[Current surveillance policy for Barrett's oesophagus in the Netherlands]

OBJECTIVE

To gain more insight into current surveillance and treatment of patients with Barrett's oesophagus with the aim of developing new guidelines.

DESIGN

Questionnaire.

METHOD

In 2004, a questionnaire was sent to 337 physician-endoscopists who were all registered with the Netherlands Society of Gastroenterology. The questionnaire inventoried various aspects of surveillance and treatment of patients with Barrett's oesophagus.

RESULTS

Of the 289 respondents (86%), 96% carried out surveillance or had it carried out, on at least a proportion of their patients with Barrett's oesophagus. A total of 258 respondents (89%) carried out the surveillance themselves. An endoscopic indication of the presence of Barrett's oesophagus was, for 31% of the respondents, enough reason to carry out surveillance of this condition irrespective of the results of pathological investigations. 75% applied an age limit for surveillance for Barrett's. The median age limit is 75 years (interquartile distance: 70-75) and 46% of the treating professionals limited themselves to patients who, on the basis of age and co-morbidity, may undergo oesophageal resection. The choice of treatment in early neoplasia, surgical or endoscopic, depends not only on the histological diagnosis, but also on the age and the co-morbidities of the patient.

CONCLUSION

Surveillance of Barrett's oesophagus is widespread in the Netherlands, and in general is carried out in accordance with international guidelines. The possibilities of treating patients with high-grade dysplasia or intramucosal carcinoma of the oesophagus endoscopically, and of consulting external advisory bodies are still insufficiently utilized.

Diagnosis of gastrointestinal lesions during treatment with non-steroidal anti-inflammatory drugs

Probably all non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of gastrointestinal (GI) mucosal injury. The most frequent lesions are gastric erosions in the pre-pyloric region. Non-steroidal anti-inflammatory drugs also increase the incidence of peptic ulcers, although it is not yet clear whether more gastric ulcers or more duodenal ulcers are produced. Gastrointestinal symptoms are prevalent during NSAID treatment, but there is no correlation between symptoms and lesions. Clinical presentation may therefore vary considerably: many symptomatic patients will have no lesions, whereas others will present with complications but no symptoms. Blood loss is the most frequent complication of NSAID-induced GI lesions. Bleeding is usually 'silent' and occult. Overt haemorrhage, though rare, is more frequent in patients taking NSAIDs. Other complications, such as penetration and perforation, may also occur. Endoscopy is the diagnostic method of choice, as this method can detect even superficial mucosal lesions. However, because of the lack of correlation between symptoms and lesions, it is difficult to ascertain which patients are at risk and thus to avoid unnecessary diagnostic procedures. Future efforts should therefore be directed towards the prevention of NSAID-induced GI lesions.

[Decreasing prevalence of Helicobacter pylori: a consequence of treatment of gastroduodenal ulcers]

Four patients with gastroduodenal ulcers in the absence of Helicobacter pylori illustrate the decreasing prevalence of this microorganism. One was a 19-year-old boy with nausea, diarrhoea and weight loss caused by multiple gastroduodenal ulcers due to the Zollinger-Ellison syndrome. Another was a 36-year-old man with abdominal discomfort caused by an ulcer due to Crohn's disease. The other two cases concerned a 29-year-old man and a 68-year-old woman with relapsing ulcer disease and active bleeding, in whom no causal factors could be determined. Recent studies suggest a decreasing prevalence of H. pylori leading to both a relative and an absolute decrease of gastroduodenal ulcers attributed to H. pylori. Future treatment strategies will have to take these altered prevalence rates into consideration.

Effect of Helicobacter pylori eradication on chronic gastritis during omeprazole therapy

BACKGROUND

We have previously observed that profound acid suppressive therapy in Helicobacter pylori positive patients with gastro-oesophageal reflux disease is associated with increased corpus inflammation and accelerated development of atrophic gastritis.

AIM

To investigate if H pylori eradication at the start of acid suppressive therapy prevents the development of these histological changes.

PATIENTS/METHODS

In a prospective randomised case control study, patients with reflux oesophagitis were treated with omeprazole 40 mg once daily for 12 months. H pylori positive patients were randomised to additional double blind treatment with omeprazole 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg twice daily or placebo for one week. Biopsy sampling for histology, scored according to the updated Sydney classification, and culture were performed at baseline, and at three and 12 months.

RESULTS

In the persistently H pylori positive group (n=24), active inflammation increased in the corpus and decreased in the antrum during therapy (p=0.032 and p=0.002, respectively). In contrast, in the H pylori positive group that became H pylori negative as a result of treatment (n=33), active and chronic inflammation in both the corpus and antrum decreased (p<or =0.0001). The decrease in active and chronic inflammation in the corpus differed significantly compared with the persistently H pylori positive group (both p=0.001). For atrophy scores, no significant differences were observed between H pylori eradicated and persistently H pylori positive patients within one year of follow up. No changes were observed in the H pylori negative control group (n=26).

CONCLUSIONS

H pylori eradication prevents the increase in corpus gastritis associated with profound acid suppressive therapy. Longer follow up is needed to determine if H pylori eradication prevents the development of atrophic gastritis.

Atrophic gastritis during long-term omeprazole therapy affects serum vitamin B12 levels

BACKGROUND

Omeprazole maintenance therapy for gastro-oesophageal reflux disease (GERD) has been associated with an increased incidence of atrophic gastritis in H. pylori-infected patients and with a decreased absorption of protein-bound, but not of unbound cobalamin.

AIM

: To test the hypothesis that the combination of decreased cobalamin absorption and atrophic gastritis decreases serum cobalamin levels during omeprazole therapy.

METHODS

Forty-nine H. pylori-positive GERD patients were treated with omeprazole for a mean (+/- s.d.) period of 61 (25) months. At the start of omeprazole treatment (T0) and at the latest follow-up visit (T1), serum was obtained for measurement of cobalamin. Corpus biopsy specimens were obtained at entry and follow-up for histopathological scoring according to the updated Sydney classification.

RESULTS

At inclusion, none of the 49 patients had signs of atrophic gastritis. During follow-up, 15 patients (33%) developed atrophic gastritis, nine of whom had moderate to severe atrophy. These 15 patients did not differ from the other 34 patients with respect to age, serum cobalamin at T0 or the duration of follow-up. During follow-up, no change was observed in the median serum cobalamin level in the 34 patients without atrophy; (T0) 312 (136-716) vs. (T1) 341 (136-839) pmol/L (P=0.1). In the 15 patients who developed atrophy, a decrease in cobalamin was seen from 340 (171 to 787) at baseline to 285 (156-716) at latest follow-up (P < 0.01).

CONCLUSIONS

The development of atrophic gastritis during omeprazole treatment in H. pylori-positive GERD patients is associated with a decrease of serum vitamin B12 levels.

Omeprazole versus high-dose ranitidine in mild gastroesophageal reflux disease: short- and long-term treatment. The Dutch Reflux Study Group

OBJECTIVE

Patients with reflux esophagitis suffer from a chronic condition that may cause considerable discomfort because of recurrent symptoms and diminished quality of life. This study was designed to evaluate acute and long-term treatment comparing standard doses of omeprazole and high-dose ranitidine.

METHODS

Patients with endoscopically verified symptomatic esophagitis grade I or II were initially treated with omeprazole 20 mg daily or ranitidine 300 mg twice daily for 4-8 wk. Patients who were symptom free were randomized to maintenance treatment with omeprazole 10 mg daily or ranitidine 150 mg twice daily. Patients were seen every 3 months or at symptomatic relapse.

RESULTS

The percentage of asymptomatic patients after 4 and 8 wk treatment were 61% and 74%, respectively, for omeprazole and 31% and 50%, respectively, for ranitidine. Of 446 patients treated initially, 277 were asymptomatic, of whom 263 entered the maintenance study. The estimated proportion of patients in remission after 12 months of maintenance treatment with omeprazole 10 mg daily (n = 134) and ranitidine 150 mg twice daily (n = 129) were 68% and 39%, respectively (p < 0.0001).

CONCLUSIONS

Omeprazole 20 mg daily is superior to high-dose ranitidine in the symptomatic treatment of reflux esophagitis grade I and II. Furthermore, omeprazole at half the standard dose is more effective than ranitidine in a standard dose in keeping patients in remission for a period of 12 months.

Hypergastrinaemia during long-term omeprazole therapy: influences of vagal nerve function, gastric emptying and Helicobacter pylori infection

AIM

elucidate the mechanisms that lead to severe hypergastrinaemia during long-term omeprazole therapy for gastro-oesophageal reflux disease (GERD).

PATIENTS AND METHODS

A total of 26 GERD patients were studied during omeprazole maintenance therapy. Twelve patients with severe hypergastrinaemia (gastrin > 400 ng/L) were compared with 14 control patients (gastrin < 300 ng/L). Helicobacter pylori serology and a laboratory screen were obtained in all patients. Gastric emptying was scored by the evidence of food remnants upon endoscopy 12 h after a standardized meal. Gastric antrum and corpus biopsies were analysed for histological parameters, as well as somatostatin and gastrin concentrations. All patients underwent a meal-stimulated gastrin test and the hypergastrinaemia patients also underwent a vagal nerve integrity assessment by pancreatic polypeptide testing (PPT).

RESULTS

Severe hypergastrinaemia patients had a longer duration of treatment (80 vs. 55 months; P = 0.047) and were characterized by a higher prevalence of H. pylori infection (9/12 vs. 2/14, P = 0.004), corpus mucosal inflammation and atrophic gastritis (P < 0.04). This was reflected in lower serum pepsinogen A concentrations (mean +/- S.E.M. 53.6 +/- 17.9 vs. 137 +/- 16.0 mg/L, P = 0.03), pepsinogen A/C ratio (1.8 +/- 0.3 vs. 4.1 +/- 0.6, P = 0.005) and mucosal somatostatin concentrations (2.75 +/- 0.60 vs. 4.48 +/- 1.08 mg/g protein, P = 0.038). Two patients in the hypergastrinaemia group had signs of delayed gastric emptying, but none in the normogastrinaemia group did (P = N.S.). In addition, both groups had a normal meal-stimulated gastrin response.

CONCLUSION

Severe hypergastrinaemia during omeprazole maintenance therapy for GERD is associated with the duration of therapy and H. pylori infection, but not with abnormalities of gastric emptying or vagal nerve integrity.

[Reflux esophagitis; is the preventive eradication of Helicobacter pylori needed in patients on omeprazole?]

The pattern of Helicobacter pylori gastritis depends on acid secretion. Profound acid suppressive therapy with proton pump inhibitors leads to a decrease of antral gastritis, but an increased severity of corpus gastritis. As such, maintenance therapy with these drugs for gastroesophageal reflux disease has consistently been associated with an increased incidence of atrophic gastritis in H. pylori infected patients. For this reason, the preventive effect of H. pylori eradication in these patients needs to be considered; this is being studied in prospective trials.

Omeprazole as a diagnostic tool in gastroesophageal reflux disease

OBJECTIVE

To determine the diagnostic value of empirical treatment with omeprazole in the diagnosis of gastroesophageal reflux disease (GERD).

METHODS

Patients with symptoms suggestive of GERD underwent upper gastrointestinal endoscopy and 24-h esophageal pH monitoring. Patients with reflux esophagitis grade 0 or 1 were included in the study and were randomized to double-blind treatment with either 40 mg omeprazole or placebo o.m. The effect of treatment was evaluated after 1 and 2 wk with a symptom questionnaire with a four-grade Likert scale, and symptomatic response outcome was compared with the results of 24-h pH-metry.

RESULTS

Ninety-eight patients were included; however, 13 were excluded from the final analysis because of protocol violation. Of the remaining 85 patients, 54 had no signs of esophagitis at endoscopy, and 31 had esophagitis grade 1. The pH registration showed pathological gastroesophageal reflux in 47 patients (55%). Forty-one patients were randomized to treatment with omeprazole and 44 to placebo. There was a significant correlation between the pH registration result and response to omeprazole (p = 0.04, chi2), but not to placebo (p = 0.16). With pH-metry as the gold standard, the omeprazole test had positive and negative predictive values of 68% and 63%, respectively, for the diagnosis of GERD. When the omeprazole test was used as the gold standard, the positive and negative predictive values of pH monitoring were 68 % and 63 %, respectively. Similar sensitivity was found when the pH-metry was compared with presence of esophagitis.

CONCLUSION

Determination of the symptomatic response to 40 mg of omeprazole for 14 days is a simple and inexpensive tool for the diagnosis of GERD, with a sensitivity and specificity comparable to 24-h pH monitoring.

Factors predicting relapse during maintenance treatment with famotidine in patients with healed reflux esophagitis. Dutch Esophagitis Study Group

Little is known about possible predictive factors influencing the relapse rate in patients with healed reflux esophagitis during maintenance therapy with histamine2 (H2)-receptor antagonists. Therefore, the efficacy of famotidine 20 mg twice daily was evaluated in an open-label prospective study in 317 patients who had experienced healing of erosive reflux esophagitis after treatment with famotidine; 259 patients completed the study and were assessable according to study protocol. The cumulative endoscopic relapse rates at 4, 8, and 12 months were 20%, 30%, and 36%, respectively, according to the per-protocol analysis. The most predictive determinant of relapse was the duration of acute treatment required to achieve healing: Relapse occurred significantly less often in patients who experienced healing with 6 weeks of acute treatment than in those who experienced healing with 12 and 24 weeks of treatment. The second most important determinant was the initial endoscopic severity of the disease. Patients with initial grade I esophagitis had significantly fewer relapses. Relapse rate appeared to be unrelated to initial severity and duration of symptoms, smoking habits, or strength of acute treatment. The results showed that maintenance therapy with famotidine 20 mg twice daily is effective in a large proportion of patients with healed reflux esophagitis, with few adverse effects reported.

Effect of short- and long-term treatment with omeprazole on the absorption and serum levels of cobalamin

AIMS

To evaluate absorption of protein-bound and unbound cyanocobalamin before and during treatment with omeprazole, and cobalamin levels in patients on long-term treatment with omeprazole.

METHODS

In eight former duodenal ulcer patients absorption of unbound and protein-bound cobalamin was determined by measuring 24-h urinary excretion of unbound 58Co-cyancobalamin or protein-bound 57Co-cyanocobalamin during a modified Schilling test. Tests were performed before and during treatment with 20 mg and 40 mg omeprazole daily for 9 days. Serum cobalamin levels were assessed in 25 patients with gastro-oesophageal reflux disease (GERD) before and during long-term maintenance therapy with omeprazole. Mean treatment duration was 56 months (range 36-81 months).

RESULTS

Urinary excretion of unbound cobalamin was unchanged with both dosages of omeprazole. Excretion of 57Co-cyanocobalamin, however, decreased significantly during treatment with both 20 mg omeprazole (mean +/- S.E.M.: 1.31 +/- 0.20 vs. 0.54 +/- 0.17%; P < 0.02) and 40 mg omeprazole (1.25 +/- 0.26 vs. 0.29 +/- 0.06%; P < 0.02). Mean serum cobalamin levels (+/- S.E.M.) before and during therapy with omeprazole in GERD patients were 298 +/- 27 and 261 +/- 16 pg/mL (normal range 180-900 pg/mL), respectively (P = N.S.).

CONCLUSIONS

Absorption of protein-bound, but not unbound, cyanocobalamin is decreased when measured by a modified Schilling test during treatment with omeprazole. However, no change in serum cobalamin levels was observed in patients with GERD after treatment with omeprazole for up to 7 years.

Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication

BACKGROUND

Helicobacter pylori infection plays an important part in the development of atrophic gastritis and intestinal metaplasia, conditions that predispose patients gastric cancer. Profound suppression of gastric acid is associated with increased severity of gastritis caused by H. pylori, but it is not known whether acid suppression increases the risk of atrophic gastritis.

METHODS

We studied patients from two separate cohorts who were being treated for reflux esophagitis: 72 patients treated with fundoplication in Sweden and 105 treated with omeprazole (20 to 40 mg once daily) in the Netherlands. In both cohorts, the patients were followed for an average of five years (range, three to eight). After fundoplication, the patients did not receive acid-suppressive therapy. The presence of H. pylori was assessed at the first visit by histologic evaluation in the fundoplication group and by histologic and serologic evaluation in the omeprazole group. The patients were not treated for H. pylori infection. Before treatment and during follow-up, the patients underwent repeated gastroscopy, with biopsy sampling for histologic evaluation.

RESULTS

Among the patients treated with fundoplication, atrophic gastritis did not develop in any of the 31 who were infected with H. pylori at base line or the 41 who were not infected; 1 patient infected with H. pylori had atrophic gastritis before treatment that persisted after treatment. Among the patients treated with omeprazole, none of whom had atrophic gastritis at base line, atrophic gastritis developed in 18 of the 59 infected with H. pylori(P<0.001) and 2 of the 46 who were not infected (P=0.62).

CONCLUSIONS

Patients with reflux esophagitis and H. pylori infection who are treated with omeprazole are at increased risk of atrophic gastritis.

Long-term sequelae of Helicobacter pylori gastritis

Chronic Helicobacter pylori gastritis has been put forward as a risk factor for development of gastric mucosal atrophy and gastric cancer. The purpose of our study was to investigate the long-term effects of H pylori gastritis on the gastric mucosa. We prospectively studied 49 subjects negative for H pylori and 58 positive subjects for a mean follow-up of 11.5 years (range 10-13 years). Serum samples were obtained at the initial and follow-up visits for determination of H pylori IgG antibodies. Gastroscopies with biopsy sampling were done in all patients at both visits. Biopsy specimens were used for assessment of H pylori infection and histology. Development of atrophic gastritis and intestinal metaplasia occurred in 2 (4%) uninfected and 16 (28%) infected subjects. Regression of atrophy was noted in 4 (7%) infected subjects. Development of atrophic gastritis and intestinal metaplasia was significantly associated with H pylori infection (p = 0.0014; odds ratio 9.0, 95% CI 1.9-41.3). The proportion of atrophic gastritis in the study population showed an annual increase of 1.15% (0.5-1.8%). We conclude that H pylori infection is a significant risk factor for development of atrophic gastritis and intestinal metaplasia. Our findings support strongly the causative role of this infection in gastric carcinogenesis.

Pharmacological management of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) ranges from episodic symptomatic reflux without oesophagitis to severe oesophageal mucosal damage, such as Barrett's metaplasia or peptic stricture. The multifactorial pathogenesis of GORD prevents medical cure of the disease. GORD is a chronic disease with a high tendency to relapse, requiring a long term treatment strategy in practically all patients. Complete healing of all mucosal lesions is not necessarily the aim of treatment in all patients. In milder forms of reflux disease, symptom relief is the most important goal. Many patients with mild GORD do well on symptomatic self-care with antacids and/or alginate. In addition, lifestyle changes should be advised to all patients: these improve symptoms and enhance the efficacy of therapy. In the acute treatment of GORD the prokinetic drug cisapride has been shown to be effective in relieving symptoms and healing grade I to II oesophagitis. Cisapride decreases symptomatic and endoscopic relapse in patients with mild GORD. Histamine H2-receptor antagonists are effective in relieving reflux symptoms in about 50% of patients, but with regard to healing, H2-antagonists appear to be mainly effective in grades I and II and not in higher grades of oesophagitis. Maintenance treatment with H2-antagonists is mainly symptomatically effective in patients with mild GORD. Proton pump inhibitors (PPIs) provide significantly higher healing rates of reflux oesophagitis than H2-antagonists, even in the more severe cases of oesophagitis and Barrett's ulcers. PPIs are also effective in patients with oesophagitis refractory to treatment with H2-antagonists. PPIs have become the drugs of first choice in healing of all patients with more severe forms of reflux oesophagitis, and increasingly also for patients with milder forms of oesophagitis, certainly those who fail to respond to other drugs. In maintenance treatment of GORD, PPIs are the most effective drugs, offering the possibility of keeping nearly all patients in remission with adjusted doses. Current patient data of up to 5 years indicate the safety of this strategy for this period, but the exact consequences of strong acid inhibition over a longer period still have to be clarified. At present, all but a few patients with GORD can be managed adequately by medical therapy.

Safety of acid-suppressing drugs

There is an extensive literature on the adverse effects of drugs that inhibit gastric acid secretion. This study presents a critical examination of interactions between antisecretory drugs and other compounds, the frequency of serious adverse effects relating to various body systems, the safety of antisecretory drugs in pregnancy, and longer-term safety data from postmarketing surveillance studies. While interactions with some other drugs, alcohol, and certain carcinogens are of potential concern, in practice clinically significant reactions appear to be rare if they occur at all. A small number of major side-effects have been documented, but they occur rarely, and postmarketing surveillance has not detected other longer-term sequelae. Safety of these drugs in pregnancy is not established, as data are so few. It is concluded that antisecretory agents, by comparison with most other classes of drugs, are remarkably well tolerated.

Long-term treatment with omeprazole for refractory reflux esophagitis: efficacy and safety

OBJECTIVE

To evaluate the long-term efficacy and safety of omeprazole in patients with gastroesophageal reflux disease resistant to treatment with histamine-2 (H2)-receptor antagonists.

DESIGN

Cohort analytic study with a mean follow-up of 48 months (range, 36 to 64 months).

SETTING

Patients receiving ambulatory care from referral centers.

PATIENTS

91 patients with gastroesophageal reflux disease resistant to treatment with an H2-receptor antagonist but subsequently responsive to 40 mg of omeprazole daily.

INTERVENTION

Open maintenance therapy consisting of 20 mg of omeprazole daily in 86 patients and 40 mg daily in 5 patients.

OUTCOME MEASURES

Endoscopy to assess healing; side effects, laboratory values, fasting serum gastrin level, and gastric corpus biopsies to assess safety.

RESULTS

Esophagitis recurred in 47% of the patients receiving 20 mg of omeprazole daily, but all rehealed after the dose was doubled. Seven of 40 patients (18%) had a second relapse after a mean follow-up time of 24 months (range, 9 to 36 months) that was successfully treated with a further 20-mg dose increment for a mean period of 36 months (range, 6 to 39 months). Median gastrin levels increased initially from 60 ng/L before study entry to 162 ng/L (P < 0.01) with treatment and reached a plateau during maintenance treatment. Very high gastrin levels (> 500 ng/L) were observed in a subgroup (11%) of patients. The incidence of micronodular hyperplasia increased from 2.5% of the patients at first biopsy to 20% at the last biopsy (P = 0.001), with a corresponding progression of gastritis to subatrophic or atrophic gastritis from less than 1% to 25% (P < 0.001), which was more pronounced in patients with very high serum gastrin levels.

CONCLUSIONS

Maintenance therapy with omeprazole was effective for at least 5 years in patients with gastroesophageal reflux disease resistant to treatment with H2-receptor antagonists. Treatment was accompanied by a persistent increase in serum gastrin levels and an increase of micronodular argyrophil cell hyperplasia and subatrophic or atrophic gastritis.

Prevention of duodenal ulcer relapse by long-term treatment with omeprazole

Duodenal ulcer is a chronic disease with a high risk of relapse--if left untreated, the relapse rate is 50-80% per year (1). However, the relapse rate can be effectively reduced by inhibition of gastric acid secretion. Although many patients can be managed with episodic therapy, controlled either by the patient or doctor, continuous maintenance treatment is often necessary for patients with severe forms of the disease and those at risk of complications (2). Maintenance therapy with single night-time doses of an H2-receptor antagonist reduces relapse rates from approximately 75% to 25% per year (3). As omeprazole is more effective than the H2-receptor antagonists in the acute treatment of duodenal ulcer, healing virtually all patients within 4 weeks (4), it may also be more effective in the maintenance treatment of duodenal ulcer disease. To date, three studies have reported the effect of omeprazole on relapse rates of duodenal ulcer. A Danish multicentre study involved 195 patients, who were treated with omeprazole, either 10 mg once daily, or 20 mg once daily on Friday, Saturday and Sunday (weekend therapy), or with placebo (5). After 6 months, the remission rates were 67% and 70%, respectively, for those patients receiving omeprazole--significantly higher than in those receiving placebo (17% after 6 months). An Italian multicentre study of 81 patients found that omeprazole, both 10 mg once daily, and 20 mg once daily at weekends (Friday, Saturday and Sunday), was equally effective in preventing relapse. The proportions of patients in remission were 81% and 70%, respectively, after 6 months (6).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of famotidine 20 mg twice a day versus 40 mg twice a day in the treatment of erosive or ulcerative reflux esophagitis

Two different doses of famotidine (20 mg twice a day versus 40 mg twice a day) were evaluated in a double-blind, randomized multicenter study in 474 symptomatic patients with erosive ulcerative reflux esophagitis. A total of 238 patients were treated with famotidine 20 mg and 236 patients with 40 mg at breakfast and dinner-time. Relief of symptoms was significant in all patients after six and 12 weeks and not different in both treatment groups. Overall endoscopic healing was significantly better in the famotidine 40 mg twice a day group compared with 20 mg twice a day at week 6 (58% versus 43%; P < 0.05) and at week 12 (76% versus 67%; P < 0.05). Extending treatment to 24 weeks with 40 mg of famotidine twice a day in those patients not healed after 12 weeks did not result in further symptom relief or in significantly better overall healing. The differences in efficacy of these two doses were more pronounced with increasing severity of esophagitis. Analyzed by grade of esophagitis at entrance, healing was significantly better with famotidine 40 mg twice a day at week 6 for grade II, at week 12 for grades III and IV, and at week 24 for grade IV esophagitis. The results show that in the treatment of erosive/ulcerative reflux patients famotidine 40 mg twice a day is more effective and achieves faster healing than famotidine 20 mg twice a day.

Long-term omeprazole therapy does not affect Helicobacter pylori status in most patients

Fifty-one patients were treated with 20-60 mg omeprazole for reflux oesophagitis resistant to H2-blocker therapy during a mean of 49 months of follow-up. With use of a standardized enzyme-linked immunosorbent assay technique specific IgG and IgG Helicobacter pylori antibodies were determined in serum obtained at the start of therapy and at the most recent visit. At the start of therapy 26 patients (51%) had evidence of H. pylori infection, as demonstrated by increased IgG and IgA antibody levels. During follow-up, 4 of these 26 patients (15%) became H. pylori seronegative. It is concluded that long-term treatment with omeprazole has no effect on H. pylori status in most patients.

Intrinsic factor secretion and cobalamin absorption. Physiology and pathophysiology in the gastrointestinal tract

Intrinsic factor is produced by the gastric parietal cell. Its secretion is stimulated via all pathways known to stimulate gastric acid secretion: histamine, gastrin, and acetylcholine. There is, however, a different mode of secretion for both substances: atropine, vagotomy, and H2 receptor antagonists inhibit both intrinsic factor and acid secretion, but secretin and the hydrogen-potassium ATPase antagonist omeprazole have no effect on intrinsic factor while substantially reducing acid secretion. Cobalamin in food is bound to animal protein. Cobalamin deficiency due to inadequate dietary intake is rarely seen in extreme vegetarians (vegans). In the stomach cobalamin is liberated from its protein binding by peptic digestion and bound to R-proteins. Hypochlorhydria or achlorhydria, whether medically induced or not, may impair cobalamin uptake. The cobalamin-R-protein complex is split by pancreatic enzymes in the duodenum, where cobalamin is bound to intrinsic factor. Pancreatic insufficiency may lead to cobalamin deficiency. Lack of intrinsic factor is the commonest cause of cobalamin deficiency; very rarely, aberrant forms of intrinsic factor are produced, but the clinical syndrome is similar. Gram-negative anaerobe bacteria bind the cobalamin-intrinsic factor complex, and bacterial overgrowth of the small intestine diminishes cobalamin resorption. Parasitic infections with fish tape-worm and Giardia lamblia are also associated with cobalamin malabsorption. The cobalamin-intrinsic factor complex binds to the ileal receptors in the terminal ileum. Cobalamin absorption may be impaired after resection or by diseases affecting more than 50 cm of the terminal ileum, such as Crohn's disease, coeliac disease, tuberculosis, lymphoma or radiation. There is clearly a wide diversity in the aetiology of cobalamin deficiency, which requires a versatile diagnostic approach.

Effect of long-term treatment with omeprazole on serum gastrin and serum group A and C pepsinogens in patients with reflux esophagitis

Twenty-nine nongastrectomized and three partially gastrectomized patients with chronic reflux esophagitis resistant to 12 weeks' treatment with histamine H2-receptor antagonists were treated with a daily oral dose of 20-40 mg of omeprazole for 12-30 months. Basal serum gastrin, serum pepsinogen A, and serum pepsinogen C concentrations were monitored at regular intervals. Serum gastrin levels significantly (P less than 0.01) increased threefold to fourfold during the first 1-2 months of the study when all patients ingested 40 mg of omeprazole daily. Dose reduction to 20 mg did not significantly decrease gastrin levels. Serum gastrin levels showed a trend to further increase after the first 3 months of treatment, reaching statistically significant differences for values from the 3-12-month period (P less than 0.05) and from the 3-24-month period (P less than 0.005). Women and patients with high basal serum gastrin levels before omeprazole treatment were more likely to achieve higher serum gastrin levels during omeprazole treatment. Serum pepsinogen A and C levels were significantly (P less than 0.01) increased at all time intervals during long-term treatment with omeprazole. No significant tendency toward higher serum pepsinogen C levels in time was observed. However, serum pepsinogen A levels and the ratio of pepsinogen A to pepsinogen C further increased significantly (P less than or equal to 0.05) during the initial 3-12-month period. However, this trend was not observed anymore afterward. Antrectomized patients did not show increases in serum gastrin and serum pepsinogen A and C levels, suggesting that hypergastrinemia may be involved in the observed hyperpepsinogenemia.

Pharmacology of pepsinogen secretion: influence of pentagastrin on pepsinogen secretion in man

To investigate the effect of pentagastrin on serum and urinary pepsinogens and gastric pepsin, eight healthy male volunteers were studied twice during continuous intragastric perfusion with either NaCl 0.9% or 0.1 M HCl in random order. To the perfusate 3 mg/ml phenol red was added as inert recovery marker. Gastric content was aspirated in 15-minute samples, 4 basally and subsequently 6 during continuous i.v. infusion of pentagastrin 1.5 micrograms/kg/h. Furthermore, serum and urine samples were collected immediately before and after each test. Gastric pepsin output increased after pentagastrin. There were no differences in basal or stimulated pepsin output during saline or HCl perfusion despite marked differences in intra-gastric acidity and acid delivery to the duodenum. In addition, no significant changes in serum pepsinogen levels or urinary pepsinogen excretion were observed after pentagastrin infusion. It is concluded that pentagastrin stimulates gastric pepsin secretion directly, but does not stimulate the release of pepsinogens into the systemic circulation.

Gastrointestinal lesions during treatment with non-steroidal anti-inflammatory drugs (NSAIDs)

Probably all non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of gastrointestinal (GI) mucosal injury. Not only gastric and duodenal but also oesophageal, small bowel and colonic lesions have been reported. Gastroduodenal lesions are seen most frequently and of these, gastric erosions in the prepyloric region are most prominent. NSAIDs also increase the incidence of peptic ulcers although it is not yet clear whether more gastric or duodenal ulcers are produced. GI symptoms are prevalent during NSAID treatment but there is no correlation between symptoms and lesions. Clinical presentation may, therefore, vary considerably: many symptomatic patients will have no lesions whereas others will present with complications but no symptoms. Blood loss is the most frequent complication of NSAID induced GI lesions. Bleeding is usually silent and occult, the incidence of overt haemorrhage, although rare, is also increased. Other complications such as penetration and perforation may also occur. Endoscopy is the diagnostic method of choice as most mucosal lesions are superficial. However, because of the lack of correlation between symptoms and lesions it is difficult to select patients at risk and to avoid unnecessary procedures. Results of studies performed show that treatment of NSAID induced gastroduodenal lesions with conventional anti-ulcer therapy is probably effective. There are also indications that preventive therapy is effective.

Repeated high oral doses of omeprazole do not affect intrinsic factor secretion: proof of a selective mode of action

The effect of 60 mg oral omeprazole daily for 9 days on intrinsic factor and gastric acid secretion was studied in eight healthy volunteers. Gastric secretion studies were performed during saline and 0.1 M HCl perfusion before and after omeprazole administration. During dosing with omeprazole, basal gastric acid output diminished by 94%, and pentagastrin-stimulated acid output by 97%. Basal, peak and steady-state stimulated intrinsic factor output were unaffected by omeprazole. It is concluded that high oral doses of omeprazole suppress gastric acid secretion to very low levels but they do not affect intrinsic factor secretion. Intrinsic factor secretion was also unaffected by profound hypochlorhydria.

Effects of omeprazole on gastric secretory functions

Omeprazole is the first H+-K+-adenosine triphosphatase antagonist available for clinical use. It has a very strong, long-lasting inhibitory effect on gastric acid secretion. The effect is very selective: pepsin and intrinsic factor secretion are unaffected. Once-daily doses of 30-40 mg cause a more than 95% reduction of intragastric acidity. Lower doses have less predictable results. During treatment with omeprazole serum gastrin levels increase. After cessation of treatment gastric acid secretion and serum gastrin levels rapidly return to pretreatment levels. No rebound phenomena are observed after treatment.

The effects of omeprazole and ranitidine on 24-hour pH in the distal oesophagus of patients with reflux oesophagitis

Ambulatory 24-h pH monitoring in the distal oesophagus was performed in seven patients with erosive or ulcerative reflux oesophagitis to compare the effects of omeprazole and ranitidine in the management of gastro-oesophageal reflux disease. In a double-blind, crossover study patients were treated with either 60 mg o.m. omeprazole or 150 mg b.d. ranitidine. The pH measurements were performed before treatment and on the fourteenth day of treatment with either regimen. The total acid exposure time (percentage total time pH less than 4) was abnormal in six out of seven patients before treatment. During treatment with omeprazole the acid exposure time of five patients was normal in comparison with only two patients during ranitidine therapy. However, even with a rather high dose of omeprazole, pathological gastro-oesophageal reflux may still occur.

Effect of high dose omeprazole on gastric pepsin secretion and serum pepsinogen levels in man

To investigate the effect of omeprazole on serum and urinary pepsinogens and on gastric pepsin, 8 healthy male volunteers were studied before and after 9 days of treatment with omeprazole 60 mg/day p.o. Fasting serum samples and 24 h urine specimens were obtained, and gastric contents were aspirated at 15-min intervals, 4 prior to and 6 during pentagastrin 1.5 micrograms.kg-1.h-1 i.v. during intra-gastric perfusion with NaCl 0.9% and phenol red 3 mg.ml-1 as an inert recovery marker. Basal and pentagastrin-stimulated volume and acid secretion were significantly decreased. The basal and pentagastrin stimulated pepsin output remained unchanged but pepsin concentration in gastric secretion was increased. Administration of omeprazole resulted in a significant increase in the serum PGA and PGC levels. The 24-h urinary excretion of PGA increased, but that of PGC remained unchanged, and so did the renal clearances of creatinine and pepsinogen A. The renal clearance of pepsinogen C decreased. It was concluded that omeprazole did not affect gastric pepsin output, but, due to the decreased volume output, the concentration of pepsin in the gastric secretion was increased. Omeprazole increased the serum levels of pepsinogen A and C because more pepsinogen was released into the systemic circulation. This might be due to greater back-diffusion of pepsinogen from the gastric mucosa into the systemic circulation as a result of the higher pepsinogen concentration in gastric secretion.

Lack of effect of antacids on plasma concentrations of omeprazole given as enteric-coated granules

Twelve male volunteers were studied after a single oral dose of 20 mg omeprazole given as enteric-coated granules with and without concomitant administration of 10 ml of a potent liquid antacid (buffering capacity 56.6 mmol 10 ml-1) under fasting conditions. No statistically significant differences were detected in median Cmax (0.41 approximately equal to 0.53 mumol l-1), the geometric mean AUC (0.80 approximately equal to 0.81 mumol l-1 h) or median tmax (1.25 h), with and without antacid.

Double-blind multicentre comparison of omeprazole and ranitidine in the treatment of reflux oesophagitis

Omeprazole 60 mg once daily was compared with ranitidine 150 mg twice daily in an endoscopically-controlled, double-blind randomised trial in 51 outpatients with erosive or ulcerative reflux oesophagitis (grade 2 or 3). Endoscopy was repeated after 4 weeks and, in the absence of healing, again after 8 weeks. Symptoms were assessed before entry and after 2, 4, and 8 weeks. Patients who were unhealed after 8 weeks were blindly switched to the other drug and treatment was continued for another 4 to 8 weeks. The healing rate (change to grade 0 or 1 oesophagitis) after 4 weeks was 19 of 25 patients treated with omeprazole and 7 of 26 patients treated with ranitidine (p = 0.002). The corresponding figures after 8 weeks were 22 of 25 and 10 of 26 (p = 0.001). The higher healing rate with omeprazole was reflected in a significantly faster and stronger improvement of reflux symptoms. 13 patients, who were unhealed after 8 weeks on ranitidine, were healed after switching treatment. Healing was achieved in 1 of 3 patients who were switched to ranitidine. There were no adverse events or changes in laboratory variables of clinical importance. Omeprazole is superior to ranitidine in the short-term treatment of reflux oesophagitis.

Effect of single and repeated doses of oral omeprazole on gastric acid and pepsin secretion and fasting serum gastrin and serum pepsinogen I levels

The effect of omeprazole on gastric acid and pepsin secretion and fasting serum gastrin and serum pepsinogen I levels was studied in 12 healthy volunteers. Omeprazole, 40 mg enteric-coated granules, or placebo was given once daily for nine days in a double-blind crossover study design. Twenty-four hours after a single dose of omeprazole, mean basal and mean pentagastrin-stimulated acid output decreased significantly. This effect was more pronounced after nine days of treatment. Basal pepsin output was significantly reduced only in those subjects with basal anacidity during omeprazole treatment. Stimulated pepsin output was slightly reduced after a single dose but unaltered after nine days of omeprazole. Fasting serum gastrin and serum pepsinogen I levels increased significantly during omeprazole treatment. It is concluded that omeprazole is a potent and selective inhibitor of gastric acid secretion, probably without a direct effect on pepsin secretion. However, in cases of basal anacidity during omeprazole administration, basal pepsin secretion is reduced. During omeprazole treatment, fasting serum levels of gastrin and pepsinogen I rise.

The influence of omeprazole on the synthesis and secretion of pepsinogen in isolated rabbit gastric glands

Regulation mechanisms of pepsinogen (EC 3.4.23.) synthesis and secretion were studied by following newly synthesized [14C]-labeled pepsinogen during culture of isolated rabbit gastric glands. Omeprazole, a substituted benzimidazole, while almost completely abolishing acid production at 10(-4) M, strongly stimulated secretion of preformed and newly synthesized pepsinogen. Although the pepsinogen synthesis at this concentration of omeprazole was reduced to about 55% of the control rate, a two-fold absolute increase of total secreted pepsinogen was found. This increase was not due to a non specific leakage through disruption of chief cell membranes, as no increase of lactate dehydrogenase in the culture medium could be demonstrated. The stimulated secretion was influenced neither by 10(-3) M cimetidine, 10(-3) sodium thiocyanate nor 10(-4) M atropine. No additivity was found between the carbachol (10(-4) M) or dibutyryl cyclic AMP (10(-3) M) and the omeprazole induced pepsinogen secretion.

Is the measurement of blood cimetidine levels useful?

1 Blood cimetidine levels were measured up to 5 h after oral intake of 200 mg cimetidine with breakfast in 13 duodenal, 5 gastric and 15 anastomotic ulcer patients. 2 There were larger inter individual differences in results. The mean peak blood concentrations was 1.14 +/- 0.07 microgram/ml (range 0.54-1.94 microgram/ml), the mean period during which the blood concentration exceeded 0.5 microgram/ml was 141 +/- 11 min (range 23-306 min) and the mean area under the cimetidine blood concentration curve (AUC) was 166 +/- 8 microgram ml-1 min (range 96-280 microgram ml-1 min). Coefficient of variation of these parameters was 33%, 43% and 29% respectively. 3 There were no significant differences in these parameters between non-operated patients and patients with a partial gastrectomy. 4 In 11 patients restudied after 2 to 5 months blood cimetidine levels proved well reproducible; mean coefficient of variation of peak blood levels was 8.5 +/- 2.4%, of time during which blood levels exceeded 0.5 microgram/ml 7.6 +/- 2.5% and of the AUC 5.0 +/- 1.0%. 5 There was no difference in peak blood levels, duration of blood level exceeding 0.5 microgram/ml and blood cimetidine AUC between 24 patients healed after 4 weeks cimetidine therapy and 9 in whom healing took longer. Likewise, there was no evidence of lower blood cimetidine concentrations in 9 patients who relapsed during maintenance cimetidine treatment compared with 24 who did not relapse.

Effect of treatment with cimetidine for one year on gastrin cell and parietal cell function and sensitivity to cimetidine in patients with duodenal or gastric ulcers

Twenty-two duodenal and 16 gastric ulcer patients were treated with 400 mg cimetidine twice daily for one year after their ulcers had healed. No change in gastric acid secretion was observed before and after treatment in 20 duodenal and 13 gastric ulcer patients. Similarly, the inhibitory effect of 200 mg cimetidine on gastric acid secretion was unaltered in 11 duodenal and 6 gastric ulcer patients studied and cimetidine blood concentration were unchanged in 9 duodenal and 4 gastric ulcer patients after one year. In 7 duodenal and 6 gastric ulcer patients the serum gastrin response to a standard test meal before and after treatment was identical.

Cimetidine does not accelerate skin graft rejection in mice

The influence of cimetidine on skin graft rejection was studied in a well defined transplantation model of inbred mice. Four allogeneic transplantation combinations with increasing antigenic disparity and one xenograft combination were studied. Cimetidine (25 mg/kg body weight) was administered intraperitoneally at 8-hr intervals until rejection occurred. No differences in graft survival were observed between cimetidine-treated groups and saline-treated controls in any of the combinations studied.

Cimetidine in anastomotic ulceration after partial gastrectomy

In order to assess the efficacy of cimetidine in patients with endoscopically anastomotic ulcer after partial gastrectomy, 21 such patients entered a double-blind prospective clinical trial. At endoscopy after 4 wk of treatment, 8 of 12 patients treated with 1 g of cimetidine daily compared with 1 of 9 patients who received a placebo had healed ulcers (P less than 0.05). Evaluation of symptoms relief supported the efficacy of cimetidine compared with placebo. Healing rate after 1 mo of treatment with cimetidine was 67% and increased to 86% after 2 mo. During 1 year of maintenance therapy with 800 mg cimetidine daily, 3 of 19 patients relapsed. No serious side effects were observed. The results of this study demonstrate a beneficial effect of cimetidine on healing and symptoms of anastomotic ulcers.

Long-term treatment with histamine H2-receptor antagonists in Zollinger-Ellison syndrome

Continuous treatment of three Zollinger-Ellison patients with histamine H2-receptor antagonists for 14, 26 and 31 months resulted in effective relief of complaints and marked reduction in gastric acid secretion. In one of the patients the dose of cimetidine had to be doubled after 15 months of treatment because of a rise in basal gastric acid secretion accompanied by recurrent diarrhea. Fasting and secretin-stimulated serum gastrin levels were not affected by long-term treatment with histamine H2-receptor antagonists. No side-effects were observed in the three patients on long-term treatment.