Clinical trial: levofloxacin-based quadruple therapy was inferior to traditional quadruple therapy in the treatment of resistant Helicobacter pylori infection

BACKGROUND

The efficacy of levofloxacin-based quadruple therapy in resistant Helicobacter pylori infection is not known.

AIM

To test the efficacy of levofloxacin-based quadruple therapy and traditional quadruple therapy in resistant H. pylori infection.

METHODS

One hundred and two patients with resistant H. pylori infection were randomized to 1 week of either EBAL (esomeprazole 40 mg b.d., bismuth subcitrate 240 mg b.d., amoxicillin 1 g b.d. and levofloxacin 500 mg b.d.) or EBMT (esomeprazole 40 mg b.d., bismuth subcitrate 240 mg b.d., metronidazole 400 mg t.d.s. and tetracycline 500 mg q.d.s.). (13)C-urea breath test was performed at week 12 to assess post-treatment H. pylori status.

RESULTS

In intention-to-treat analysis H. pylori eradication was achieved in 37 of 51 (73%) subjects in EBAL and 45 of 51 (88%) subjects in EBMT groups, respectively (P = 0.046). Per-protocol eradication rates of EBAL and EMBT groups were 78% and 94%, respectively (P = 0.030). The intention-to-treat eradication rate was statistically lower for EBAL than EMBT (56% vs. 90%, P = 0.013) among those who had failed more than one course of eradication therapy. Previous levofloxacin triple therapy did not affect the efficacy of either protocol significantly.

CONCLUSIONS

Levofloxacin-based quadruple therapy was inferior to traditional quadruple therapy for resistant H. pylori infection.

Stability of E-cadherin methylation status in gastric mucosa associated with histology changes

BACKGROUND

We have previously shown reversal of E-cadherin methylation in gastric mucosa from patients with dyspepsia at week 6 after Helicobacter pylori-eradication therapy. But the long-term methylation status of these patients was unknown.

AIM

To investigate the methylation status at E-cadherin at year 3 after H. pylori-eradication therapy.

METHODS

35 patients (25 with and 10 without H. pylori eradicated) enrolled in our previous study were recruited into the present study (year 3 analysis). Methylation at E-cadherin was evaluated by methylation-specific polymerase chain reaction method.

RESULTS

There was no difference in age and sex distribution in the two groups. Methylation at E-cadherin in patients with H. pylori eradicated at weeks 0, 6 and year 3 were 52%, 20% and 20%, respectively. Concordant methylation status at week 6 and year 3 was 92%. Methylation at E-cadherin in patients without H. pylori at weeks 0, 6 and year 3 were 50%, 60% and 60%, respectively. Concordant methylation status between week 6 and year 3 was 90%. Stability of E-cadherin methylation status was associated with histological changes. No association between E-cadherin methylation status and age was observed.

CONCLUSION

The methylation pattern is stable for a long period, thus suggesting the effect of environment on methylation.

Coexistence between colorectal cancer/adenoma and coronary artery disease: results from 1382 patients

BACKGROUND

Common risk factors exist in colorectal neoplasia (cancer or adenoma) and coronary artery disease.

AIM

To investigate in a retrospective study if there is coexistence of the two events in patients > OR =50 years.

METHODS

Computer data on colonoscopies performed on symptomatic patients, the corresponding medical record and colonic histology in 1997-2000 were retrieved. History of coronary artery disease was recorded. To adjust for the factors of age and sex, bivariate logistic regression analysis was used to test for coexistence.

RESULTS

1382 patients were recruited. Colorectal neoplasia and history of coronary artery disease were present in 27% (373) and 12% (167) of patients, respectively. The mean age of patients was older in colorectal neoplasia+ (75 +/- 11 vs. 69 +/- 13 years, P < 0.0001) and in coronary artery disease+ (79 +/- 9 vs. 69 +/- 12 years, P < 0.0001) patients. Male was the predominant sex in colorectal neoplasia+: 33% vs. 22% (P < 0.0001), but not in coronary artery disease+ (P = 0.29). Colorectal neoplasia+ patients were more likely to have coronary artery disease+ [21.2% (79/373) vs. 8.8% (89/1098) (P < 0.0001)]. Bivariate logistic regression analysis showed strong association between the two events (OR: 2.12, 95% CI: 1.5, 3.0).

CONCLUSION

There is strong coexistence of colorectal neoplasia and coronary artery disease, probably due to exposure to common risk factors.

Eradication of Helicobacter pylori infection reverses E-cadherin promoter hypermethylation

BACKGROUND

E-cadherin methylation is important in gastric carcinogenesis. Reversing hypermethylation may halt the carcinogenic process. We have previously reported that Helicobacter pylori infection is associated with E-cadherin methylation in chronic gastritis patients.

AIM

To examine if eradication of H pylori could reverse E-cadherin methylation.

METHODS

Patients with dyspepsia and positive for H pylori infection, with a mucosal biopsy showing chronic active gastritis, were randomised to receive H pylori eradication therapy (group 1, n = 41) or no treatment (group 2, n = 40), and were followed up prospectively. Gastric mucosae were taken for methylation assay at week 0 (before treatment) and week 6 (after treatment). Archived specimens of intestinal metaplasia with H pylori infection (n = 22) and without (n = 19) were retrieved for methylation analysis. Methylation was assessed using methylation specific polymerase chain reaction and sequencing.

RESULTS

Methylation at E-cadherin was detected in 46% (19/41) and 17% (7/41) of patients at weeks 0 and 6, respectively, in group 1 (p = 0.004); 78.9% (15/19) of specimens were unmethylated after eradication of H pylori. Mucosal biopsy showed chronic inactive gastritis in 35 patients, intestinal metaplasia in one, and normal mucosa in five at week 6. Methylation was detected in 47.5% (19/40) and 52.5% (21/40) of patients at weeks 0 and 6, respectively, in group 2 (P = 0.5). Gastric mucosal biopsy showed persistent chronic active gastritis in all cases. Methylation frequency did not differ in H pylori positive or negative intestinal metaplastic specimens (72.7% v 63%; p = 0.5).

CONCLUSION

H pylori eradication therapy could reverse methylation in patients with chronic gastritis. This demonstrates an environmental effect on methylation.

Lansoprazole, levofloxacin and amoxicillin triple therapy vs. quadruple therapy as second-line treatment of resistant Helicobacter pylori infection

AIM

To test the efficacy of levofloxacin-based second-line therapy for resistant Helicobacter pylori infection.

METHODS

One hundred and six patients who failed H. pylori eradication were randomized to receive (i) lansoprazole 30 mg, amoxicillin 1 g, levofloxacin 500 mg, all given twice daily for 7 days (LAL); or (ii) lansoprazole 30 mg twice daily, metronidazole 400 mg thrice daily, bismuth subcitrate 120 mg and tetracycline 500 mg four times daily for 7 days (quadruple). Post-treatment H. pylori status was determined by (13)C-urea breath test.

RESULTS

Intention-to-treat and per-protocol H. pylori eradication rates were 57/60% for the LAL group and 71/76% for the quadruple group respectively. Metronidazole, clarithromycin, amoxicillin and levofloxacin resistance were found in 76%, 71%, 0% and 18% of patients, respectively. Levofloxacin resistance led to treatment failure in the LAL group. For patients with dual resistance to metronidazole and clarithromycin, the eradication rates were 79% in the LAL group (levofloxacin-sensitive) and 65% in the quadruple group (P=0.34).

CONCLUSION

Lansoprazole, amoxicillin plus levofloxacin second-line therapy is comparable with quadruple therapy in efficacy. Subjects, especially those with dual resistance to metronidazole and clarithromycin, may consider levofloxacin-based therapy for levofloxacin-sensitive strains.

Update on clarithromycin resistance in Helicobacter pylori in Hong Kong and its effect on clarithromycin-based triple therapy

AIM

To determine the antibiotic susceptibility of Helicobacter pylori and evaluate the efficacy of a clarithromycin-based triple therapy in relation to antibiotic resistance.

METHODS

Consecutive patients referred for upper endoscopy due to dyspeptic symptoms were recruited. Gastric biopsies were obtained for the CLO test, histology and culture. Antibiotic susceptibility was assessed by the E-test. Patients with H. pylori infection received rabeprazole 20 mg, clarithromycin 500 mg, and amoxicillin 1,000 mg, all twice daily for 7 days.

RESULTS

Of 234 patients recruited, 124 were H. pylori-positive and culture was successful in 102 patients. The updated prevalences of resistance to clarithromycin, amoxicillin and metronidazole were 7.8, 0 and 39.2%, respectively. A total of 86 patients received 1-week triple therapy with rabeprazole 20 mg, clarithromycin 500 mg, and amoxicillin 1,000 mg, all twice daily, and 81 patients attended the follow-up test. Eradication rates by per-protocol and intention-to-treat analysis were 92.6 and 87.2%, respectively. The eradication rate by per protocol was significantly higher in patients with clarithromycin-susceptible strains than in those with clarithromycin-resistant strains (98.6 vs. 28.6%, p < 0.001).

CONCLUSION

Clarithromycin resistance reduces the clinical efficacy of clarithromycin-based triple therapy. However, due to the low prevalence of clarithromycin resistance, clarithromycin-based therapy is still the first choice for clinical use.

Prognostic determinants for chronic hepatitis B in Asians: therapeutic implications

BACKGROUND

Identifying risk factors for the development of complications of chronic hepatitis B (CHB) is important for setting up treatment criteria.

AIM

To determine risk factors for the development of complications in Asian CHB patients.

PATIENTS AND METHODS

A total of 3233 Chinese CHB patients (mean follow up 46.8 months) were monitored for liver biochemistry, viral serology, hepatitis B virus (HBV) DNA levels, acute exacerbation, hepatitis B e antigen (HBeAg) seroconversion, and development of cirrhotic complications and hepatocellular carcinoma.

RESULTS

Median age for HBeAg seroconversion and development of complications was 35 years and 57.2 years, respectively. Patients with alanine aminotransferase (ALT) levels of 0.5-1 times the upper limit of normal (ULN) and 1-2x ULN had an increased risk for the development of complications compared with patients with ALT levels <0.5x ULN (p<0.0001 for both). HBeAg/antibody to hepatitis B e antigen status, and number of episodes, duration, and peak ALT levels of acute exacerbations were not associated with an increased risk of complications. In patients with complications, 43.6% had HBV DNA levels less than 1.42x10(5) copies/ml. Male sex, stigmata of chronic liver disease, old age, low albumin, and high alpha fetoprotein levels on presentation were independently associated with increased cumulative risk of complications. Male sex, presence of hepatitis symptoms, old age, low albumin level, and presence of complications on presentation were independently associated with shorter survival.

CONCLUSION

Prolonged low level viraemia causing insidious and continual liver damage, as reflected by ALT levels of 0.5-2x ULN, is the most likely pathway for the development of complications in Asian CHB patients.

Hepatic necroinflammation and fibrosis in patients with genotypes Ba and C, core-promoter and precore mutations

The role of infection with hepatitis B virus (HBV) genotypes on liver histology is largely unknown. The aim of study was to investigate the relationships between HBV genotypes (B, C), core-promoter (CP) and precore mutants and liver histology in 66 patients. Liver biopsies were scored by histologic activity index (HAI). HBV genotypes were determined by enzyme-linked immunosorbent assay (ELISA). Eighteen (27.3%) and 48 patients (72.7%) had genotype B (all were subtype Ba) and C, respectively. Forty-seven (71.2%) and 27 (40.9%) had CP and precore mutations, respectively. Patients with genotype C compared with subtype Ba had higher median scores of HAI-necroinflammation (HAI-NI) (7 vs 3), HAI-fibrosis (HAI-F) (1 vs 0) and total HAI (8.5 vs 3) (all P < 0.03). Patients with CP mutations compared with wild-type had higher median scores of HAI-NI (7 vs 3), HAI-F (3 vs 0) and total HAI (9 vs 3) (all P < 0.03). Forty patients (83.5%) with genotype C had CP mutations. Age and alanine aminotransferase levels were positively correlated with HAI scores while albumin levels were negatively correlated (P < 0.01 for all, except albumin levels and HAI-F, P = 0.08). There was no association between precore mutations and HAI scores. Multivariate analysis indicated that higher alanine aminotransferase (ALT) levels were associated with higher HAI scores (P < 0.04) and CP mutations were associated with higher HAI-NI (P = 0.034), but not with HAI-F score (P = 0.3). CP mutations were associated with more severe necroinflammation. The association between genotype C and poor histology was probably because of the association between genotype C and CP mutations.

Validated questionnaire on diagnosis and symptom severity for functional constipation in the Chinese population

BACKGROUND

Functional constipation is a common problem in clinical practice. No validated questionnaire is available in Chinese.

AIM

To develop a validated questionnaire for diagnosis and symptom assessment in functional constipation for the Chinese population.

METHODS

One hundred and eleven patients with constipation and 110 healthy controls were presented with a 24-item constipation questionnaire in the Chinese language. Quality of life in constipation patients was assessed by Short Form-36. Polyethylene glycol was prescribed, for 4 weeks, to 20 patients with newly diagnosed constipation. The questionnaire was administered before and 4 weeks after treatment. Concept, content, construct, discriminant validity and reliability of the questionnaire were assessed.

RESULTS

Six items were selected by logistic regression to account for most of the differences between controls and constipated patients with a good reproducibility and internal consistency. A cut-off score of > or =5 was determined to discriminate between controls and constipated patients with a sensitivity of 91% and a specificity of 91%. The constipation questionnaire correlated negatively with seven domains of the Short Form-36 and discriminated between constipated patients who reported symptomatic improvement during polyethylene glycol treatment.

CONCLUSIONS

The Chinese constipation questionnaire could be used in epidemiological studies to assess the frequency and severity of constipation in patient populations and in interventional studies of constipation.

Trends in the prevalence of peptic ulcer disease and Helicobacter pylori infection in family physician-referred uninvestigated dyspeptic patients in Hong Kong

BACKGROUND

Peptic ulcer disease is mainly caused by Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs.

AIM

To investigate the trends in the prevalence of peptic ulcer disease, H. pylori infection and non-steroidal anti-inflammatory drug use in uninvestigated dyspeptic patients over recent years in Hong Kong.

METHODS

Data from consecutive patients with uninvestigated dyspeptic symptoms referred by family physicians for open access upper endoscopy during 1997 and 2003 were analysed in relation to peptic ulcer disease, H. pylori infection and non-steroidal anti-inflammatory drug use.

RESULTS

Among 2700 patients included, 405 (15%) had peptic ulcer disease and 14 (0.5%) had gastric cancer. There was a reduced trend from 1997 to 2003 in the prevalence of peptic ulcer disease (17, 20, 14, 16, 13, 14 and 14%, respectively, chi2 = 5.80, P = 0.016) (mainly because of decrease in duodenal ulcers), H. pylori infection (44, 50, 49, 44, 40, 40, 36 and 43%, respectively, chi2 = 13.55, P < 0.001) and non-steroidal anti-inflammatory drug use (13, 5, 5, 6, 3, 4, 4 and 5% respectively, chi2 = 13.61, P < 0.001). The prevalence of peptic ulcer disease, H. pylori infection and non-steroidal anti-inflammatory drug use between 2001 and 2003 were significantly lower than that between 1997 and 2000 (17% vs. 13%, OR = 0.78, 95% CI: 0.63-0.96, P = 0.020 for peptic ulcer disease; 47% vs. 39%, OR =0.72, 95% CI: 0.60-0.86, P < 0.001 for H. pylori infection; and 6% vs. 4%, OR = 0.56, 95% CI: 0.39-0.82, P = 0.002 for non-steroidal anti-inflammatory drug use). H. pylori infection was associated with both duodenal ulcer (OR = 15.87, 95% CI: 10.60-23.76, P < 0.001) and gastric ulcer (OR = 3.12, 95% CI: 2.15-4.53, P < 0.001) whereas non-steroidal anti-inflammatory drug use was only associated with gastric ulcer (OR = 2.97, 95% CI: 1.70-5.20, P < 0.001).

CONCLUSIONS

The prevalence of peptic ulcer disease, mainly duodenal ulcers, was reduced in association with a decreasing trend in the prevalence of H. pylori infection and non-steroidal anti-inflammatory drug use from 1997 to 2003.

A pilot study of participation in faecal occult blood testing and screening colonoscopy after health education in Hong Kong

Colorectal cancer is the second commonest cancer in Hong Kong. The screening behaviour of the Chinese population has not been assessed. The aim of this study is to report a pilot study of educating and subsequent evaluation of colorectal cancer screening behaviour in the Hong Kong Chinese population. Subjects were invited to attend a free health talk on colorectal cancer. Both self-paid faecal occult blood testing (FOBT) and free screening colonoscopy were offered after the education programme. Of the participants taking part in the education programme 113/119 (95%) completed the FOBT. Of the FOBT 8/113 (7%) showed positive result and three patients had neoplasia at colonoscopy. Twenty-five patients with negative FOBT also completed colonoscopy; two had adenomas. Screening colonoscopy after FOBT was accepted by 28% of subjects. Those younger than 65 years and those with a positive FOBT (7/8 versus 25/105 for those with negative FOBT, P=0.0003) were more likely to agree to screening colonoscopy. In conclusion, health education is important for ensuring high acceptance and implementation of colorectal cancer screening in Hong Kong Chinese. FOBT is an acceptable and feasible screening method in Hong Kong.

Effect of cyclo-oxygenase inhibitors on Helicobacter pylori susceptibility to metronidazole and clarithromycin

BACKGROUND

We previously reported that aspirin inhibited Helicobacter pylori growth and suppressed the mutagenic effect of metronidazole.

AIM

To determine the effects of a cyclo-oxygenase (COX)-2-specific inhibitor, SC-236, and a non-selective COX inhibitor, indometacin, on the growth, urease activity and antimicrobial susceptibility of H. pylori.

METHODS

Three H. pylori reference strains, and 18 clinical isolates were treated with SC-236 or indometacin for 24 and 48 h. Growth, urease activity and susceptibility to clarithromycin and metronidazole of the bacteria were assessed by viable colony counting, spectrophotometry and E-test respectively.

RESULTS

SC-236 and indometacin inhibited H. pylori growth in a dose-dependent manner with the lowest inhibitory concentrations of 0.03 and 0.1 mm, and the lethal concentrations of 0.09 and 0.3 mm, respectively. The numbers of CFU/mL in Brucella broth containing 0.09 mm SC-236 were 2 log lower at 24 h, and even 3 log lower at 48 h than that at 0 h (P = 0.035, compared with the vehicle control). Treatment of 0.3 mm indometacin reduced the number of CFU/mL by 1 log at 24 h compared with that at 0 h (P = 0.037 compared with the vehicle control). Helicobacter pylori urease activity began to decrease with 0.06 mm SC-236 at 24 h (P = 0.016), and 0.3 mm indometacin at 48 h (P = 0.025). MICs of metronidazole and clarithromycin against H. pylori were decreased significantly in the presence of 0.03 mm SC-236 or 0.1 mm indometacin (all P < 0.001).

CONCLUSION

Both SC-236 and indometacin suppressed the growth and urease activity of H. pylori in a dose-dependent manner, and increased its susceptibility to the antibiotics.

Different presentation of hepatitis B-related hepatocellular carcinoma in a cohort of 1863 young and old patients - implications for screening

AIM

To compare the clinico-pathological features of hepatitis B virus-related hepatocellular carcinoma in young and old patients.

METHODS

The clinico-pathological characteristics of hepatitis B virus-related hepatocellular carcinoma were compared in 1863 consecutive patients (121 patients, </=40 years; 1742 patients, > 40 years) seen at a single institution over the last 13 years.

RESULTS

Young patients presented more often with pain (P < 0.0001), hepatomegaly (P = 0.01) and ruptured hepatocellular carcinoma (P = 0.02), whereas old patients presented with ankle oedema (P = 0.001), ascites (P = 0.002) and by routine screening (P = 0.035). Liver function, Child-Pugh grading and indocyanine green test were better preserved in young patients. They also had a higher alpha-foetoprotein concentration (P = 0.001), larger tumour size (P = 0.001) and more frequent metastasis (P = 0.008), but a similar surgical resection rate (33.6% vs. 28%), to old patients. There was no difference between the two groups in the overall post-resection survival rate, but there was a shorter survival in young patients with unresectable disease (3.6 months vs. 4.6 months, P = 0.004). Young patients with hepatocellular carcinoma often show a later presentation, but a higher resectability rate and similar survival rates, than old patients. The screening programme should include young hepatitis B virus carriers, even in the absence of cirrhosis.

The role of cholecystectomy in reducing recurrent gallstone pancreatitis

BACKGROUND AND STUDY AIM

Endoscopic sphincterotomy (ES) or cholecystectomy can prevent recurrent acute pancreatitis (RAP) in patients with gallstone-related pancreatitis. However, it is unknown whether cholecystectomy after ES offers additional benefit in preventing RAP in these patients. This is a retrospective study to assess whether cholecystectomy can decrease the incidence of RAP in patients with gallstone-related pancreatitis.

PATIENTS AND METHODS

Records from 139 patients with gallstone-related pancreatitis were analyzed. Of these, 58 patients had gallbladder stones with concomitant common bile duct (CBD) stones and 81 patients had gallbladder stones without CBD stones. Of the 58 patients who had both gallbladder and CBD stones, 37 (63.8 %) did not undergo cholecystectomy after ES (group 1) and 21 patients (36.2 %) did undergo cholecystectomy after ES (group 2). Of the 81 patients who had gallbladder stones but who did not have CBD stones, 54 (66.7 %) did not undergo cholecystectomy (group 3) and 27 (33.3 %) did undergo cholecystectomy (group 4).

RESULTS

At the time of analysis, three patients (8.1 %) in group 1 and three patients (14.3 %) in group 2 developed RAP. There was no significant difference in the estimated probability of occurrence of RAP over time between group 1 and group 2 ( P = 0.41). However, there was a significantly higher probability of patients developing RAP over time in group 3 compared with group 4 (6/54 vs. 0/27 respectively, P = 0.04).

CONCLUSION

In patients with gallbladder stones without CBD stones, cholecystectomy can decrease the incidence of RAP. In patients with both gallbladder and CBD stones, however, the risk of RAP was not further reduced by cholecystectomy after ES and complete removal of CBD stones.

Prevalence and characteristics of familial hepatocellular carcinoma caused by chronic hepatitis B infection in Hong Kong

BACKGROUND

Hepatitis B virus infection is an important aetiological factor for hepatocellular carcinoma. Clusters of hepatocellular carcinoma have been observed in families infected with hepatitis B virus.

AIM

To investigate the prevalence and characteristics of hepatocellular carcinoma associated with familial hepatitis B virus in Hong Kong.

METHODS

Hepatitis B virus patients were screened for familial hepatocellular carcinoma using a standardized questionnaire. The clinical features of patients with familial hepatocellular carcinoma were compared with those of 118 patients with sporadic hepatocellular carcinoma attending the clinic during the same period.

RESULTS

A total of 5080 patients were interviewed. Validation of the questionnaire indicated that the reliability was high. There were 22 families with familial hepatocellular carcinoma, giving a prevalence of 4.3 families/1000 hepatitis B virus carriers. The mean age of onset was 48.5 +/- 13 years in familial hepatocellular carcinoma and 62 +/- 11 years in sporadic hepatocellular carcinoma (P = 0.005). The ages of onset were 59 +/- 11, 40 +/- 10 and 18 +/- 4 years in the first, second and third generations, respectively (P < 0.0001), suggesting an anticipation phenomenon. Familial hepatocellular carcinoma patients were more likely to present with pain (70% vs. 10%, P < 0.0001), but not on routine screening (14% vs. 52%, P < 0.0001), than sporadic hepatocellular carcinoma patients.

CONCLUSION

The prevalence of familial hepatocellular carcinoma is significant in Hong Kong. These patients show specific clinical features when compared with patients with sporadic hepatocellular carcinoma.

Double-blind, randomized controlled study to assess the effects of lansoprazole 30 mg and lansoprazole 15 mg on 24-h oesophageal and intragastric pH in Chinese subjects with gastro-oesophageal reflux disease

BACKGROUND

Previous studies have suggested that the acid secretory capacity of the Chinese population is lower than that of the Western population.

AIM

To compare the effect of lansoprazole 30 mg and 15 mg once daily on the 24-h oesophageal and intragastric pH profiles in Chinese patients with gastro-oesophageal reflux disease.

METHODS

Forty-four patients (male to female ratio, 27 : 17; mean age, 53 years; 55% with oesophagitis) with gastro-oesophageal reflux disease were randomized to receive lansoprazole 30 mg or 15 mg once daily for 4 weeks. Measurement of the 24-h oesophageal and intragastric pH, gastro-oesophageal reflux disease symptoms and quality of life was performed at baseline and during the last week of each dosing period.

RESULTS

Lansoprazole 30 mg maintained an intragastric pH > 4 for 10.5 h vs. 9.6 h for lansoprazole 15 mg (P = 0.44). The percentage total time at oesophageal pH < 4 was similar for lansoprazole 30 mg and 15 mg (2.0% vs. 2.3%, P = 0.30). The proportion of patients with complete cure of heartburn and acid regurgitation and the quality of life assessment were similar for lansoprazole 30 mg and 15 mg. Both dosages of lansoprazole were well tolerated and the compliance was 100% in both groups.

CONCLUSION

Lansoprazole dosages of 30 mg and 15 mg once daily provide a satisfactory decrease for oesophageal acid exposure and are equally effective for the treatment of gastro-oesophageal reflux disease in the Chinese population.

Cholestatic jaundice caused by sequential carbimazole and propylthiouracil treatment for thyrotoxicosis

A 36-year-old Chinese man presented to the Queen Mary Hospital in August 1999 with a 2-week history of jaundice due to propylthiouracil treatment for thyrotoxicosis. He had previously received carbimazole but had developed an urticarial skin rash after 2 weeks of treatment. The patient developed liver failure and fulminant pneumonitis shortly after hospital admission. Despite receiving treatment with broad-spectrum antibiotics and intravenous immunoglobulin, he died 11 days after the onset of the respiratory symptoms. Postmortem examination using electron microscopy showed typical glycogen bodies within the cytoplasm of the hepatocytes, which corresponded to eosinophilic cytoplasmic inclusion bodies visible under light microscopy. Immunohistochemical studies of the inclusion bodies were positive for carcinoembryonic antigen and albumin, and negative for fibrinogen, complement protein C3, immunoglobulins G, M, and A, alpha-fetoprotein, and alpha-1-antitrypsin. This is the first report of a patient who received two sequential antithyroid drugs and developed predominate cholestasis with unique histological features. Extreme caution should be taken when a patient develops allergy to one type of antithyroid drug, because cross-reactivity may develop to the other type.

Coping strategies, illness perception, anxiety and depression of patients with idiopathic constipation: a population-based study

BACKGROUND

Functional constipation has important psychological elements.

AIM

To investigate the prevalence of functional constipation in an Asian population, and the interplay among functional constipation, anxiety/depression, perception and coping strategies.

METHODS

An interview of 3282 patients was made by telephone survey. Constipation was diagnosed by Rome II criteria. Coping ability and anxiety/depression were assessed by validated questionnaires.

RESULTS

Fourteen percent of the interviewees had constipation. Anxiety and depression scores were higher in constipated than in healthy subjects (P < 0.0001 and < 0.0001), and in female than male patients (P = 0.02 and < 0.0001). Patients who were aware of their symptoms perceived greater impact on their lives (P < 0.001). Frequent use of coping strategies associated with lower anxiety scores (P < 0.0001). Female were more frequently aware of the symptoms (P = 0.004), less frequently used coping strategies (P = 0.008). Regression analysis showed that female and high anxiety level were the independent factors for predicting the perception of constipation, whereas anxiety was the only independent factor for predicting the use of coping strategies.

CONCLUSION

Constipation associated with anxiety and depression is prevalent in the general Asian population. Female sex and anxiety are important aetiological factors in constipation, affecting perception and the use of coping strategies.

A validated symptoms questionnaire (Chinese GERDQ) for the diagnosis of gastro-oesophageal reflux disease in the Chinese population

BACKGROUND AND AIMS

To develop a validated gastro-oesophageal disease (GERD) symptom questionnaire for the Chinese population.

METHODS

One hundred Chinese patients with GERD and 101 healthy Chinese controls were presented with a 20-item GERD questionnaire in the Chinese language (Chinese GERDQ). Quality of life in GERD patients was assessed by SF-36. A standard dose of proton pump inhibitors for 4 weeks was prescribed to 35 patients with newly diagnosed GERD. The Chinese GERDQ was performed before, 4 weeks and 8 weeks after treatment. Concept, content, construct, discriminant validity and reliability of the questionnaire were assessed.

RESULTS

Seven items were selected by logistic regression to account for most of the differences between controls and GERD patients with a good reproducibility and internal consistency. A cut-off score of equal or greater than 12 was determined to discriminate between controls and GERD patients with a sensitivity of 82% and a specificity of 84%. The Chinese GERDQ correlated negatively with five domains of the SF-36 and discriminated between GERD patients who reported symptomatic improvement during proton pump inhibitor treatment and symptoms deterioration upon withdrawal of proton pump inhibitor treatment.

CONCLUSIONS

The Chinese GERDQ could be used in epidemiological studies to assess the frequency and severity of GERD in patient populations and in interventional studies of GERD.

Promoter methylation of E-cadherin gene in gastric mucosa associated with Helicobacter pylori infection and in gastric cancer

BACKGROUND

E-cadherin is an adhesion molecule involved in tumour invasion/metastasis. Silencing of E-cadherin by promoter CpG methylation has been shown in both familial and sporadic gastric cancers. Helicobacter pylori is a class I carcinogen in gastric cancer.

AIMS

This study was undertaken to investigate the association between methylation of E-cadherin and H pylori in gastric mucosa from dyspeptic patients, and in intestinal metaplasia and primary and metastatic adenocarcinoma from surgical specimens of patients with gastric cancer.

METHODS

E-cadherin methylation was studied using methylation specific polymerase chain reaction in microdissected tissue from biopsies or surgical resection specimens. E-cadherin expression was studied by immunohistochemistry.

RESULTS

E-cadherin methylation was present in 31% (11/35) of gastric mucosae from dyspeptic patients, and was associated with H pylori infection (p=0.002), but was independent of the age of the patient or presence or absence of gastritis. E-cadherin methylation was present in 0% (0/8) of normal mucosa, 57% (12/21) of intestinal metaplasias, and 58% (15/26) of primary and 65% (21/32) of metastatic cancers. E-cadherin methylation status was concordant in 92% (11/12) of intestinal metaplasias and primary cancers, and in 85% (17/20) of primary and metastatic cancers from the same resected specimen. E-cadherin methylation in gastric cancer was associated with depth of tumour invasion (p=0.02) and regional nodal metastasis (p=0.05).

CONCLUSION

E-cadherin methylation is an early event in gastric carcinogenesis, and is initiated by H pylori infection.

A large population study of spontaneous HBeAg seroconversion and acute exacerbation of chronic hepatitis B infection: implications for antiviral therapy

BACKGROUND AND AIM

Clinical data on spontaneous hepatitis B e antigen (HBeAg) seroconversion and acute exacerbation of chronic hepatitis B (CHB) virus infection from large population studies are lacking. In the present study we examined the clinical features and significance of HBeAg seroconversion and acute exacerbation in 3063 Chinese CHB patients.

METHODS

Clinical assessment, liver biochemistry, hepatitis B virus (HBV) serology and HBV DNA, time of HBeAg seroconversion, and acute exacerbation were monitored.

RESULTS

Median age at HBeAg seroconversion was 34.5 years. The cumulative HBeAg seroconversion rate significantly increased with alanine aminotransferase (ALT) levels on presentation (p<0.0001). For patients with ALT levels more than twice the upper limit of normal (ULN) on presentation, the HBeAg seroconversion rate at the fifth year of follow up was 72.4%. After HBeAg seroconversion, 65.2% (73/110) of patients had undetectable HBV DNA levels by the Digene Hybrid Capture assay. Of these, 78.1% still had HBV DNA levels detectable by the Amplicor HBV Monitor Test. We found that 37.5% antibody to HBeAg (anti-HBe) positive patients had undetectable HBV DNA levels by the Digene Hybrid Capture assay before acute exacerbation. Acute exacerbations of longer duration, with higher peak ALT, bilirubin, and alpha fetoprotein levels were associated with an increased HBeAg seroconversion rate (p<0.0001-0.045). Acute exacerbation with peak ALT levels more than five times the ULN carried a 46.4% chance of HBeAg seroconversion within three months. HBeAg seroreversion and mortality occurred in 2.7% and 0.7% of acute exacerbations, respectively.

CONCLUSION

In the present study we have provided information on HBeAg seroconversion and acute exacerbation, which are important in decision making for CHB treatment and in designing clinical trials.

Long-term prospective follow-up of endoscopic oesophagitis in southern Chinese--prevalence and spectrum of the disease

AIMS

To study the prevalence, clinical characteristics and long-term outcome of oesophagitis in Chinese patients.

METHODS

Clinical and endoscopic data were collected prospectively from consecutive patients who underwent upper endoscopy between 1997 and 2001. Patients with endoscopic oesophagitis were graded according to the Los Angeles system and analysed according to their clinical presentation, endoscopic details, Helicobacter pylori status, non-steroidal anti-inflammatory drug history, co-morbidity and mortality.

RESULTS

A total of 22,628 upper endoscopies were performed in 16,606 patients. Of these, 631 (3.8%) had endoscopic oesophagitis, 14 had benign oesophageal stricture (0.08%) and 10 had Barrett's oesophagus (0.06%). Most patients (94%) had either Los Angeles grade A or grade B oesophagitis. Patients who died during follow-up had a significantly higher incidence of co-morbid illness (100% vs. 63%, P < 0.001). By Cox regression analysis, the presence of gastrointestinal bleeding (P = 0.008), advanced age (P = 0.004) and the use of Ryle's tube (P = 0.043) were identified to be independent factors associated with mortality.

CONCLUSIONS

Complicated gastro-oesophageal reflux disease is uncommon in the Asian population. Advanced age, use of Ryle's tube and the presence of gastrointestinal bleeding are associated with a poor long-term outcome, which is a reflection of the severe underlying co-morbidity.

Normal 24-hour ambulatory proximal and distal gastroesophageal reflux parameters in Chinese

OBJECTIVE

To quantify normal proximal and distal oesophageal acid parameters in healthy Chinese.

DESIGN

Observational study.

SETTING

University teaching hospital, Hong Kong.

SUBJECTS AND METHODS

Twenty healthy adults who were not on medication and were free from gastrointestinal symptoms were recruited by advertisement. Ambulatory oesophageal acid (pH<4) exposure parameters were recorded at distal and proximal sites, 5 and 20 cm, respectively above the lower oesophageal sphincter.

RESULTS

The 95th percentile for reflux parameters assessed in the distal/proximal oesophagus were: percent total time pH<4, 4.6/0.7%; percent upright time pH<4, 7.0/1.1%; percent supine time pH<4, 4.5/0.5%; number of reflux episodes, 73/12; number of reflux episodes with pH<4 for >5 minutes, 4/0; and the longest single acid exposure episode, 11.2/3.0 minutes.

CONCLUSION

Physiological gastroesophageal reflux occurs in healthy Chinese. These initial data provide a preliminary reference range that could be utilised by laboratories studying Chinese subjects.