATIENTS AND METHODS

Records of patients with ulcer bleeding from 1995 to 2000 were reviewed. Patients with initially negative tests were retested 4-8 weeks after the bleeding episode. Sensitivity of urease, histology or a combination of the two to detect H. pylori at initial endoscopy and the efficacy of delayed Urea Breath Test in detecting missed infection was determined.

RESULTS

The study included 429 patients. A delayed second test detected H. pylori infection in 57 out of 72 (79%) of initially negative patients. The sensitivity for detecting H. pylori was 76%, 78% and 86% for urease, histology and their combination, respectively. The prevalence of H. pylori was 95% in duodenal and 88% in gastric ulcer. In addition, only one test was performed in 17 of the 32 patients who were considered negative.

CONCLUSION

Not even the combination of a negative urease and histology in the initial endoscopy is able to rule out infection in bleeding ulcer patients. A delayed test should be performed to rule out Helicobacter pylori infection completely.

Helicobacter pylori-associated ulcer bleeding: should we test for eradication after treatment?

BACKGROUND

Eradication of Helicobacter pylori after peptic ulcer haemorrhage reduces the risk of recurrence. Because H. pylori treatment is very effective, it is unclear whether testing to confirm eradication is worthwhile.

AIMS

To examine whether patients with H. pylori-associated peptic ulcer haemorrhage should be tested for successful eradication after completion of antibiotic therapy.

METHODS

A Markov cost-effectiveness model was developed to compare testing vs. non-testing of H. pylori eradication in peptic ulcer haemorrhage. Probability estimates and average costs were derived from published information.

RESULTS

Testing for H. pylori eradication resulted in a benefit of 0.07 quality-adjusted life-years and cost 836 US dollars less than the strategy of not confirming eradication. Testing remained the superior strategy when varying the model regarding age, the initial success of eradication, various test and retreatment strategies, and the rate and costs of recurrent bleeding. Assuming a high eradication rate (95%), the test strategy becomes more expensive only if the cost of H. pylori testing reaches 265 US dollars; however, even under these conditions it remains cost-effective.

CONCLUSIONS

Patients with H. pylori-associated peptic ulcer bleeding should be tested to confirm eradiation of H. pylori after completion of antibiotic treatment.

Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection

BACKGROUND & AIMS

NSAIDs and Helicobacter pylori are risk factors for the development of peptic ulcers. A prospective study was conducted to determine prevalence of NSAID use, H pylori infection, and outcome of peptic ulcer bleeding.

METHODS

In 2000, data of all 361 patients presenting with peptic ulcer bleeding were prospectively collected in a defined geographical area, including 14 hospitals, and serving a catch area of 1.68 million persons. Follow-up data after a mean of 31 months were obtained from 211 patients.

RESULTS

The overall incidence was 21.5 cases per 100,000 persons. Mean age of the group was 70.9 years, 55% were male, and 41% had severe or life-threatening comorbidity. NSAIDs were used by 52%, and in only 17% concomitant acid suppressive therapy was given. H pylori infection was tested in 64%. Of the patients tested for H pylori, 43% were positive. Twenty-three percent were H pylori negative and not using NSAIDs. Rebleeding during initial admission occurred in 19%. Mortality during initial admission was 14%. During follow-up mortality was high, 29%.

CONCLUSIONS

Half of all ulcer bleeding was associated with NSAID use. Only a minority of NSAID users used concomitant acid suppressive therapy. H pylori is not assessed systematically in all patients with ulcer bleeding. Almost a quarter of the ulcers were associated with neither H pylori infection nor NSAID use. Mortality, both during hospitalization and follow-up, was substantial.

An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit?

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection.

DESIGN

A prospective observational study followed by a case-control study.

SETTING

Seven ICUs in the Paris area, five of them located in teaching hospitals.

PATIENTS

All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04).

CONCLUSIONS

Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.

Polymerase chain reaction: A sensitive method for detecting Helicobacter pylori infection in bleeding peptic ulcers

AIM: To assess the sensitivity and specificity of polymerase chain reaction (PCR) in detecting Helicobacter pylori (H pylori) infection in patients with bleeding peptic ulcers, and to compare its diagnostic efficacy with other invasive and non-invasive tests.

METHODS: From April to September 2002, H pylori status in 60 patients who consecutively presented with gastroduodenal ulcer bleeding was examined by rapid urease tests (RUT), histology, culture, PCR, serology and urea breath tests (UBT).

RESULTS: The sensitivity of PCR was significantly higher than that of RUT, histology and culture (91% vs 66%, 43% and 37%, respectively; P = 0.01, < 0.001, < 0.001, respectively), but similar to that of serology (94%) and UBT (94%). Additionally, PCR exhibited a greater specificity than serology (100% vs 65%, P < 0.01). However, the specificity of PCR did not differ from that of other tests. Further analysis revealed significant differences in the sensitivities of RUT, culture, histology and PCR between the patients with and those without blood in the stomach (P < 0.01, P = 0.09, P < 0.05, and P < 0.05, respectively).

CONCLUSION: PCR is the most accurate method among the biopsy-based tests to detect H pylori infection in patients with bleeding peptic ulcers. Blood may reduce the sensitivities of all biopsy-based tests.

Peptic ulcer bleeding: is Helicobacter pylori a risk factor in an endemic area?

BACKGROUND/OBJECTIVE

A high prevalence of Helicobacter pylori infection has been reported in Iran. Although the importance of H. pylori in the induction of peptic ulcer disease is clearly defined, only few studies have addressed its role in bleeding from peptic ulcers. We evaluated the role of H. pylori in peptic ulcer bleeding.

METHODS

Patients with acute peptic ulcer bleeding (PUB) and those with peptic ulcer disease without bleeding ('controls') were enrolled. Upper GI endoscopy and rapid urease test were performed in both groups. Histological study for detection of H. pylori was performed in patients with active bleeding, if RUT was negative. Other variables evaluated included sex, age, smoking, previous history of bleeding, non-steroidal anti-inflammatory drugs use, ulcer size, ulcer location, and duration of acid-peptic disease. Multivariate logistic regression analysis was performed to identify independent risk factors.

RESULTS

161 patients with PUB and 287 control patients were enrolled. H. pylori infection was seen more frequently in patients with duodenal ulcer than gastric ulcer (88.9% vs. 60.5%, p< 0.001). Univariate analysis showed that patients with PUB were more often male, older in age, used NSAID, had history of PUB in the past, had ulcer located in the stomach and not in the duodenum, and more often had large ulcer (>1 cm). Logistic regression analysis showed that H. pylori infection was protective in PUB after controlling for confounders (OR 0.41, 95% CI 0.21-0.79), when ulcer location was not entered in the model. A second model including ulcer location (to test for a residual effect) showed that H. pylori infection was not a significant risk factor in PUB (OR 0.61, 95% CI 0.30-1.24).

CONCLUSIONS

H. pylori may not be an independent factor in bleeding from peptic ulcers. The lower frequency of this infection in these patients can be described by the higher frequency of bleeding from gastric ulcers, which are less H. pylori related compared with duodenal ulcer.

Mucosal polymerase chain reaction for diagnosing Helicobacter pylori infection in patients with bleeding peptic ulcers

AIM: Helicobacter pylori (H pylori) has been linked to chronic gastritis, peptic ulcers, gastric cancer and MALT-lymphoma. Conventional invasive tests are less sensitive than non-invasive tests in diagnosing H pylori infection in patients with bleeding peptic ulcers. Polymerase chain reaction is a sensitive and accurate method for diagnosing H pylori infection. The aim of this study was to evaluate the diagnostic role of mucosal polymerase chain reaction for H pylori infection in patients with bleeding peptic ulcers.

METHODS: In patients with bleeding, non-bleeding peptic ulcers and chronic gastritis, we checked rapid urease test, histology, bacterial culture and mucosal polymerase chain reaction for detecting H pylori infection. Positive H pylori infection was defined as positive culture or both a positive histology and a positive rapid urease test. For mucosal polymerase chain reaction of H pylori, we checked vacA (s1a, s1b, s1c, s2, m1, m1T, m2), iceA1, iceA2 and cag A.

RESULTS: Between October 2000 and April 2002, 88 patients with bleeding peptic ulcers (males/females: 60/28, gastric ulcers/duodenal ulcers: 55/33), 81 patients with non-bleeding peptic ulcers (males/females: 54/27, gastric ulcers/duodenal ulcers: 45/36) and 37 patients with chronic gastritis (males/females: 24/13) were enrolled in this study. In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, 45 patients (51%), 71 patients (88%) and 20 patients (54%) respectively were found to have positive H pylori infection (P<0.001). In patients with bleeding peptic ulcers, non-bleeding peptic ulcers and chronic gastritis, polymerase chain reaction for H pylori infection was positive in 54 patients (61%), 70 patients (86%) and 20 patients (54%) respectively (P<0.001). The sensitivity, positive predictive value and diagnostic accuracy of mucosal polymerase reaction for H pylori infection were significantly lower in patients with bleeding peptic ulcers (84%, 79% and 81%) than in patients with non-bleeding peptic ulcers (99%, 99% and 98%) (P<0.001, P<0.01 and P<0.001 respectively). The sensitivity, negative predictive value and diagnostic accuracy of mucosal polymerase reaction for H pylori were significantly lower in patients with bleeding peptic ulcers (84%, 83% and 81%) than in patients with chronic gastritis (100%, 100% and 100%) (P = 0.02, P = 0.02 and P = 0.001).

CONCLUSION: Mucosal polymerase chain reaction for detecting H pylori infection is not reliable in patients with bleeding peptic ulcers.

Clinical significance of cytotoxin-associated gene A status of Helicobacter pylori among non-steroidal anti-inflammatory drug users with peptic ulcer bleeding: a multicenter case-control study

BACKGROUND

The role of Helicobacter pylori infection and especially of the cytotoxin-associated gene A (CagA) product strain in peptic ulcer bleeding among non-steroidal anti-inflammatory drugs (NSAIDs) users remains controversial.

METHODS

A case-control study was carried out including 191 consecutive chronic NSAIDs users admitted to hospital because of peptic ulcer bleeding. Peptic ulcer was verified by endoscopy. Controls comprised 196 chronic NSAIDs users without signs of bleeding of similar age and gender to cases. Multivariate regression analysis was performed for further evaluation of the relationship between H. pylori, CagA status and other risk factors.

RESULTS

H. pylori infection was present in 121 (63.4%) cases compared with 119 (60.7%) controls (odds ratio (OR) = 1.14, 95% CI, 0.76-1.72). CagA-positive strains were found to be significantly more frequent in cases than in controls (65/106 versus 41/99 P = 0.008). Current smoking (OR = 2.65; 95% CI, 1.14-6.15; P= 0.02), CagA status (OR = 2.28; 95% CI, 1.24-4.19; P = 0.008), dyspepsia (OR = 6.89; 95% CI, 1.84-25.76; P = 0.004) and past history of peptic ulcer disease (OR=3.15; 95% CI, 1.43-6.92; P=0.004) were associated significantly with increased risk of bleeding peptic ulcer.

CONCLUSIONS

The results suggest that CagA-positive H. pylori infection is associated with a more than 2-fold increased risk of bleeding peptic ulcer among chronic NSAIDs users.

Diagnosis of Helicobacter pylori infection in patients with bleeding ulcer disease: rapid urease test and histology

INTRODUCTION

The endoscopic diagnosis of Helicobacter pylori infection in patients with bleeding peptic ulcer is limited by a decreased sensitivity in standard invasive tests, rapid urease test and histology. There is controversy about the convenience of using one, neither, or both diagnostic tests.

AIMS

To evaluate the results of simultaneously performed rapid urease test and histology in the diagnosis of Helicobacter pylori infection (H. pylori) in patients with bleeding peptic ulcer.

PATIENTS AND METHODS

We included 173 patients, 98 male and 75 female, with an average age of 62 years (18-88), with upper gastrointestinal bleeding secondary to duodenal ulcer (115) or gastric ulcer (58), diagnosed within 24 hours after hospital admission. None of the patients had received treatment for H. pylori, proton pump inhibitors or antibiotics in the two weeks prior to the upper gastrointestinal bleeding episode. H. pylori infection was investigated in all patients by two antral biopsy samples for histological study (hematoxilin-eosin) and one or two antral biopsies for rapid urease test (Jatrox-H.p.-test). In cases with a negative urease test and histology, a 13C urea breath test was performed. Infection was considered present when at least one invasive test or the breath test was positive, whereas both invasive tests and the breath test had to be negative to establish an absent infection.

RESULTS

152 patients (88%) showed H. pylori infection, 104 patients (90%) with duodenal ulcer and 48 patients (83%) with gastric ulcer. In all 119 cases (78%) were diagnosed by the urease test and 112 cases (74%) by histology. Both methods were used to diagnose 134 of 152 cases (88%) (p < 0.05), these being positive in 97 cases and negative in 39 cases. In 18 of these 39 cases, the breath test was positive.

CONCLUSIONS

Histology and urease test have similar diagnostic values for the identification of H. pylori in patients with bleeding peptic ulcer. Due to its rapid results, the urease test should be the method of choice. However, additional biopsies should be performed, and, when negative, a histological study should be carried out, since a combination of both methods allows a more precise diagnosis.

Evaluation of three different tests for the detection of stool antigens to diagnose Helicobacter pylori infection in patients with upper gastrointestinal bleeding

AIM

To evaluate the accuracy of several methods aimed to detect Helicobacter pylori stool antigens in patients with upper gastrointestinal bleeding.

METHODS

Thirty-four patients with upper gastrointestinal bleeding because of peptic ulcer were included. The first stool sample during hospitalization was collected, and stool antigens were determined with: polyclonal enzyme-linked immunosorbent assay (Premier-Platinum-HpSA); monoclonal enzyme-linked immunosorbent assay (Amplified-IDEIA-HpStAR); and rapid monoclonal immunochromatographic test (ImmunoCard-STAT HpSA). A patient was considered infected when H. pylori was diagnosed with invasive tests (rapid urease test or histology) or with (13)C-urea breath test. When all tests were negative, a new breath test was repeated after stopping proton pump inhibitors.

RESULTS

All patients were infected and, therefore, only sensitivity of the tests could be calculated: polyclonal enzyme-linked immunosorbent assay (74%), monoclonal enzyme-linked immunosorbent assay (94%), and rapid monoclonal immunochromatographic test (60%; concordance between the two observers was high, kappa = 0.9). Neither the presence of maelena nor the delay in obtaining stool samples explained false negatives.

CONCLUSIONS

Neither the polyclonal enzyme-linked immunosorbent assay stool antigen test nor the rapid immunochromatographic stool antigen test can be recommended to diagnose H. pylori infection in patients with upper gastrointestinal bleeding. However, the monoclonal enzyme-linked immunosorbent assay stool antigen test is highly sensitive for detecting the infection in patients with this complication, although more studies are necessary to evaluate the specificity of the method.

Meta-analysis: Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer

AIM

To perform a meta-analysis comparing the efficacy of Helicobacter pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer.

METHODS

A search was made of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and several congresses for controlled clinical trials comparing the efficacy of H. pylori eradication therapy vs. antisecretory non-eradication therapy for the prevention of peptic ulcer re-bleeding. Studies with all patients taking non-steroidal anti-inflammatory drugs were excluded. Extraction and quality assessment of the studies were performed by two reviewers.

RESULTS

In the first meta-analysis, the mean percentage of re-bleeding in the H. pylori eradication therapy group was 4.5%, compared with 23.7% in the non-eradication therapy group without long-term antisecretory therapy [odds ratio, 0.18; 95% confidence interval (CI), 0.09-0.37; 'number needed to treat' (NNT), 5; 95% CI, 4-8]. In the second meta-analysis, the re-bleeding rate in the H. pylori eradication therapy group was 1.6%, compared with 5.6% in the non-eradication therapy group with maintenance antisecretory therapy (odds ratio, 0.25; 95% CI, 0.08-0.76; NNT, 20; 95% CI, 12-100). When only patients with successful H. pylori eradication were included, the re-bleeding rate was 1%.

CONCLUSIONS

The treatment of H. pylori infection is more effective than antisecretory non-eradication therapy (with or without long-term maintenance antisecretory treatment) in the prevention of recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori, and eradication therapy should be prescribed to infected patients.

The influence of feeding on gastric acid suppression in Helicobacter pylori-positive patients treated with a proton pump inhibitor or an H2-receptor antagonist after bleeding from a gastric ulcer

BACKGROUND

This study investigated the influence of feeding on gastric acid suppression in Helicobacter pylori-positive patients treated with intravenous infusions of proton pump inhibitors (PPIs) or with H2-receptor antagonists (H2-RAs) after bleeding from a gastric ulcer.

METHODS

Forty-nine H. pylori-positive patients with bleeding gastric ulcers (44 men and 5 women) were divided into four groups: one group received an H2-RA while fasting, one group received an H2-RA while eating regularly, one group received a PPI while fasting, and one group received a PPI while eating regularly. Intragastric pH was monitored during fasting and nonfasting to calculate the pH 3 and pH 4 holding times and the mean pH.

RESULTS

During a 24-h fast, the pH 3 and pH 4 holding times and the mean pH were significantly higher in patients administered omeprazole (PPI; 93.2 +/- 9.2%, 90.6 +/- 11.1%, and 6.9 +/- 0.6, respectively) than in those administered ranitidine (H2-RA; 61.0 +/- 27.5%, 55.8 +/- 29.1%, and 4.8 +/- 1.3, respectively; P<0.001 for all). Results were similar during feeding (PPI meal, 98.9 +/- 2.6%, 98.3 +/- 3.7%, and 6.9 +/- 0.3; H2-RA meal, 59.8 +/- 17.6%, 49.7 +/- 18.0%, and 4.3 +/- 0.7, respectively; P<0.001 for all). In addition, the pH 3 and pH 4 holding times and the mean pH in the H2-RA meal group were not significantly lower than those in the H2-RA group (P=0.999, P=0.865, and P=0.687, respectively). The values in the PPI and PPI meal groups were similar (P=0.872, P=0.777, and P>0.999, respectively).

CONCLUSIONS

Gastric acid suppression during the administration of an H2-RA or a PPI soon after the cessation of gastric bleeding was scarcely affected by feeding. It may well be that H. pylori-positive patients with bleeding gastric ulcer can resume a regular diet and return to work soon after bleeding ceases.

Helicobacter pylori is not a risk factor for stress ulcer bleeding in polytraumatized patients

BACKGROUND/AIMS

The pathogenesis of acute stress-related hemorrhage in critically ill polytraumatized patients is uncertain and any role of Helicobacter pylori infection is unknown. The aim of our study was to evaluate the relationship between Helicobacter pylori serological status of patients developing stress-related bleeding and those with no appearance of upper gastrointestinal bleeding.

METHODOLOGY

In our single-center prospective cohort study we investigated over a 3-year period all consecutive patients with upper gastrointestinal hemorrhage for Helicobacter pylori infection by serology. Control group comprised 101 such patients with no evidence of hemorrhage.

RESULTS

Of 396 assessable patients, stress-related upper gastrointestinal bleeding was observed in 11 (3.1%) patients. Six (55%) of the 11 bleeding patients and 45 (45%) of the 101 control group patients had serological evidence of Helicobacter pylori infection (p=0.5). Bleeding developed significantly more often in patients with more serious injury (for ISS, p=0.04, for TRISS p=0.03). Bleeding patients showed insignificantly higher mortality (36% vs. 15%; p=0.09).

CONCLUSIONS

Helicobacter pylori infection was not significantly more prevalent in polytraumatized patients with hemorrhage when compared with control group. Our data suggest that the infection with Helicobacter pylori does not play an important role in bleeding, indicating no causative role for it in upper gastrointestinal hemorrhage of polytraumatized patients. The incidence of bleeding is low and bleeding develops usually later, in the meantime is the Helicobacter pylori infection eradicated with the antibiotics used for another purpose.

Diagnostics of Helicobacter pylori Infection in Patients with Peptic Ulcer Bleeding

BACKGROUND

In peptic ulcer bleeding, the sensitivity of H. pylori tests, in particular of the rapid urease test (RUT), has been reported to be insufficient.

AIM

To validate the RUT, serology and the urea breath test were carried out in patients with bleeding peptic ulcers, and to study the influence of H. pylori suppressive treatment (HpSuT), i. e., antibiotics and proton pump inhibitors.

PATIENTS AND METHODS

123 consecutive patients (mean age 65.5 years) with a relevant bleeding from gastric or duodenal ulcers were prospectively tested for H. pylori infection by directs tests (RUT, histology, culture, urea breath test) and by IgG serology as an indirect test. Positive H. pylori status was defined by positive histology or culture.

RESULTS

In patients without HpSuT during the preceding four weeks (N = 83), the sensitivity and specificity of RUT was 94 and 84 %, that of serology 83 and 68 % respectively. The sensitivity of urea breath test decreased from 82 to 60 % after even one day of HpSuT. In the overall group, the duration of HpSuT and preceding hospitalization were independent factors linked with negative results of all direct tests.

CONCLUSIONS

In peptic ulcer bleeding, RUT combined with histology is an adequate diagnostic approach. However, false negative results have to be considered following even short-term HpSuT or hospitalization. Non-invasive diagnosis based on serology alone is inaccurate and should be complemented by the urea breath test prior to starting HpSuT.

Bleeding duodenal ulcer: comparison between Helicobacter pylori positive and Helicobacter pylori negative bleeders

BACKGROUND AND AIMS

To provide a direct comparison of Helicobacter pylori-positive subjects bleeding from duodenal ulcer with H. pylori-negative ones, in terms of severity of bleeding and outcome.

PATIENTS AND METHODS

A case-control study was prospectively conducted in 105 H. pylori-negative duodenal ulcer bleeders and same number of sex- and age-matched H. pylori-positive ones.

RESULTS

NSAID consumption was more common among H. pylori-negative subjects (81%) compared to their H. pylori-positive counterparts (58.1%, P < 0.001). H. pylori-negative bleeders were found to need more often haemostasis (55.2% versus 31.4%, P < 0.001) or surgical intervention (15.2% versus 4.8%, P = 0.011) and to have a greater proportion of rebleeding (32.4% versus 13.3%, P = 0.001), a more prolonged hospitalisation (11.6 +/- 4.1 versus 6.2 +/- 1.5 days, P < 0.001) and a higher rate of in-hospital mortality (15.2% versus 3.8%, P = 0.005). In the overall population (N = 210), H. pylori negativity, among other known risk factors, emerged as independent predictor (odds ratio: 3.2; 95% CI: 1.5, 11.2; P = 0.004) of an unfavourable outcome (surgery or death).

CONCLUSIONS

Duodenal ulcer bleeding in H. pylori-negative subjects appears to be more severe, to have a higher rate of rebleeding, and to lead more often to surgery or fatality compared to the vast majority of H. pylori-positive duodenal ulcer bleeders.

The usefulness of capsulated 13C-urea breath test in diagnosis of Helicobacter pylori infection in patients with upper gastrointestinal bleeding

BACKGROUND

H. pylori infection and peptic ulcerations and their complications such as bleeding are causally related, but the available methods used in bleeding to confirm active H. pylori lack accuracy. AIM To evaluate the usefulness of 13C-urea breath test (UBT) in diagnosing of H. pylori infection in bleeding patients.

PATIENTS AND METHODS

Eighty-one patients with upper gastrointestinal bleeding and 258 matched controls without bleeding were enrolled to the study. UBT was performed using low-dose capsulated 13C-urea and IgG antibodies to H. pylori were determined by ELISA.

RESULTS

UBT performed in bleeding patients was positive in 77.7%. In this group anti Hp IgG was positive in 79% of cases and among them gastroscopy showed 40.7% of bleeding duodenal ulcer, 38% bleeding gastric ulcer, and 86% hemorrhagic gastritis. UBT was positive in 90.9%, 77.4%, and in 52.97% cases, respectively, and it was not statistically different from that in non-bleeding controls, duodenal and gastric ulcers and gastritis. All patients with blood or "coffee grounds" in the stomach had both UBT and serology positive.

CONCLUSION

The UBT is simple and non-invasive method, which can be successively applied also in patients with upper gastrointestinal bleeding to detect active H. pylori infection prior to emergency endoscopy.

Diagnosis of Helicobacter pylori in bleeding peptic ulcer patients, evaluation of urea-based tests

BACKGROUND/AIMS

The prevalence of Helicobacter pylori (Hp) has been reported to be lower in patients with bleeding peptic ulcers than in patients with nonbleeding peptic ulcers. This might be due to inaccuracy of the urease-based diagnostic tests when used in patients with bleeding peptic ulcers. The aims of this study were to compare the validity of the rapid urease test (RUT) and (13)C-urea breath test in patients with bleeding (group 1) and nonbleeding peptic ulcers (group 2) and to examine whether the presence of blood in the stomach influences the validity of urease-based tests.

METHODS

95 consecutive patients with bleeding peptic ulcers (48 with and 47 without blood in the stomach) and 44 with uncomplicated peptic ulcers. Biopsies for RUT and histology were obtained during endoscopy. After endoscopy a (13)C-urea breath test was performed. Positive histology was used as 'gold standard' defining positive Hp-status.

RESULTS

The prevalence of Hp-infection was 44/95 (46%) in group 1 and 29/44 (66%) in group 2 (p = 0.04). The sensitivities and specificities of RUT, (13)C-urea breath test and serology (control) were between 0.72 and 0.96; no difference was found between the groups. In group 1 the sensitivity of the RUT decreased from 0.96 when no blood was present to 0.60 when blood was present (p = 0.006). The sensitivity of (13)C-urea breath test was not affected by blood in the stomach.

CONCLUSION

When comparing patients with bleeding and nonbleeding peptic ulcers, we did not find any difference in either sensitivity or specificity of the diagnostic tests for Hp. However, the sensitivity of the RUT was lower when blood was present in the stomach, which was the case in only half of the patients. The sensitivity and specificity of the (13)C-urea breath test was not affected by the presence of blood in the stomach.

Comparison of stool immunoassay with standard methods for detection of Helicobacter pylori infection in patients with upper-gastrointestinal bleeding of peptic origin

OBJECTIVE

To assess the accuracy of the determination of Helicobacter pylori infection by a stool immunoassay in patients with upper-gastrointestinal bleeding (UGB) of peptic origin, in comparison with the routine histological study, serology, rapid urease and 13C-breath tests.

METHODS

Sixty-eight patients with endoscopically proven UGB of peptic origin were included. The presence of H. pylori was considered when observed on histology or, if negative, by the positive indications of two of the remaining tests (serology, rapid urease,13C-breath test). The accuracy of stool immunoassay was estimated according to results obtained with other diagnostic methods.

RESULTS

Lesions causing gastrointestinal bleeding were 49 duodenal ulcers, 11 gastric ulcers, six pyloric channel ulcers, 13 acute lesions of the gastric mucosa, and 16 erosive duodenitis. H. pylori infection was present in 59 (86.76%) patients. Forty-one patients had received nonsteroidal anti-inflammatory drugs. The sensitivity and specificity of the diagnostic methods were 47.5% and 100% for the rapid urease test, 93% and 87.5% for the breath test, 86.4% and 77.7% for serology, 89.4% and 100% for histology, and 96.6% and 33.3% for the stool test.

CONCLUSIONS

The detection of H. pylori antigen in stools in patients with UGB of peptic origin has a good sensitivity (96.6%) but a low specificity (33.3%) for the diagnosis of H. pylori infection, which probably makes this test an inadequate tool in this setting if utilized alone.

Helicobacter pylori infection does not affect the early rebleeding rate in patients with peptic ulcer bleeding after successful endoscopic hemostasis: a prospective single-center trial

BACKGROUND AND STUDY AIMS

Eradication of Helicobacter pylori infection can reduce the rebleeding rate of peptic ulcer bleeding in the long term. There are few data on the influence of H. pylori on the rebleeding rate in the acute phase of bleeding however. We therefore prospectively investigated the influence of H. pylori infection on the early rebleeding rate in patients who had undergone successful endoscopic hemostasis treatment for peptic ulcer bleeding.

PATIENTS AND METHODS

Between January 1996 and November 2000 all patients with peptic ulcer bleeding were evaluated consecutively. The diagnosis of H. pylori infection was made at index endoscopy, using histology and the rapid urease test. Bleeding activity was assessed using the Forrest classification. After successful endoscopic hemostasis all patients received omeprazole 40 mg or pantoprazole 40 mg, intravenously, twice a day for 3 days. Rebleeding episodes were recorded over 21 days following primary hemostasis.

RESULTS

344 patients were enrolled into the study. The prevalence of H. pylori infection was 62.9 %. A total of 51 patients showed rebleeding (14.8 %), of whom 31 were H. pylori-positive (60 %). There was no statistically significant difference between the H. pylori-positive and -negative patients, however. The rebleeding rate did not differ between patients with H. pylori infection alone and patients also using nonsteroidal anti-inflammatory drugs. When stratifying patients according to activity of bleeding at index endoscopy, we were also unable to find any significant influence of H. pylori infection on the outcome of Forrest class I and IIa bleedings.

CONCLUSION

Based on our data, it can be concluded that H. pylori infection does not affect the early rebleeding rate in patients with peptic ulcer bleeding after successful endoscopic hemostasis.

[Clinical characteristics of non-steroidal anti-inflammatory drugs associated gastroduodenal ulcer bleeding]

OBJECTIVE

To study the clinical characteristics of non-steroidal anti-inflammatory drugs (NSAIDs) associated gastroduodenal ulcer bleeding.

METHODS

Patients who were hospitalized in our ward because of gastroduodenal bleeding from Jan, 1997 to Dec, 2001 were divided into two groups according to consumption of NSAIDs or not in the week previous to the onset of bleeding.

RESULTS

446 patients were investigated with 86 in NSAIDs group and 360 in non-NSAIDs group. There was no significant difference in sex, way of bleeding, history of peptic ulcer, bleeding site in stomach or duodenum, presence of erosion and the need of endoscopic injection therapy or not between the two groups. However, the patients in NSAIDs group were older than those in non-NSAIDs group. Hemoglobin level was lower in NSAIDs group (P = 0.004). There was more gastric ulcer and complex ulcer in the NSAIDs group than in non-NSAIDs group (P < 0.001). NSAIDs users had more ulcers (P < 0.001). Helicobacter pylori (Hp) was present in 72.5% of the non-NSAIDs group and 53.4% of the NSAIDs group (P = 0.001). In an another study, we found that age of the patients or Hp state didn't affect the clinical characteristics of NSAIDs ulcer bleeding.

CONCLUSIONS

The clinical characteristics of NSAIDs associated gastroduodenal bleeding should be better understood so as to decrease the occurrence of NSAIDs ulcer and its complication.

A negative rapid urease test is unreliable for exclusion of Helicobacter pylori infection during acute phase of ulcer bleeding. A prospective case control study

BACKGROUND

The reliability of the rapid urease test has not been proven in patients with peptic ulcer bleeding. Some studies show bad diagnostic results with the rapid urease test for gastrointestinal bleeding.

AIMS

To evaluate the efficacy of the rapid urease test in patients with bleeding gastric or duodenal ulcers.

PATIENTS AND METHODS

A total of 96 patients with acute peptic ulcer bleeding without proton pump inhibitor or antibiotic therapy within the last 14 days before bleeding were included into the study. During index endoscopy, specimens for histological and rapid urease test were obtained from the antrum and corpus mucosa of the stomach. Patients were also investigated by the 13C-urea breath test. Diagnostic quality parameters were calculated with the histology and the 13C-urea breath test as reference and compared with a matched control group with uncomplicated ulcers.

RESULTS

The sensitivity of the rapid urease test was 80% and the specificity 100% compared to histology and 13C-urea breath test. The negative predictive value was 75%. These values were statistically significantly different from those of the control group (sensitivity 96%, specificity 100%, negative predictive value 88%).

CONCLUSION

The exclusive use of the rapid urease test cannot be recommended in patients with peptic ulcer bleeding.