Ashok N. Shah

Prevalence of Helicobacter pylori in Peptic Ulcer Patients in Greater Rochester, NY: Is Empirical Triple Therapy Justified?

Objectives:Among patients with peptic ulcer disease, the prevalence of Helicobacter pylori has been reported to range from 80% to 90%. Thus empirical cost-effective therapy has been suggested. We surveyed patients with peptic ulcer disease in Rochester, NY.Methods:From two teaching hospitals all patients who had duodenal ulcers (DU) and/or gastric ulcers (GU) on esophagogastroduodenoscopy (EGD) with antral biopsy for histology for H. pylori and for rapid urease (CLO) test were included in the study. We examined a total of 160 patients with DU and 145 patients with GU, age range 18–92 yr, obtaining clinical data, race, medication profile, and history of use of nonsteroidal antiinflammatory drugs (NSAIDs). An ulcer was defined if the lesion with loss of mucosal integrity was ≥ 0.5 cm, with apparent depth. H. pylori was considered present if CLO test and/or histology were positive for H. pylori. To confirm the reliability of nonuse of NSAIDs, we randomly checked blood samples of 90 such patients from the ambulatory clinic for the presence of salicylates. To identify the sensitivity of the CLO test, we performed a serology test for H. pylori antibody in 100 subjects to compare the CLO test results. Also, 500 CLO test results were compared to the histology results for H. pylori.Results:Among 160 DU patients, 16 were NSAID users with negative H. pylori and excluded from the prevalence study. Of the remaining 144 patients with DU, H. pylori was present in 88 patients (61%). When these data were analyzed according to race, H. pylori was present in 54 (52%) of 104 whites compared to 34 of 40 (85%) nonwhites (blacks, Hispanics, Asians) (p < 0.01). Among 145 GU patients 18 were NSAID users with negative H. pylori and excluded from the prevalence analysis. Of the remaining 127 patients with GU, H. pylori was present in 87 patients (61%). Among them, H. pylori was present in 46 of 87 (53%) whites, whereas 31 of 40 nonwhites (78%) were H. pylori-positive (p < 0.01). Antral histology and CLO test for H. pylori were in agreement in 92% of cases. Serology and CLO test for H. pylori were in agreement in 87% of cases. None of the randomly screened patients, including 16 ulcer patients with negative H. pylori, showed presence of salicylate in blood.Conclusion:In greater Rochester, NY, where the majority of our patients with EGD were whites, the prevalence of H. pylori among ulcer patients was lower compared to other regions, particularly among whites. This suggests that an additional causative factor or factors for peptic ulcers may be present. Hence, empirical antibiotic therapy of ulcer patients without confirming the presence of H. pylori may not be justified.

Infliximab for refractory ulcerative colitis

Eight patients with active ulcerative colitis (UC), refractory to usual combination medical therapy, were treated with a single i.v. dose of chimeric monoclonal antibody to recombinant human tumor necrosis factor α; many of these patients were scheduled for surgical colectomy because of their active disease. All patients responded extremely well to a single 5 mg/kg infusion of infliximab, with marked improvement after the infusion clinically, colonoscopically, and histologically on colonic biopsy. There were no significant complications or side effects; mean duration of remission has not been determined because none of the patients have relapsed. Infliximab appears to be a potent agent for inducing remission in refractory patients with ulcerative colitis.

Reflux Esophagitis: Effect of Oral Bethanechol on Symptoms and Endoscopic Findings

We ascertained the effectiveness of oral bethanechol on symptoms and endoscopic evaluation of reflux esophagitis in a double-blind controlled study. Forty-four patients were treated with either 25-mg bethanechol tablets or placebo, each given four times daily for 4 weeks, in addition to conventional medical therapy. Both therapies significantly decreased symptoms as well as endoscopic lesions; however, endoscopic improvement was significantly better in the bethanechol-treated group. Bethanechol therapy resulted in complete endoscopic healing in 10 of 22 cases, whereas only three of 22 patients in the control group had such healing. No worsening of endoscopic lesions was seen in either group. Our study indicates that bethanechol is an effective drug offering advantages over conventional antacid therapy in the treatment of reflux esophagitis.

Regression of Fibrosis in Chronic Hepatitis C After Therapy with Interferon and Ribavirin

Interferon and ribavirin decrease necroinflammation in chronic hepatitis C with or without virological clearance; however, reversibility of fibrosis remains to be established. We evaluated the effect of combination therapy on virological and liver histopathological outcomes in 52 naïve patients and 79 patients unresponsive to interferon monotherapy with predominantly genotype 1 chronic hepatitis C. One hundred four patients completed interferon and ribavirin treatment after 24–48 weeks. Fifty-six paired liver biopsies (mean biopsy interval 28 months) were assessed by the Ishak score. Sustained virological responses were 37% in naïve patients and 22% in re-treated patients. In virological responders and nonresponders, fibrosis and necroinflammation scores decreased by −0.91 (P =0.04) and −0.5 (P =0.02) and by −2.8 (P =0.001) and −0.66 (P =0.06), respectively. Interferon and ribavirin had greater benefit on fibrosis when associated with clearance of HCV RNA. Treatment strategies in virological nonresponders who show fibrosis regression should include consideration of maintenance therapy, if such treatment eventually proves to benefit histological outcomes.

A newly recognized entity : Intraductal 'oncocytic' papillary neoplasm of the pancreas

Intraductal papillary-mucinous tumors of the pancreas are increasingly recognized, and their characteristic endoscopic and radiological features are well reported in the literature in recent years. Oncocytic features in these tumors are uncommon and unrecognized. Intraductal oncocytic papillary neoplasm is a distinct pancreatic tumor and is a recently recognized entity. We report a case of a 69-yr-old patient who presented with symptoms mimicking pancreatitis, resulting in delay in the diagnosis of her pancreatic tumor. She underwent a successful Whipples procedure and subsequently has remained well. The resected specimen showed an intraductal oncocytic papillary-mucinous neoplasm. The entity is new and the literature information is inadequate at present to judge the biological behavior of this tumor. We discuss this recently recognized entity.

Celecoxib associated esophagitis: review of gastrointestinal side effects from cox-2 inhibitors.

BACKGROUND With the extensive use of COX-2 inhibitors to treat inflammatory and pain syndromes, gastrointestinal adverse effects are being increasingly observed. CASE REPORT An 87-year-old white man with chronic peptic esophageal stricture presented to us with dysphagia and odynophagia. The patient was taking Celecoxib for 5 months for trigeminal neuralgia. An upper endoscopy revealed severe desquamative esophagitis. Celecoxib was discontinued and the patient was started on esomeprazole. The patients symptoms improved in 1 month. Three months later, EGD revealed complete healing of the esophageal mucosa. DISCUSSION Because recent studies have shown that COX-2 inhibitors are similar to NSAIDs with regards to absorption, in contrast to premarketing trials, extensive use of COX-2 inhibitors is likely to demonstrate gastrointestinal adverse effects similar to those caused by traditional NSAIDs. Our patient had severe esophagitis caused by Celecoxib and aggravated by reflux of achlorhydric gastric contents after dilatation of the stricture. SUMMARY We report for the first time severe esophagitis caused by the COX-2 inhibitor Celecoxib.

Adenocarcinoma and Barrett's esophagus following surgically treated achalasia

phy has been performed previously in this disease. Yellin and Donovan12 found dilated bile ducts and biliary stones in four of five cases who had ERCP. The greatly dilated common bile duct and common hepatic duct, both filled with biliary mud and stones, are typical. The absence of mature worms may have been due to secondary bacterial infection which appears to kill the organism.10 Eggs of C. sinensis were found within the stones, and it is possible that they formed as a nidus for stone formation. 13 Our patient was given antibiotic prophylaxis prior to edoscopic cholangiography, since cholangitis has been induced by such procedures.14 Therapy has been directed toward establishment of adequate drainage of the biliary system, usually by choledochoduodenostomy.15 The size of the anastomosis must be large enough to allow the passage of stones, as a small anastomotic opening is associated with a high incidence of postoperative cholangitis.15 An apparent toxic effect of sodium diatrizoate (Hypaque) on the C. sinensis has been observed. Irrigation of the biliary tree with contrast agent has been suggested as a method of eradicating the organisms.12 In our patient, this was very effective in removing the biliary mud which could not be grasped with forceps or the stone retrieving basket, or be retrieved by means of a balloon. Clearly, this method would only be successful in the presence of a choledochoenterostomy with an anastomosis large enough to allow the passage

Sustained improvement in health-related quality of life measures in patients with inflammatory bowel disease receiving prolonged anti-tumor necrosis factor therapy

The aim of this study was to determine whether the effects of prolonged therapy (≥1 year) with anti‐tumor necrosis factor (TNF) agents were sustained on the health‐related quality of life (HRQoL) in patients with inflammatory bowel disease (IBD).

Infliximab is an effective therapeutic agent for ulcerative colitis

Common wisdom has been that ulcerative colitis and Crohns disease are two different diseases and that they are at least partially mediated by different subsets of immune system dysfunction. Recently studies have shown significant benefit from infliximab in patients with Crohns disease. We employed infliximab for treating patients with ulcerative colitis (UC) refractory to maximal medical therapy. Of seventeen consecutive patients with UC; involving entire colon in 10 and left colon in 17, 8 hospitalized patients and 9 patients treated at ambulatory setting received intravenous administration of infliximab in a dose of 5 mg|[sol]|kg once in 16 patients and twice in 1 patient in 5 days. Sixteen exhibited dramatic and significant improvement clinically, endoscopically and histologically. Thus only 1 of 8 hospitalized patients failed to respond to have total colectomy. None of all 9 patients treated at ambulatory setting required hospitalization. Dramatic clinical, endoscopic and histological improvement occurred in 6 days in most of these patients and the improvement lasted 2 to 10 months. In all 8 Prednisone dependent patients who were followed for 5 months or longer after infliximab, Prednisone therapy was no longer required. No significant side effect related to infliximab was observed. We conclude that infliximab is an effective agent for inducing remission of patients with UC as it is for Crohns disease patients. Our observations strongly suggest that the treatment avoids surgical intervention in most of hospitalized UC patients and minimizes the number of UC patients for hospitalization. Large multi-center trials are warranted.

Sunflower seed rectal bezoar in an adult

A 61-year-old man with a history of mild mental retardation, seizure disorder, type 2 diabetes mellitus, and benign prostatic hyperplasia, presented to his primary care doctor with a 3-day history of constipation, episodes of painful, watery diarrhea, abdominal pain, and inability to empty his bladder. The patient admitted to having eaten a large bag of unshelled sunflower seeds 5 days earlier. He denied fever, chills, nausea, and vomiting. Office physical examination disclosed a sharp, thorny mass at the anal verge. Several sunflower seeds were extracted. Digital rectal disimpaction, however, was limited by severe pain, and the patient was hospitalized. On admission abdominal plain x-rays (Fig. 1) showed no free air or air-fluid levels. A rectal bezoar characterized by an ill-defined mass was evident in the distal sigmoid and rectal ampulla. Another attempt at digital disimpaction was unsuccessful because of pain. The patient was given several mineral oil enemas in an attempt to lubricate the bezoar; however, it was not possible to administer the mineral oil proximal to the sunflower seed mass because of pain and a concern about perforation. Mineral oil was also given by mouth. The patient remained unable to urinate, and a urinary bladder catheter was placed. Only a few seeds were passed in a 24-hour period. After adequate sedation was achieved with midazolam and propofol, flexible sigmoidoscopy revealed a large, thorny, irregular aggregation of sunflower seeds that retained its shape even when probed with the tip of the endoscope (Fig. 2). Manual disimpaction was performed and many sunflower seeds, shelled and unshelled, were retrieved (Fig. 3). Several hours after the procedure the patient developed a fever. Treatment with ampicillin, gentamicin, and metronidazole was started because of concern for bowel perforation; however, urinary cultures indicated a urinary tract infection, and antibiotics were changed to ciprofloxacin. An attempt was made to combine mineral oil by mouth and per rectum, along with polyethylene glycol by mouth to flush out the remaining sunflower seeds. On the following day, digital examination of the anal