L. Bozzola

Role of Helicobacter pylori Infection on Upper Gastrointestinal Bleeding in the Elderly (A Case-Control Study)

Nonsteroidal antiinflammatory drug (NSAID) useis known to be associated with a high incidence of uppergastrointestinal tract bleeding in the elderly. Theincreased prevalence of Helicobacter pylori (HP) infection, which also occurs with age, suggeststhat an interaction between NSAID use and HP infectionmay explain the higher incidence of ulcer complicationsin the elderly. The aim of the present study was to determine if a relationship existsbetween HP infection and NSAID use in elderly patientswith upper gastrointestinal bleeding. This was a case-control study on 146 elderly patients (73/group). The bleeding group consisted of 37 males and 36females (mean age 80.4 years, range 70-96) with symptoms(hematemesis, melena, anemia with loss of more than 3 ghemoglobin), and endoscopic stigmata of bleeding. The control group consisted of 73 age- andsex-matched patients with the same endoscopic diagnosisbut with no endoscopic stigmata of bleeding. NSAID usewas evaluated by interview at the time of endoscopy, and HP infection was confirmed in all cases byhistology and the rapid urease test. Statisticalanalyses were performed using the chisquare test andlogistic regression. In both groups, 46.57% of patients were affected with gastric ulcer, 36.98% withduodenal ulcer, and 16.43% with erosive gastritis. Thebleeding group had a significantly higher percentage ofNSAID users (53.42% vs 19.17%, P < 0.0001) and a lower percentage of HP-positive patients(47.94% vs 72.60%, P = 0.004). The NSAID use pattern wasas follows: occasional users (sporadic, as needed duringthe previous week): 53.8% of bleeding cases and 50% of controls; acute users (continuoustherapy for less than one month): 17.9% of bleedingcases and 28.5% of controls; and chronic users(continuous therapy for more than one month): 28.2% ofbleeding cases and 21.4% of controls. The logisticregression demonstrated that NSAID use was significantlyrelated to an increase risk of bleeding both in gastric(odds ratio: 4.98, 95% CI: 1.83-13.6) and duodenal ulcer patients (odds ratio: 10.2, 95% CI: 2.25-46.7) while HP-positivity presented a significantinverse relationship with bleeding only in subjects withgastric lesions (odds ratio: 0.20, 95% CI: 0.07- 0.55). NSAID use and HP infection were alsoshown to be independent, unrelated factors, with theoverall risk of bleeding in HP-positive NSAID usersidentified to be significantly less than in HP-negative NSAID users. In conclusion, in elderlypatients: (1) NSAID use increases the risk of uppergastrointestinal bleeding while HP infection wasassociated with a low risk for gastric bleeding; and (2)the two factors are independent variables, thereforethe HP-positive NSAID user has a lower risk than theHP-negative NSAID user.

Incidence of secondary Helicobacter pylori resistance to antibiotics in treatment failures after 1-week proton pump inhibitor-based triple therapies: a prospective study

BACKGROUND Antibiotic-resistant Helicobacter pylori strains are becoming increasingly prevalent, although it is not clear to what extent the new resistant organisms will spread. AIM To evaluate the incidence of secondary Helicobacter pylori resistance to metronidazole, clarithromycin and/or amoxycillin after one-week proton pump inhibitor based triple therapy failure in patients who were, before therapy infected with Helicobacter pylori strains susceptible to these antibiotics. PATIENTS AND METHODS Enrolled in the study were 97 consecutive Helicobacter pylori-positive subjects infected by Helicobacter pylori strains susceptible to metronidazole, clarithromycin and amoxycillin. Activity of tested antibiotics was determined by means of the E-test. Patients were treated for seven days with a proton pump inhibitor, omeprazole 20 mg twice daily or pantoprazole 40 mg once daily, plus clarithromycin 250 mg twice daily and metronidazole 250 mg four times daily; or with a proton pump inhibitor plus amoxycillin 1 g twice daily and clarithromycin 500 mg twice daily. Two months after completion of therapy, endoscopy and gastric biopsies for histology, rapid urease test and culture were repeated. RESULTS Four patients were dropped from the study Overall Helicobacter pylori cure rates expressed as both intention-to-treat and per-protocol analyses, were, respectively 80% (40/50) and 81.6% (40/49) with proton pump inhibitor, clarithromycin and metronidazole and 76.6% (36/47) and 81.8% (36/44) with proton pump inhibitor amoxycillin and clarithromycin. No significant differences were observed between the two treatments. Subjects in whom treatment failed were significantly younger and had less active ulcer than cured patients. Of treatment failures, 70.6% (12 out of 17 subjects) de veloped a secondary resistance to metronidazole (35.33% and/or clarithromycin (64.7%). Secondary antibiotic resistance occurred in 77. 8% of treatment failures treated with proton pump inhibitor, clarithromycin and metronidazole and in 62.5% of those treated with proton pump inhibitor, amoxycillin and clarithromycin. Considering all patients treated, the overall incidence of secondary metronidazole and/or clarithromycin resistance after therapy was reported in 12.9% of subjects (12 out of 93 treated patients). CONCLUSIONS Secondary Helicobacter pylori resistances to metronidazole and/or clarithromycin occurred in large percentages in patients with treatment failure after the one-week proton pump inhibitor-based triple therapies, proton pump inhibitor, clarithromycin and metronidazole and proton pump inhibitor, amoxycillin and clarithromycin. It is likely that new antibiotics or treatment strategies will be needed in the near future to successfully treat Helicobacter pylori infection.

Occult hepatitis B virus infection does not affect liver histology or response to therapy with interferon alpha and ribavirin in intravenous drug users with chronic hepatitis C

BACKGROUND the frequency and the impact of occult HBV infection in patients with chronic hepatitis C infection is still a matter of some controversy. OBJECTIVES our aim was to evaluate the prevalence of occult HBV infection and assess its impact on liver biochemistry, HCV viral titre, liver histology and on outcome of therapy in patients with chronic hepatitis C. STUDY DESIGN paired liver biopsies and serum samples were collected from 51 patients (84% IVDUS) with HBsAg negative chronic hepatitis C, and tested for HBV-DNA with nested PCR. Liver biopsies were further studied histologically, with morphometric analyses and immunostaining techniques. Twenty-five were treated with alpha Interferon and ribavirin and followed for at least 18 months. RESULTS HBV DNA was detected in 29.4% of liver tissue specimens and in only one (1.9%) serum sample. Three liver specimens were positive for surface gene, nine for core gene, three for both and none for the X gene. No significant difference in mean transaminase values, HCV viral titre, HCV genotype, or grading and staging and morphometric analysis was observed in patients with or without HBV DNA. Moreover, all 51 liver specimens were negative for both HBsAg and HBcAg. Sustained response to combination therapy was achieved in 40% of patients with and in 53% of patients without HBV DNA in the liver specimens (P=NS). CONCLUSIONS HBV DNA is frequently found in the liver of patients with chronic hepatitis C. However, the lack of any significant impact on HCV viral titre, liver enzymes, histological parameters and response to therapy, suggests that in most cases HBV DNA detected in the liver by PCR may be either an integrated or low level replicative form.

Efficacy of 7 day lansoprazole-based triple therapy for Helicobacter pylori infection in elderly patients.

Background: The prevalence of Helicobacter pylori increases with age. However, data regarding the effects of anti‐H. pylori treatments in the elderly are very scarce.

Ventricular late potentials, interstitial fibrosis, and right ventricular function in patients with ventricular tachycardia and normal left ventricular function

We examined 40 patients with ventricular tachycardia (VT) and no evidence of heart disease, and found a 50% prevalence of ventricular late potentials (VLPs) on the signal-averaged electrocardiogram. This finding was associated with a significantly higher content of fibrous tissue on endomyocardial biopsy and a lower right ventricular ejection fraction. Thus, VLPs are frequently found in idiopathic VT, are a marker for subclinical anatomic and functional abnormalities of the right ventricle, and may be associated with a worse outcome.

Cure of Helicobacter pylori infection in the elderly : effects of eradication on gastritis and serological markers

Background: Specific data on anti‐H. pylori treatments in elderly people are very scarce. The aim of the study was to evaluate in the elderly the efficacy of different anti‐H. pylori therapies and the behaviour of serum anti‐H. pylori antibodies, pepsinogen A and C, and PGA/PGC ratio induced by the anti‐H. pylori treatment.

The Long-Term Clinical Outcome of Elderly Patients with Helicobacter pylori-Associated Peptic Ulcer Disease

The objective of this study was to evaluate the long-term efficacy of Helicobacter pylori (HP) eradication treatment in elderly patients with HP-associated peptic ulcer. A total of 56 subjects, 25 affected with gastric ulcer (GU, 9 males, 16 females, mean age 77.8 years, range 67–93) and 31 with duodenal ulcer (DU, 19 males, 12 females, mean age 76.5 years, range 65–87) were confirmed to be HP-positive by gastric histology and the rapid urease test. All patients were then consecutively treated with omeprazole for 4 weeks plus one or two antibiotics for 1 week as anti-HP treatment. Clinical checkups were then performed every 3 months for 1 year for the evaluation of symptoms and clinical recurrences. Endoscopy with gastric biopsies was repeated after 1, 3 and 12 months for the evaluation of ulcer healing, HP infection and chronic gastritis activity. Statistical analysis was performed by means of the Student t test for unpaired data, the Fisher exact test (two-tailed), and the McNemar χ2 test. After 4 weeks of treatment, endoscopy confirmed healing of the ulcer in all patients, regardless of the treatment used to cure HP infection. Two months after the end of therapy, a total of 44 patients were HP-negative and 12 patients were still HP-positive. During the 1-year follow-up period 1/44 (2.2%) of the HP-eradicated patients and 5/12 (41.6%) of the still HP-positive patients suffered relapses (p = 0.001): the difference between the two groups remained statistically significant when patients were divided into the subgroups, GU (p = 0.01) and DU (p = 0.04). Two months after the end of therapy, there was still a significant reduction of symptoms both in HP-eradicated (p < 0.0000) and in HP-positive (p = 0.002) patients. After 1 year, however, there was a significantly decreased symptomatology only in HP-eradicated subjects (p < 0.0000) and not in patients still HP-positive. After both 2 months and 1 year of follow-up, chronic gastritis activity demonstrated a significant improvement only in HP-eradicated patients (p = 0.0000). In conclusion, the eradication of HP infection significantly improved the long-term clinical outcome of peptic ulcer disease in the elderly, reducing the recurrences of GU and DU, the patient’s symptomatology and the histological signs of chronic gastritis activity. The cure of HP infection is, therefore, strongly recommended in elderly patients with HP-associated peptic ulcer disease.

H. pylori infection in HIV-positive patients : A serohistological study

Sixty-seven consecutive patients infected withthe human immunodeficiency virus (HIV-1), 72% of whichwith overt AIDS, were examinated by upper endoscopy dueto various indications and evaluated for the prevalence of H. pylori infection. Theinfection was studied by performing both histologicalexamination of gastric biopsies and serological testingfor anti-H. pylori IgG antibodies. The H. pyloriprevalence rate was 55% in histology; no significantdifferences were observed in HIV-infected subjects andthose with overt AIDS (52% vs 63%, respectively; P =NS). Positive histological testing appeared to bedirectly related to the peripheral CD4+lymphocyte count (minimum rates of 43% were detected in6 patients with CD4+ < 100 ×106/liter and maximum rates of 78% inpatients with CD4+ > 200 ×106/liter, respectively; P < 0.05) and inversely related to the frequency ofantibiotic treatments performed over the six monthsprior to endoscopy. Low CD4+ counts were alsoapparently associated with low-grade H. pyloriinfection. Serological testing was positive for anti-H. pylori IgGantibodies in 39% of patients; compared to histology,serology displayed a sensitivity of 57% and aspecificity of 81%. The discrepancy between histologicaland serological positive results for H. pylori wasnoted to be higher in the more advanced phases of HIVinfection. Based upon our results, the serologicaltesting for anti-H. pylori IgG antibodies seems to require cautious interpretation in HIV-positivepatients.

Cure of Helicobacter pylori infection in elderly patients: comparison of low versus high doses of clarithromycin in combination with amoxicillin and pantoprazole

Advancing age may influence clarithromycin’s pharmacokinetics. No studies have yet compared the effects of different dosages of clarithromycin in combination with a proton pump inhibitor and amoxicillin in elderly patients.

Influence of Helicobacter pylori infection on severity of oesophagitis and response to therapy in the elderly

BACKGROUND The prevalence both of Helicobacter pylori infection and oesophagitis is higher in the elderly, than in adult and young populations. However the relationship between Helicobacter pylori infection and the clinical behaviour of oesophagitis has not yet been clarified. AIM To evaluate the influence of Helicobacter pylori infection on the severity and clinical outcome after treatment of oesophagitis in elderly patients. METHODS A total of 271 elderly patients (134 male, 137 female, mean age = 79.2 years, range 65-96) with grade 1 to 3 oesophagitis were studied. At baseline, the patients were divided into 3 groups according to Helicobacter pylori infection: Group 1 = 88 Helicobacter pylori-negative patients; Group 2 = 59 Helicobacter pylori-positive patients and Group 3 = 124 Helicobacter pylori-positive patients who underwent a one-week proton pump inhibitor-based triple therapy for the eradication of Helicobacter pylori infection. All patients were treated with proton pump inhibitors for two months; patients in Group 3 were also treated for one week with proton pump inhibitors plus two antibiotics. After two months, endoscopy and histology were repeated. RESULTS At baseline, 32.5% of patients were Helicobacter pylori-negative and 67.5% were Helicobacter pylori-positive. No baseline differences in severity of oesophagitis were found between Helicobacter pylori negative and positive patients. After proton pump inhibitor therapy, the complete resolution of oesophagitis was observed in 80.7% of Group 1, 76.3% of Group 2 and 75.8% of Group 3 (p=ns). Dividing patients also according to the severity of oesophagitis, no difference in healing rates between the three Groups were observed. CONCLUSIONS In this elderly population, Helicobacter pylori infection did not influence the severity of oesophagitis at baseline or the response to short-term treatment with proton pump inhibitors. Furthermore, Helicobacter pylori eradication therapy did not influence the healing rate of oesophagitis.