Guido N. J. Tytgat

Current concepts in the management of Helicobacter pylori infection--the Maastricht 2-2000 Consensus Report.

Significant progress and new insights have been gained in the 4 years since the first Maastricht Consensus Report, necessitating an update of the original guidelines. To achieve this, the European Helicobacter Pylori Study Group organized a meeting of specialists and experts from around the world, representatives from National Gastroenterology Societies and general practitioners from Europe to establish updated guidelines on the current management of Helicobacter pylori infection. The meeting took place on 21–22 September 2000.

Barrett's esophagus, development of dysplasia and adenocarcinoma

Barretts esophagus is considered to be a premalignant condition, and long-term surveillance seems mandatory with a careful search for dysplasia and carcinoma by means of multiple and repeated sets of biopsies. Reliable nonhistologic markers indicative of dysplasia or developing carcinoma are not yet available. To investigate development of dysplasia and carcinoma a prospective follow-up study was performed on 50 patients with Barretts esophagus, without carcinoma at entrance to the study, for a period of 1.5-14 yr (mean, 5.2 yr). Barretts epithelium was classified as fundic type, junctional or cardia type, or specialized columnar type. When classification in one of these three types was not possible because of lack of the characteristic features of the epithelia, the epithelium was classified as intermediate type. At entrance to the study, low-grade dysplasia was found in 6 patients, high-grade in 1 patient. During follow-up, dysplasia increased in frequency as well as in severity and was found almost exclusively in the specialized columnar- and intermediate-type epithelium. At the end of the observation period dysplasia had been found in 13 patients, in 10 scored as low-grade and in 3 as high-grade, and adenocarcinoma had developed in another 5 patients. This prospective study shows an incidence of carcinoma in Barretts esophagus of 1 in 52 patient-years, a 125-fold increase compared with the general Dutch population. A sequence of worsening of dysplasia with development of carcinoma was observed in specialized columnar and intermediate-type epithelium. The results of this study support the need for a long-term clinical, endoscopic, and histologic follow-up program in patients with Barretts esophagus.

Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones

BACKGROUND Endoscopic sphincterotomy (EST) for the removal of bileduct stones is associated with acute complications and a permanent loss of biliary-sphincter function. Endoscopic balloon dilation (EBD) causes less trauma to the biliary sphincter, but may be less effective in allowing stone removal. METHODS 218 consecutive patients with bileduct stones on endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. 202 who met all eligibility criteria were randomly assigned EST or EBD. The patients were observed in hospital for at least 24 h and followed up at 1 month and 6 months. Complications were classified by an expert panel unaware of treatment allocation and outcome. Analysis was done by intention to treat. FINDINGS After a single ERCP, all stones were removed from 92 (91%) of 101 patients assigned EST and 90 (89%) of 101 assigned EBD (p = 0.81); in nine of the latter, successful removal required additional EST. Mechanical lithotripsy was used to fragment stones in 31 EBD procedures and 13 EST procedures (p < 0.005). Early complications (before 15 days) occurred in 24 EST patients and 17 EBD patients (p = 0.29). One patient died of retroperitoneal perforation after EBD. Four patients had bleeding after EST. Seven patients in each group had pancreatitis. Complications during follow-up occurred in 23 EST patients and 18 EBD patients (p = 0.48). Acute cholecystitis was observed in seven EST patients and one EBD patient (p < 0.05). INTERPRETATION The success rate of EBD was similar to that of EST. We found there is no evidence of the previously suggested higher risk of pancreatitis with EBD and suggest that EBD is preferred in patients at risk of bleeding after EST. Preservation of biliary-sphincter function after EBD may prevent long-term complications and reduce the risk of acute cholecystitis during follow-up. This procedure is a valuable alternative to EST in patients with bileduct stones.

Diagnosis of Helicobacter pylori infection with a new non-in vasive antigen-based assay

Summary Background Helicobacter pylori is a common human pathogen implicated in certain gastrointestinal diseases. In the search for new non-invasive techniques to diagnose H pylori infection, we evaluated an EIA for H pylori antigen in stool (HpSA). Methods In a prospective multicentre study, stool specimens from 501 patients (276 men, 225 women; age range 17–88 years, mean 52) undergoing gastroscopy in 11 centres throughout Europe were tested with HpSA and the carbon-13-urea breath test. At endoscopy, four biopsy samples were taken for histology (haematoxylin and eosin) and H pylori detection (giemsa in both antrum and corpus, culture and rapid urease test). Patients were defined as positive for H pylori if histology (antrum, corpus, or both) and urease test were positive, or if culture was positive. Patients classified as having H pylori infection received an eradication regimen; 107 were reassessed 4 weeks after therapy. Findings Of 272 patients with H pylori infection by the predefined criteria, 256 were positive by HpSA (sensitivity 94·1% [95% CI 90·6–96·6]). Of 219 patients without infection, 201 were negative by HpSA (specificity 91·8% [87·3–95·1]). Interpretation The stool assay was a reliable and easy-to-use tool for diagnosis of H pylori infection. The test was accurate even shortly after treatment.

Helicobacter pylori : basic mechanisms to clinical cure 1996

Helicobacter pylori :basic mechanisms to clinical cure 2000 , Helicobacter pylori :basic mechanisms to clinical cure 2000 , مرکز فناوری اطلاعات و اطلاع رسانی کشاورزی

Effect of acid suppression on efficacy of treatment for Helicobacter pylori infection

Eradication of Helicobacter pylori from the stomach by triple therapy with bismuth, tetracycline, and metronidazole cures peptic ulcer disease. We investigated whether concomitant acid inhibition with omeprazole would improve the results of triple therapy. 108 consecutive patients with peptic-ulcer disease and biopsy-proven H pylori infection were randomised to 7 days of triple therapy with or without omeprazole 20 mg twice daily. Patients in the omeprazole-treated group were pretreated with 3 days of omeprazole. Eradication of H pylori was assessed by 10 endoscopic biopsies for urease test, histology, and culture 4-6 weeks after treatment. 53 of 54 (98.1%) patients treated with omeprazole were cured compared with 45 of 54 (83.3%) of those not treated (p = 0.02), a difference in efficacy of 14.8% (95% Cl 4.2-25.4%). Most side effects were mild and did not interfere with compliance; 105 patients (97.2%) finished treatment. Gastro-intestinal side effects were significantly fewer in the omeprazole group. We conclude that the addition of omeprazole to triple therapy improves efficacy, lessens side effects, and is sufficiently efficacious to obviate the need for a diagnostic test of cure in compliant patients.

Benign biliary strictures. Surgery or endoscopy

OBJECTIVE This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. SUMMARY BACKGROUND DATA Surgery is considered the treatment of choice, offering more than 80% long-term success. Endoscopic stenting has been reported to yield similar results and might be a useful alternative. METHODS In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Thirty-five patients were treated surgically and 66 by endoscopic stenting. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. RESULTS Mean length of follow-up was 50 +/- 3.8 and 42 +/- 4.2 months for surgery and endoscopy, respectively. Early complications occurred more frequently in the surgically treated group (p < 0.03). Late complications during therapy, occurred only in the endoscopically treated group. In 46 patients, the endoprostheses were eventually removed. Recurrent stricturing occurred in 17% in both surgical and endoscopic patients. CONCLUSIONS Surgery and endoscopy for benign biliary strictures have similar long-term success rates. Indications for surgery are complete transections, failed previous repairs, and failures of endoscopic therapy. All other patients are candidates for endoscopic stenting as the initial treatment.

Intestinal metaplasia and Helicobacter pylori: an endoscopic bioptic study of the gastric antrum.

To study the relationship between intestinal metaplasia and Helicobacter pylori infection, 2274 gastroscopic antral biopsies taken from 533 patients were examined. Overall, intestinal metaplasia was found in 135 patients (25.3%) and H pylori in 289 patients (54.2%). The prevalence of intestinal metaplasia and H pylori was age related, being more common in patients greater than or equal to 50 years compared with patients less than 50 years (intestinal metaplasia, p less than 0.001 and H pylori, p less than 0.05). Intestinal metaplasia was found more often in H pylori positive patients compared with H pylori negative patients (33.9% v 15.2%, p less than 0.001). The mean age of intestinal metaplasia positive patients who were also H pylori positive was 64 (13.3) years, whereas the mean age of intestinal metaplasia positive patients who were H pylori negative was 72 (14.7) years (p less than 0.005). The extent of intestinal metaplasia was not statistically different in the latter two groups. Although our data do not prove a causal relationship between H pylori infection and the histogenesis of intestinal metaplasia it is suggested that H pylori infection is an important factor in the development of intestinal metaplasia, which is generally recognised as a precursor lesion of intestinal type gastric carcinoma.

Long term results of pneumatic dilation in achalasia followed for more than 5 years

OBJECTIVE:We aimed to evaluate the long term therapeutic outcome in achalasia patients treated with pneumatic dilation, specifically focusing on those patients treated more than 15 yr ago.METHODS:All patients treated in our center whose records were available for review were asked to fill out a questionnaire assessing their degree of dysphagia, retrosternal pain, regurgitation, weight loss, and coughing during the night. The number of dilations was collected from the clinical records. The results of the treatment were classified into four different classes (excellent, good, moderate, poor). For those patients who had died, the cause of death was ascertained from the medical records or from the general practitioner.RESULTS:The questionnaires were distributed to 249 patients, 32 of whom had died. Of the 125 patients who completed the questionnaire, 81 (45 male and 36 female) were treated more than 5 yr ago. The mean follow-up was 12 ± 1 yr. The therapeutic success rate was 50%, obtained after a median of four dilations (interquartile range = 3–6). Of this cohort, 25 patients (18 male and seven female, aged 35–84 yr) were treated more than 15 yr ago (mean follow-up = 20.5 ± 0.5 yr). The median number of dilations was four (interquartile range = 3–7), with a therapeutic success rate of 40%. Two patients experienced a perforation, and seven were referred for surgery. Six patients out of 32 (19%) died of esophageal cancer.CONCLUSIONS:The long term success rate of pneumatic dilation is rather low, resulting in permanent successful treatment of achalasia in only 40–50% of patients. Achalasia is a risk factor for esophageal cancer.

Endoscopic ultrasonography for the evaluation of smooth muscle tumors in the upper gastrointestinal tract: an experience with 42 cases

Before surgery, 12 patients with suspected leiomyoma and 12 patients with suspected leiomyosarcoma were studied by endoscopic ultrasonography (EUS), computed tomography (CT), endoscopy, and barium swallow. The results were correlated with surgery and histology. Ten leiomyomas, one benign gastric ulcer, one carcinoid metastasis, eight leiomyosarcomas, two leiomyoblastomas, one mucus secreting adenocarcinoma, and one bronchial carcinoma were diagnosed. Eighteen additional patients suspected to have benign submucosal lesions by endoscopy and barium meal were treated non-surgically, and studied by EUS and CT. EUS was superior to other imaging techniques in the detection, staging, and follow-up of submucosal smooth muscle tumors because of clear imaging of the intramural abnormality and adjacent lymph nodes.