Paolo Mulè

Prevalence of peptic ulcer in Helicobacter pylori positive blood donors.

This study aimed to determine the importance of raised antibodies to Helicobacter pylori in an asymptomatic population. A total of 128 asymptomatic blood donors who were seropositive for H pylori and consented to endoscopy were investigated. These subjects were from a population of 1010 blood donors screened for antibodies to H pylori. A questionnaire was completed to determine if any subjects had complained of symptoms, and they subsequently had endoscopy. Altogether 121 of 128 were positive for H pylori by histology and urease test and/or culture and all 121 had chronic active gastritis on histology. Twenty five of these subjects had peptic ulcer (20 duodenal, five gastric), a further 21 had erosive duodenitis, and two were found to have gastric cancer. H pylori associated peptic ulcer disease and duodenitis occur more frequently than previously recognised and this suggests that H pylori infection, even if asymptomatic, is of far greater clinical relevance than originally thought.

Peptic ulcer disease and Helicobacter pylori infection

The most significant epidemiologic findings over this review period have been the isolation of Helicobacter pylori from feces and the results of the Eurogast Study firmly linking colonization by H. pylori to the development of gastric carcinoma. With respect to the mechanisms of pathogenesis, the purification of the cytotoxin and an investigation of its mode of action are also important. Similarly, the demonstration of the effect of H. pylori on somatostatin and gastrin-releasing peptide levels open further avenues of research. Numerous serologic tests are currently available, and an increasing use in screening procedures to reduce endoscopy workloads can be anticipated. The current regimen giving the highest eradication rate is bismuth, metronidazole, and tetracycline for 2 weeks, although the use of omeprazole with antibiotics is becoming more prevalent. Finally, the development of a vaccine is likely to be a major research area for the future.

Helicobacter pylori status, endoscopic findings, and serology in HIV-1-positive patients.

We have carried out a large prospective study of the frequency ofH. pylori infection and HIV-1 status in a community of ex-drug abusers including subjects with (N=210) and without (N=259) upper gastrointestinal symptoms, endoscopy and serology. Control groups were patients with upper gastrointestinal symptoms not at high risk of HIV-1 infection (N=219) and asymptomatic blood donors (n=322).H. pylori was present in 52% of symptomatic community resident having endoscopy and 55% of the control patients with symptoms but not at high risk of HIV-1 infection.H. pylori was less common in HIV-1-positive patients (40%) than those who were negative (66%;P<0.001). In patients with AIDS (33%), the frequency ofH. pylori infection was reduced compared to HIV-1-positive patients without AIDS (53%;P=0.05). All the residents with AIDS had upper gastrointestinal symptoms. In community residents, peptic ulcer was always associated withH. pylori infection. ByH. pylori serology, there was no difference in the frequency of infection in asymptomatic residents (56%) whether HIV-1 positive (55%) or HIV-1 negative (58%) compared with those residents with symptoms. Overall,H. pylori was less common in HIV-1-positive residents (49%) than those who were HIV-1 negative (61%;P<0.05). This difference was due mainly to the low frequency of infection in residents with AIDS (33%).H. pylori infection is common in HIV-1 positive patients, and only slightly reduced when compared with at-risk HIV-1-negative subjects. Peptic ulcer is associated withH. pylori in HIV-1 infection. Serology is a reliable marker ofH. pylori infection in HIV-1-positive patients, including those with advanced disease.

Gastric retention of sucralfate gel and suspension in upper gastrointestinal diseases

This study was designed to compare by scintigraphy the gastric retention of a new dosage form of sucralfate as gel (Gastrogel) with that of sulcralfate suspension in 25 patients with upper gastrointestinal symptoms referred for routine endoscopy. After endoscopy 4 subgroups were defined: macroscopically normal mucosa (n= 7), antral gastritis and/or erosions (n= 6), gastric ulcer (n= 6) and duodenal ulcer (n= 6). Each patient received either sucralfate gel or sucralfate suspension in equivalent doses (5 ml containing 1 g sucralfate). Both formulations were labelled with 111 MBq 99m Tc‐DTPA before administration. The mean value of t½ in the total group was significantly longer when patients were taking sucralfate gel (61.6 min) compared to sucralfate suspension (33.8 min) (P < 0.001). The mean values of t½ were significantly longer for sucralfate gel compared to sucralfate suspension also among the subgroups (macroscopically normal P < 0.02, antral gastritis P < 0.05, gastric ulcer P < 0.02 and duodenal ulcer P < 0.05). After 2 and 3 hours, the percentage residual activity in the gastric area was significantly higher following administration of sucralfate gel compared to sucralfate suspension. This study has shown that, compared to sucralfate suspension, sucralfate gel persists longer in the stomach of patients with gastritis and peptic ulcer.

Biliary Surgery without the Surgeon

Since the introduction of endoscopic retrograde cholangiopancreatography in the 1970s and of endoscopic sphincterotomy (EST) in 1974, endoscopic techniques for the diagnosis and therapy of biliary and pancreatic disorders have proliferated. Although some procedures have become part of routine practice, for example EST for postcholecystectomy bile duct stones and stent insertion for inoperable biliary strictures, the place of others is unclear at present and should be evaluated by prospective randomized clinical trials. The choice of either an endoscopic or a transhepatic approach for biliary disease is usually dictated by local expertise, but these should be regarded as complementary rather than competing techniques, and complex biliary problems should be managed jointly by the endoscopist, interventional radiologist and hepatobiliary surgeon.

Rupture of gastroesophageal varices DEA managing

This article on upper digestive tract bleeding, dedicated to the rupture of gastroesophageal varices, deals with the issues connected to their treatment in the Emergency Room. The authors refer to concepts of epidemiology, natural history, physiopathology of the oesophageal and gastric varices and elements of therapy, including both specific (stabilisation) and specific (pharmacology and endoscopy) aspects, based on the latest scientific evidence. The main interest of the ER doctor obviously involves the measures needed to achieve haemodynamic stabilisation and specific pharmacological therapy. Although the article does not examine the endoscopic and prophylactic measures taken by ER doctors, these are dealt with briefly for a better understanding of the issue as a whole.