Albert Villoria

Meta-analysis : high-dose proton pump inhibitors vs. standard dose in triple therapy for Helicobacter pylori eradication

Background  The evidence on whether high‐dose proton pump inhibitors (PPIs) increase cure rates of Helicobacter pylori treatment has not been previously assessed.

Physical activity and intestinal gas clearance in patients with bloating.

BACKGROUND:Patients complaining of abdominal bloating have impaired tolerance and clearance of intestinal gas loads. Mild exercise enhances intestinal clearance and prevents retention of intestinal gas loads in healthy subjects. Our aim was to evaluate the putative beneficial effects of physical activity in patients with abdominal bloating.METHODS:In eight patients complaining of bloating, seven with irritable bowel syndrome, and one with functional bloating, according to Rome II criteria, a gas mixture was continuously infused (12 mL/min) into the jejunum for 120 min with simultaneous duodenal lipid perfusion (1 kcal/min). Gas evacuation, perception (0–6 scale), and abdominal girth were measured at 15-min intervals. Paired studies were randomly performed in the supine position during intermittent pedaling (5 min with 3-min rest intervals at 40 rpm and 0.15 kp load) versus rest (as control).RESULTS:During rest, a significant proportion of the gas infused was retained in the gut (45 ± 9%, P < 0.01 vs basal), but retention was significantly lower during exercise (24 ± 7%, P < 0.05 vs rest). Gas retention during rest was associated with significant abdominal symptoms (3.6 score; P < 0.01 vs basal), and symptoms also improved during exercise (2.8 score, P < 0.05 vs rest). During the test, patients developed abdominal distension, which was related to the volume of gas retained (r = 0.68, P < 0.05).CONCLUSION:Mild physical activity enhances intestinal gas clearance and reduces symptoms in patients complaining of abdominal bloating.

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

Aliment Pharmacol Ther 2011; 34: 888–900

Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: A multicenter study

Background: Despite medical therapy, 30% of patients with ulcerative colitis (UC) need to undergo surgery. Around 50% of patients with proctocolectomy with ileal pouch–anal anastomosis (IPAA) develop complications of the pouch. Clinical evidence for the use of infliximab (IFX) in refractory pouchitis is limited. The aim of this study was to report efficacy of IFX in these patients. Methods: A retrospective, multicenter study was designed. Patients older than 18 years with chronic refractory pouchitis treated with IFX (5 mg/kg) were included. Short‐term IFX efficacy was evaluated at week 8 and mid‐term efficacy at weeks 26 and 52. Complete response was defined as cessation of diarrhea and urgency and partial response as marked clinical improvement but persisting symptoms. The modified Pouchitis Disease Activity Index (mPDAI) without endoscopy was calculated when available. Results: Thirty‐three consecutive UC patients with chronic refractory pouchitis were included (18 male, mean age 45 years, range 21–67). At week 8, 21% patients achieved complete response and 63% showed partial clinical response. At weeks 26 and 52, 33% and 27% achieved complete response and 33% and 18% showed partial clinical response, respectively. Thirteen patients (39%) withdrew treatment (four for lack of efficacy, four for loss of response and five for adverse events). None of the potential factors analyzed had an influence on response to IFX. Conclusions: IFX was effective in the short‐ and mid‐term in patients with chronic refractory pouchitis. However, medication had to be discontinued in a high number of patients. (Inflamm Bowel Dis 2011;)

Impaired intestinal gas propulsion in manometrically proven dysmotility and in irritable bowel syndrome

Background  Intestinal manometry is the current gold standard for diagnosing small bowel dysmotility; however, the functional significance of abnormal manometry is unknown. Our aim was to determine whether, and to what extent, intestinal gas propulsion is impaired in patients with manometrically proven dysmotility compared with healthy controls and patients with IBS.

Systematic review and meta-analysis: susceptibility-guided versus empirical antibiotic treatment for Helicobacter pylori infection

BACKGROUND The cure rate of standard triple therapy for Helicobacter pylori infection is unacceptably low. Susceptibility-guided therapies (SGTs) have been proposed as an alternative to standard empirical treatments. The aim of this study was to perform a systematic review and meta-analysis evaluating the efficacy of SGTs. METHODS A systematic search was performed in multiple databases. Randomized controlled trials comparing cure rates of SGTs versus those of empirical therapy were selected and analysed separately for first- and second-line treatments. A meta-analysis was performed using risk ratio (RR) and number needed to treat (NNT) to measure the effect. RESULTS Twelve studies were included in the meta-analysis. In first-line treatment, SGT was more efficacious than empirical 7-10 day triple therapy (RR 1.16, 95% CI 1.10-1.23, I (2) = 33%; NNT = 8). Most studies used a 7-10 day triple therapy and randomized the patients after endoscopy and/or culture, thus precluding the comparison of SGT versus non-invasive testing and empirical treatment in clinical practice. For second-line therapy, only four studies were found. Results were highly heterogeneous and no significant differences were found (RR 1.11, 95% CI 0.82-1.51, I (2) = 87%). CONCLUSIONS Once endoscopy and culture have been performed, SGT is superior to empirical 7 or 10 day triple therapy for first-line treatment. Further studies are needed to evaluate the effectiveness of SGT in clinical practice, especially when compared with currently recommended first-line quadruple therapies.

Colonic Responses to Gas Loads in Subgroups of Patients With Abdominal Bloating

OBJECTIVES:We sought to evaluate colonic gas accommodation, ileocecal competence, and colonic clearance in subgroups patients with abdominal bloating.METHODS:Thirty-six patients complaining of abdominal bloating (12 constipation-predominant irritable bowel syndrome (IBS-C), 12 diarrhea-predominant irritable bowel syndrome (IBS-D), and 12 functional bloating) and 18 healthy controls were studied. Abdominal perception and girth were measured during: (i) 1 h continuous infusion of gas at 24 ml/min into the rectum (accommodation period) and (ii) 30 min free rectal gas evacuation (clearance period). In eight patients and eight healthy subjects, the gas infused was labeled with radioactive xenon (74 MBq 133Xe), and gas distribution was determined by scintigraphy.RESULTS:Colonic gas accommodation produced significantly more abdominal symptoms and distension in patients than in healthy subjects (3.8±0.2 vs. 2.4±0.3 perception score; P<0.001; 10.9±0.6 vs. 8.3±0.5 mm girth increment; P=0.009). Scintigraphy showed no differences in colonic gas distribution and no ileal gas reflux, but patients exhibited impaired gas clearance from the proximal colon (63%±10% clearance in 30 min vs. 80%±2% in health; P=0.042), resulting in more residual gas (506±46 vs. 174±47 ml; P<0.001), perception (1.9±0.2 vs. 1.0±0.2 score; P=0.015), and girth increment (4.2±0.7 vs. 2.2±0.5 mm; P=0.024); IBS-C patients exhibited increased sensation and objective distension, as opposed to sensation only in IBS-D and distension only in functional bloating.CONCLUSIONS:Patients with abdominal bloating have normal colonic accommodation and ileocecal competence but impaired gas clearance from the proximal colon after retrograde infusion, and the consequences of this dysfunction are related to bowel habit.

Cost-minimization analysis favours intravenous ferric carboxymaltose over ferric sucrose for the ambulatory treatment of severe iron deficiency.

Objective Intravenous iron is widely used to treat iron deficiency in day-care units. Ferric carboxymaltose (FCM) allows administration of larger iron doses than iron sucrose (IS) in each infusion (1000 mg vs. 200 mg). As FCM reduces the number of infusions required but is more expensive, we performed a cost-minimization analysis to compare the cost impact of the two drugs. Materials and Methods The number of infusions and the iron dose of 111 consecutive patients who received intravenous iron at a gastrointestinal diseases day-care unit from 8/2007 to 7/2008 were retrospectively obtained. Costs of intravenous iron drugs were obtained from the Spanish regulatory agencies. The accounting department of the Hospital determined hospital direct and indirect costs for outpatient iron infusion. Non-hospital direct costs were calculated on the basis of patient interviews. In the pharmacoeconomic model, base case mean costs per patient were calculated for administering 1000 mg of iron per infusion using FCM or 200 mg using IS. Sensitivity analysis and Monte Carlo simulation were performed. Results Under baseline assumptions, the estimated cost of iron infusion per patient and year was €304 for IS and €274 for FCM, a difference of €30 in favour of FCM. Adding non-hospital direct costs to the model increased the difference to €67 (€354 for IS vs. €287 for FCM). A Monte Carlo simulation taking into account non-hospital direct costs favoured the use of FCM in 97% of simulations. Conclusion In this pharmacoeconomic analysis, FCM infusion reduced the costs of iron infusion at a gastrointestinal day-care unit.

Abdominal Accommodation: A Coordinated Adaptation of the Abdominal Wall to Its Content

BACKGROUND AND AIM: We previously showed that colonic gas infusion increases the girth and modifies the muscular activity of the anterior abdominal wall. We hypothesized that abdominal accommodation to volume loads is an active process instrumented by the coordinated activity of the anterior wall and the diaphragm.METHODS: To increase intraabdominal volume in healthy subjects, a gas was infused into the colon (1.44 L in 1 h) while measuring girth (by tape measure) and electromyography (EMG) activity of the anterior wall (via four pairs of surface electrodes) and the diaphragm (via six ring electrodes over an esophageal tube in the hiatus). After preliminary feasibility studies (N = 12), postural activity (N = 6) and responses to colonic gas loads, both with the trunk erect (N = 8) and in supine position (N = 8), were studied. A morphometric analysis was performed by computed tomography, image analysis (N = 8).RESULTS: In the erect position, anterior wall tone was higher and diaphragmatic tone was lower than in the supine position. With the trunk erect, gas infusion induced diaphragmatic relaxation (by 21 ± 3%; P < 0.05) and anterior wall contraction (16 ± 4% EMG increment; P < 0.05). By contrast, in the supine position, it induced diaphragmatic contraction (15 ± 6%, P < 0.05), while the anterior wall, in the absence of postural tone, showed no change (3 ± 2%, NS). Gas infusion was associated with girth increase (7.3 ± 1.0 mm with the trunk erect and 8.6 ± 1.4 mm in the supine position) and diaphragmatic ascent (17.6 ± 5.2 mm; P < 0.05).CONCLUSION: The degree of abdominal distension produced by intraabdominal volume increments results from posture-related abdomino-phrenic muscular responses.

Intestinal tone and gas motion

Abstract  The intestine propels and evacuates large gas loads without detectable phasic contractions by manometry. We hypothesized that intestinal gas motion is produced by changes in gut tone and capacitance. In 13 healthy subjects, changes in duodenal tone were measured by a barostat during continuous perfusion of lipids (Intralipid®, 1 kcal min−1) into the duodenum for 60 min. In separate groups, the effects of jejunal gas infusion (N2, CO2 and O2 in venous proportions at 12 mL min−1 starting after 15 min lipid perfusion) and sham infusion were tested. Gas outflow was collected continuously via an intrarectal cannula. Duodenal lipid perfusion produced a rapid duodenal relaxation (volume increased by 48 ± 18%; P < 0.01 vs basal). Gas infusion increased gas evacuation (184 ± 59 mL), and this was associated with a tonic contraction of the duodenum (R = 0.86; P < 0.01) that completely reverted the lipid‐induced duodenal relaxation (volume decreased by 42 ± 13%; P < 0.05). During sham infusion only 52 ± 28 mL of gas were evacuated (P < 0.05 vs gas infusion), and the duodenum remained relaxed due to the effect of lipids (0 ± 1% volume reduction; ns). In conclusion, intestinal gas propulsion and clearance is associated with a tonic contraction of the gut wall and reduced gut capacitance.