Hsiu Chi Cheng

Resistance to metronidazole, clarithromycin and levofloxacin of Helicobacter pylori before and after clarithromycin‐based therapy in Taiwan

Background and Aim:  Clarithromycin‐based triple therapy has been commonly applied as the first‐line therapy for Helicobacter pylori eradication. Levofloxacin could serve as an alternative in either first‐line or second‐line regimens. This study surveyed the prevalence of levofloxacin resistance of H. pylori isolates in naive patients and in patients with a failed clarithromycin‐based triple therapy.

H. pylori eradication prevents the progression of gastric intestinal metaplasia in reflux esophagitis patients using long-term esomeprazole.

OBJECTIVES:This study aimed to determine whether Helicobacter pylori eradication limits the progression of precancerous changes, manifested as intestinal metaplasia (IM), in patients with reflux esophagitis using long-term esomeprazole.METHODS:Three hundred twenty-five reflux esophagitis patients were enrolled and randomly assigned to (i) the H. pylori–positive eradication group receiving 1-week triple therapy (n=105); (ii) H. pylori–positive non-eradication controls (n=105); and (iii) H. pylori–negative controls (n=115). All the patients received continuous esomeprazole until sustained symptomatic response, and when possible, shifted to on-demand therapy (ODT) thereafter. Serial gastroscopy was scheduled on enrollment and at the end of the first and second years to assess the prevalence and progression or regression of gastric atrophy (AT) and IM.RESULTS:There were 93 patients in the H. pylori–eradication group, 83 in the non-eradication controls, and 100 in the negative controls to complete the study. The negative controls had no progression of AT and IM during follow-up. For the H. pylori–positive eradication group, there was significant regression of AT and IM during follow-up (P<0.05). In the H. pylori–positive non-treated controls, the prevalence rates of AT and IM were significantly greater on the second year than on enrollment (P<0.05). During the second-year follow-up, the patients in the eradication group achieved more regression and less development of AT and IM than did the non-eradication controls (P<0.001).CONCLUSIONS:In patients using long-term esomeprazole for reflux esophagitis, screening for and eradicating H. pylori infection are necessary in order to limit the progression or cause the regression of gastric precancerous changes.

The Efficacy of High- and Low-Dose Intravenous Omeprazole in Preventing Rebleeding for Patients with Bleeding Peptic Ulcers and Comorbid Illnesses

This study sought to determine if high-dose omeprazole infusion could improve the control of rebleeding in patients with comorbid illnesses and bleeding peptic ulcers. After achieving hemostasis by endoscopy, 105 patients were randomized into high-dose (n = 52) and low-dose (n = 53) groups, receiving 200 and 80 mg/day omeprazole, respectively, as a continuous infusion for 3 days.Thereafter, oral omeprazole, 20 mg/day, was given. The cumulative rebleeding rates comparatively rose in both groups (high-dose vs. low-dose group), beginning on day 3 (15.4% vs. 11.3%), day 7 (19.6% vs. 20%), and day 14 (32.7% vs. 28.9%), until day 28 (35.4% vs. 33.3%), and were not significantly different between the two groups (P > 0.50). Multiple logistic regression confirmed that a serum albumin level < 3 g/dL was an independent factor associated with rebleeding (P = 0.002). For patients with comorbidities, 3-day omeprazole infusion, despite increasing the daily dose from 80 to 200 mg, was not adequate to control peptic ulcer rebleeding.

Long-term Outcome of Pyogenic Liver Abscess : Factors Related With Abscess Recurrence

Background/Aims Long-term surveillance of pyogenic liver abscess remains unavailable. We thus aimed to identify the recurrence rates of pyogenic liver abscess among various etiologies and pathogens, and to elucidate the factors related with this recurrence. Methods Six-hundred and one patients with pyogenic liver abscess were prospectively enrolled to observe abscess recurrence during a mean follow-up period of up to 6.06 years. On the basis of the etiology of the initial abscess, patients were divided into different subgroups as follows: there were 152 (25.3%) patients classified as cryptogenic, 229 (38.1%) with diabetes mellitus, 144 (24%) with underlying biliary tract disease, and 76 (12.6%) with other organic diseases or mixed subgroups. Results The cumulative recurrence rates of pyogenic liver abscess were lower in both the cryptogenic (2.0%) and diabetic (4.4%) groups than in the underlying biliary tract disease (23.8%) group (log-rank test, P<0.001). The diabetic group had a higher rate of Klebsiella pneumoniae infection and a lower rate of Escherichia coli infection than the biliary tract group (P<0.001). For patients infected with K. pneumoniae, the recurrence rate of pyogenic liver abscess was as low as that of the diabetes and the cryptogenic groups (P>0.05). Conclusions Pyogenic liver abscess is more commonly recurrent in patients with underlying biliary tract disease. Irrespective of diabetic status or cryptogenic etiology, the recurrence of K. pneumoniae-infected liver abscess is low in the long-term.

The Impact of Body Mass Index on the Application of On-Demand Therapy for Los Angeles Grades A and B Reflux Esophagitis

BACKGROUND AND AIMS:Patients with Los Angeles grade A or B reflux esophagitis (RE-AB) can potentially be switched from active-phase therapy to on-demand esomeprazole as maintenance therapy. Body mass index (BMI) correlates significantly with reflux symptoms. We investigated whether BMI affects the efficacy of esomeprazole in active-phase or subsequent on-demand therapy.METHODS:Three hundred fifty patients with RE-AB were prospectively enrolled to receive an 8-wk course of esomeprazole (40 mg/day) as active-phase therapy. Based on the daily severity of acid regurgitation and heartburn, the cumulative proportions of patients with sustained symptomatic response (SSR), defined as free from symptoms for the last 7 days, were compared among different BMI groups (control: BMI <25 kg/m2, overweight: BMI 25–30 kg/m2, obese: BMI >30 kg/m2). In patients who had achieved SSR by week 8, on-demand therapy for 2 months was started. The number of 40-mg esomeprazole tablets used per 4-wk period was recorded.RESULTS:SSR rates were lower in both the overweight and obese groups than in the control group (P < 0.001). During on-demand therapy, the mean number of tablets used per 4-wk period was lower in the control group than in either the overweight or the obese group (13.2 vs 15.3 or 16.2, P < 0.05). The failure rate of on-demand therapy increased with increasing BMI—2.4%, 5.3%, and 14.2%, respectively, for the control, overweight, and obese groups (P = 0.002).CONCLUSION:For RE-AB, a higher BMI decreases the rate of SSR after 8-wk of esomeprazole therapy, and increases the need for medication and the failure rate of on-demand therapy.

Levofloxacin‐Containing Triple Therapy to Eradicate the Persistent H. pylori after a Failed Conventional Triple Therapy

Objective:  To identify the optimal dosage of levofloxacin to eradicate persistent Helicobacter pylori when triple therapy with amoxicillin, clarithromycin, and omeprazole fails.

Gender difference of circulating ghrelin and leptin concentrations in chronic Helicobacter pylori infection.

Background:  Both ghrelin and leptin are important appetite hormones secreted from the stomach. We examined whether demographic background, Helicobacter pylori infection, or its related gastritis severity could be associated with circulating ghrelin and leptin levels.

H. pylori cagL amino acid sequence polymorphism Y58E59 induces a corpus shift of gastric integrin α5β1 related with gastric carcinogenesis

We tested whether cagL amino acid sequence polymorphisms of Helicobacter pylori correlated to clinico‐histological outcomes and gastric α5β1 integrin expressions. One hundred forty five patients with H. pylori infection and 47 noninfected controls were enrolled to check gastric integrin α5β1 intensities topographically. The collected isolates were screened for cagL‐genotype by polymerase chain reaction (PCR), and assessed for amino acid sequence polymorphisms using sequence translation. Our H. pylori isolates were predominantly (98.6%) cagL‐genopositive, 95.8% of which had the RGD motif in their amino acid sequences. The isolates from the gastric cancer (GCA) patients indicated a higher rate of amino acid sequence polymorphisms—Y58 and E59—than those of the non‐GCA patients (P < 0.05). The polymorphisms as Y58E59 noted with increased risk of GCA up to 4.6‐fold (95%CI: 1.8–11.9). H. pylori‐infected patients had higher integrin α5β1 than noninfected patients (P < 0.05). Furthermore, cagL‐Y58E59 H. pylori infection predisposed an upward shift in integrin α5β1 (P = 0.007) in the corpus, leading to more severe corpus chronic inflammation (P < 0.05). H. pylori CagL amino acid polymorphisms like Y58E59 correlate with a higher risk of GCA, and may regulate a corpus shift of gastric integrin α5β1 to lead to severe corpus gastritis during gastric carcinogenesis. Mol. Carcinog.

Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities

BACKGROUND Patients with comorbidities have an increased risk of ulcer rebleeding, especially within the 28 days after endoscopic therapy. Omeprazole infusion can prevent rebleeding after endoscopic therapy in patients with peptic ulcer bleeding. However, the optimal duration is uncertain, especially for those patients with comorbidities. OBJECTIVE To determine whether prolonged low-dose intravenous omeprazole could reduce rebleeding for patients with comorbidities. DESIGN A prospective randomized control study. SETTING National Cheng Kung University, Tainan, Taiwan. PATIENTS A total of 147 patients with comorbidities and peptic ulcer bleeding controlled by endoscopic hemostasis were enrolled. INTERVENTIONS The enrolled patients were randomized into either the 7-day low-dose group or the 3-day high-dose group, who received 3.3 mg/h or 8 mg/h continuous omeprazole infusion, respectively. After omeprazole infusion, oral esomeprazole 40 mg every day was given. MAIN OUTCOME MEASUREMENTS To compare the rebleeding rates within 28 days after gastroscopy between the 2 study groups. RESULTS The 7-day cumulative rebleeding rate was similar between the 2 groups (9.5% vs 9.7%, P > .05), but the 7-day low-dose group had a lower risk of rebleeding between the 8th and 28th day compared with the 3-day high-dose group (0% vs 10.7%, P = .03; relative risk, 0.52 [95% CI, 0.43-0.63]). The Kaplan-Meier curves confirmed that the 7-day low-dose group had a significantly higher cumulative rebleeding-free proportion between the 8th and 28th day than the 3-day high-dose group (P = .02, log-rank test). CONCLUSIONS In Asian patients, prolonged low-dose omeprazole infusion for 7 days may reduce peptic ulcer rebleeding during the first 28 days in patients with comorbidities.

Double-dosed pantoprazole accelerates the sustained symptomatic response in overweight and obese patients with reflux esophagitis in Los Angeles grades A and B.

OBJECTIVES:Body mass index (BMI) in the range defined as overweight or obese adversely decreases the sustained symptomatic response (SSR) to proton pump inhibitors for patients with reflux esophagitis of Los Angeles grade A or B (RE-AB). We thus investigated whether double-dosed pantoprazole can accelerate SSR in such patients.METHODS:A total of 200 overweight or obese patients with RE-AB were evenly randomized into a double-dosed group (receiving 8-week pantoprazole 40 mg twice daily) or a standard-dosed control group (receiving 8-week pantoprazole 40 mg per day and one blank tablet at night). In each patient, demographic factors and the genotype of S-mephenytoin 4′-hydroxylase (CYP2C19) were checked and defined as poor metabolizer (PM), or homologous extensive metabolizer (HomoEM), or heterologous extensive metabolizer (HeteroEM). The cumulative proportions of patients with SSR were compared during the 8-week period.RESULTS:Both intention-to-treat and per-protocol analyses disclosed that the rates of SSR were higher in the double-dosed group than in the standard-dosed group from week 4 (P=0.005) until week 8 (P=0.01). While using standard-dosed pantoprazole, PMs had better rates of SSR during the 8-week period than both HomoEMs and HeteroEMs (P<0.05). By using double-dosed pantoprazole, the cumulative rates of SSR were improved as early as week 4 for both HomoEMs and HeteroEMs (P<0.005, log-rank test).CONCLUSIONS:For RE-AB in overweight and obese patients, double-dosed pantoprazole effectively accelerates the SSR, especially for those with CYP2C19 genotypes as HeteroEM or HomoEM. Accordingly, it offers an earlier shift into on-demand pantoprazole for RE-AB patients with high BMI.