Seven-day proton pump inhibitor, amoxicillin and clarithromycin triple therapy. factors that influence Helicobacter pylori eradications success

AIM

To evaluate which factors influence eradication success with standard triple therapy for Helicobacter pylori.

PATIENTS AND METHODS

A prospective study was made of 891 patients infected by H. pylori and diagnosed with duodenal ulcer (n=422), gastric ulcer (n=221), or functional dyspepsia (n=248). Initially, an endoscopy with biopsies of antrum and body (haematoxylin-eosin stain), and a 13C-urea breath test were performed. All patients were treated for seven days with either omeprazole 20 mg twice daily in 442 patients (OCA) or pantoprazole 40 mg twice daily in 449 patients (PCA), associated to clarithromycin (500 mg twice a day) and amoxicillin (1 g twice a day). Two months after completing therapy urea breath test was repeated to confirm eradication.

RESULTS

Mean age +/- SD was 51.6 +/- 15 years, 61% were male. Overall eradication rate was 73.7% (95% CI 69-77%) and 80.8% (77-84%) with OCA and PCA therapy, respectively, showing significant difference between treatment regimens (chi 2 =6.3; p= 0.01). As refers to underlying diseases, H. pylori eradication was achieved in 77.4% (74-80%) of peptic ulcers and 77% (71-82%) of functional dyspepsia (p=n.s.). With our two treatment regimens (OCA/PCA) eradication success was 74/81% in peptic ulcer (p=0.03), and 72/80% in functional dyspepsia (p=0.1). In the multivariate analysis, type of therapy was the only variable that correlated with eradication success (odds ratio 1.5; 95% CI: 1.1-2.1) (chi2 model: 6,4; p=0.01).

CONCLUSIONS

Standard triple therapy containing a proton pump inhibitor, clarithromycin and amoxicillin for seven days achieves in our community a moderate eradication success; this result could improve by using pantoprazole instead of omeprazole. This therapy is equally effective in patients with peptic ulcer and functional dyspepsia.

Diagnosis and grading of intrapulmonary vascular dilatation in cirrhotic patients with contrast transesophageal echocardiography

BACKGROUND/AIMS

The use of transesophageal contrast echocardiography (TOCE) in the diagnosis of intrapulmonary vascular dilatation (IVD) and hepatopulmonary syndrome (HPS) needs to be studied. We tested the specificity of TOCE using traditional criteria and the value of a new method based on TOCE, a grading scale and a selected contrast.

METHODS

1) Several solutions were tested and two were selected: 20% mannitol and 0.9% saline. 2) 71 cirrhotic patients and 20 controls were studied. Left atrium opacification with contrast was classified into 6 degrees by TOCE. Mild and significant IVD were considered in relation to results in controls. Patients were studied with saline and mannitol-TOCE. Results were compared to transthoracic contrast echocardiography (TTCE), to gas exchange abnormalities and to Child class.

RESULTS

The reproducibility of TOCE grading was excellent, (Kappa >0.9). IVD detection using TTCE, mannitol-TOCE and saline-TOCE was 29.5%, 55% (25% mild and 30% significant), and 45% (38% mild and 7% significant), respectively. The best agreement with TTCE (reference method) was obtained with mannitol-TOCE, using significant IVD as the cut point. By this criterion, 18% reached the criteria of HPS using TTCE and 22% using mannitol-TOCE. Patients with IVD by TTCE had non-significant changes in gas exchange determinations. Patients with significant IVD by saline TOCE had lower mean PaO2 levels (67.3+/-14 vs. 79.5+/-11 mm Hg, p<0.05) than patients without IVD. Patients with significant IVD by mannitol TOCE had higher mean AaPO2 (29.3+/-14 vs. 19.7+/-9 mm Hg; p<0.005) and lower mean PaCO2 levels (30.1+/-4.4 vs. 33.4+/-4.8 mm Hg; p<0.05) than patients without IVD. Severity of IVD by TOCE correlated to Child class (r = 0.43; p<0.001).

CONCLUSIONS

The presence of contrast in the left atrium cannot be a criterion of IVD when TOCE is used. Our semi-quantitative scale has proved to be feasible and reproducible, presenting a good agreement with TTCE, and has shown better correlation with gas exchange abnormalities and Child class. Saline TOCE appears to be more specific in the detection of hypoxemic patients with IVD, but mannitol TOCE adds sensitivity.

Posttransplant liver granulomatosis associated with hepatitis C?

BACKGROUND

Liver granulomatosis is an occasional finding in posttransplant liver biopsies. Its diagnosis is made more difficult by the variety of conditions that can lead to it. In the nontransplant setting, the association of liver granulomatosis and hepatitis C virus (HCV) infection has occasionally been described.

METHODS

We describe the case of a patient with a liver transplantation for an HCV-associated cirrhosis who developed an alteration of liver tests. Granulomatosis was detected on the liver biopsy.

RESULTS

Other causes of granulomatosis were satisfactorily excluded. The development of the lesions coincided with a viral flare-up.

CONCLUSION

We think that HCV can be listed among the possible causes of liver granulomas in the posttransplant setting and that it must be considered in the differential diagnosis of this condition.

[Droxicam-induced hepatitis. Description of 3 new cases and review of the literature]

Three new cases of cholestatic hepatitis caused by droxicam are described, along with a revision of the other eight cases published to date. Itching, asthenia, and jaundice were the most common symptoms. Average age was 62.8 years (range: 45-82 years), and the median time of exposition was 22.7 days (range: 5-50 days). Biochemistry of the liver showed primarily cholestasis and in 4/11 cases hypereosinophilia. Two patients presented elevated levels of cholesterol and triglycerides which disappeared within the month. Clinical manifestations persisted in one patient for eight weeks after the cessation of treatment. The three patients presented in the present series presented alteration in the biochemistry of the liver two months after initiation. Liver biopsy in three patients showed centrozonal cholestasis associated with portal inflammatory activity and presence of granulomas consistent with toxic hepatitis.

[False pancreatic pseudocyst during endoscopic retrograde cholangiopancreatography (ERCP) in a gastrectomized patient]

Endoscopic retrograde cholangiopancreatography (ERCP) is a very useful procedure for the diagnosis of biliopancreatic disorders. As a mixed endoscopic and radiologic procedure, its diagnostic yield depends heavily on the quality and skillful interpretation of radiological images. Diagnostic pitfalls must be kept in mind and avoided. We report on the case of a gastrectomized patient (Billroth II), in whom the observation during ERCP of two contrast-filled cavities, suggested the diagnosis of pancreatic pseudocysts. Other imaging procedures fully ruled out this diagnosis. The cause of this diagnostic pitfall was the accumulation of contrast in the blind end of the afferent loop. Additionally, we comment on other false cystic images in the ERCP.