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One week of treatment with esomeprazole-based triple therapy eradicates Helicobacter pylori and heals patients with duodenal ulcer disease.

Background Proton pump inhibitor (PPI) monotherapy is commonly continued for 3 weeks after Helicobacter pylori eradication with PPI-based triple therapy regimens to ensure duodenal ulcer (DU) healing. This randomized, double-blind, multicentre study evaluated whether only 1 week of triple therapy with the new PPI esomeprazole was sufficient to ensure high rates of ulcer healing and H. pylori eradication. Methods A total of 446 H. pylori-positive patients with active DU received twice daily treatment with esomeprazole 20 mg (n = 222) or omeprazole 20 mg (n = 224) in combination with amoxicillin 1 g and clarithromycin 500 mg for 1 week (EAC and OAC, respectively). Patients in the OAC group then received 3 weeks’ monotherapy with omeprazole 20 mg once daily; those treated with EAC received placebo. Ulcer healing was assessed by endoscopy on completion of therapy and H. pylori status was assessed by 13C-urea breath testing and histology 4–6 weeks later. Results Ulcer healing rates (95% CI) for intention-to-treat and per-protocol populations were: EAC + placebo 91% (87–95%) and 94% (90–97%); OAC + omeprazole 92% (88–95%) and 96% (92–98%). Corresponding H. pylori eradication rates were: EAC + placebo 86% (81–90%) and 89% (84–93%); OAC + omeprazole 88% (83–92%) and 90% (85–93%). Both eradication regimens were well tolerated, and patient compliance was high. Conclusions A 1-week regimen of esomeprazole-based triple therapy is sufficient for DU healing and H. pylori eradication in patients with DU disease.

Occurrence of Metabolic Osteopathy in Patients with Chronic Pancreatitis

Introduction: Chronic pancreatitis is an inflammatory disease manifested by maldigestion and, in an advanced stage, by malabsorption. The aim of our research was to monitor the occurrence of metabolic osteopathies (osteopenia, osteoporosis and osteomalacia) in patients with chronic pancreatitis. Patients and Methods: The group consisted of 73 patients (17 women and 56 men) in different stages of chronic pancreatitis. In all patients we determined serum concentrations of Ca, P, 25-OH vitamin D, 1,25-(OH)2 vitamin D, alkaline phosphatase and its bone isoenzyme. Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA) in the lumbar spine (L1–L4) and in the proximal femur. When bone pathology was identified by DXA, we determined the other to exclude other causes of secondary osteopathy and the 24-hour loss of calcium and phosphorus in the urine. Results: Osteopathy was found in 39% of patients, i.e. osteopenia in 26%, osteoporosis in 5% and osteomalacia in 8% of cases. Conclusion: The occurrence of relatively high percentages of metabolic osteopathies in patients with chronic pancreatitis may correlate, namely in advanced stages of the disease, with the malabsorption of vitamin D to the enterohepatic circulation. In initial forms of pancreatitis, it is not possible to exclude progression of osteopathy due to changes of the intestinal flora, with disturbance of vitamin D absorption to the intestinal mucosa.

Expression of COX-2 is associated with accumulation of p53 in pancreatic cancer: analysis of COX-2 and p53 expression in premalignant and malignant ductal pancreatic lesions.

Objectives Cyclooxygenase-2 (COX-2) and tumor suppressor p53 are molecules that are linked to the oncogenesis of pancreatic cancer. COX-2 represents a key modulatory molecule in inflammation and carcinogenesis, and is known to be implicated in the positive regulation of growth and tumorigenesis. Abnormal expression of p53 is common in many human neoplasms including pancreatic cancer. Recent studies demonstrated functional interactions between p53 and COX-2. The p53-dependent upregulation of COX-2 was proposed to be another mechanism by which p53 could abate its own growth-inhibitory and apoptotic effects. Methods In this study, we immunohistochemically analyzed the expression of COX-2 and p53 in 95 pancreatic resection specimens [adenocarcinomas, 95 lesions; pancreatic intraepithelial neoplasias (PanINs), 155; normal ducts, 70]. Results The expression of COX-2 increased progressively with the grade of ductal lesions (P<0.00001). A statistically significant difference of COX-2 expression between normal ducts and low-grade PanINs was revealed (P=0.0042). COX-2 overexpression was demonstrated in 82 PanINs (52.9%), and in 76 adenocarcinomas (80%). No significant correlation between the grade of adenocarcinoma and COX-2 expression was revealed (P=0.2). The expression of p53 again increased progressively with the grade of lesions (P<0.00001) with a significant increase in high-grade PanINs. A correlation between COX-2 and p53 expression levels in carcinomas was revealed (P=0.0002), and an accumulation of p53 was associated with COX-2 overexpression in premalignant and malignant ductal lesions. Conclusion These findings confirmed the generally accepted pancreatic cancer progression model, and supported the concept of the interactive role of COX-2 and p53 in pancreatic cancer carcinogenesis, which offers opportunities for targeted therapy and chemoprevention of pancreatic cancer using COX-2 inhibitors.

Effect of esomeprazole triple therapy on eradication rates of Helicobacter pylori, gastric ulcer healing and prevention of relapse in gastric ulcer patients

Objectives To compare esomeprazole-based triple therapy with esomeprazole alone for the eradication of Helicobacter pylori (H. pylori), healing of ulcer and prevention of relapse in H. pylori-related gastric ulcer (GU) diseases. Methods In this double-blind study, 401 H. pylori-positive patients with more than or equal to two GUs were randomized to: esomeprazole (20 mg) twice daily (bid) and amoxicillin (1000 mg) bid and clarithromycin (500 mg) bid (EAC) for 1 week, followed by placebo for 3 weeks (EAC and placebo); EAC for 1 week, followed by esomeprazole (20 mg) once daily (E20) for 3 weeks (EAC and E20); or esomeprazole (20 mg) bid and placebo antimicrobials for 1 week, followed by E20 for 3 weeks (E20 bid and E20). Patients with unhealed GUs at 4 weeks received E20 for an additional 4 weeks. Healed patients were followed up for 12 months. Results Eradication rates at 4 weeks or 8 weeks were 82% for EAC and E20, 77% for EAC and placebo and 9.5% for E20 bid and E20 (intention-to-treat analysis). Significantly more patients receiving EAC than those receiving esomeprazole alone remained free of GUs during follow-up [EAC and E20, 90%; EAC and placebo, 87%; P=0.0005 for combined group vs. esomeprazole alone [E20 bid and E20 (74%)]. All treatments were well tolerated. Conclusion Esomeprazole-based triple therapy is effective for the eradication of H. pylori, healing of GU and prevention of relapse. Esomeprazole monotherapy for 3 weeks after triple therapy may be beneficial in terms of healing.

Clinicopathological correlations of cyclooxygenase-2, MDM2, and p53 expressions in surgically resectable pancreatic invasive ductal adenocarcinoma.

Objectives: Cyclooxygenase-2 (COX-2) and p53 represent molecules linked to oncogenesis of pancreatic cancer, and there is also a known regulatory loop between mouse double minute 2 (MDM2) and p53. The complex cross talks between p53 and COX-2 and scenarios explaining patterns of p53 and COX-2 expressions in precursor and cancer lesions have been recently reported. Methods: The expressions of COX-2, p53, and MDM2 were examined using immunohistochemistry in 85 resection specimens of pancreatic ductal adenocarcinoma. Results: The positive tumor expression rates of COX-2, p53, and MDM2 were 69.4%, 60.0%, and 41.2%, respectively. Significant correlations between COX-2 and p53 expressions and between p53 and MDM2 expressions were revealed. In the Kaplan-Meier analysis, no statistically significant correlations were found among the levels of COX-2, p53, and MDM2 expressions and survival rates. In the multivariate Cox proportional hazards regression model, grade and nodal status showed to be a valuable predictor of a worse overall survival. Conclusions: The reported findings confirmed the relationship of p53, MDM2, and COX-2 with the biological process of pancreatic cancer. The expression of none of the examined proteins showed to be a valuable independent prognostic factor. On the contrary, grade and nodal status showed to be a valuable predictor of a worse survival.

Pitfalls of pancreatobiliary endoscopy after Billroth II gastrectomy.

BACKGROUND/AIMS The aim of this retrospective study is the analysis of the success rate of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in our group of patients with Billroth II gastrectomy. METHODOLOGY The study of the group was carried out during 14 years, i.e. from November 1994 to December 2008. It retrospectively evaluates 120 patients with Billroth II gastrectomy. RESULTS A cannulation success rate of 90.8% (109 of 120 patients) was reached in performing ERCP in 120 patients with Billroth II gastrectomy. There were normal ERCP results in 4 patients. ERCP results in the remaining 105 patients were pathological. Endoscopic treatment was started in all of these 105 patients immediately after diagnostic ERCP. Overall, therapeutic ERCP was completely successful in 91 of 105 patients (86.66%) who were originally treated with endoscopy. CONCLUSIONS ERCP in patients with Billroth II gastrectomy is much more demanding in contrast with standard procedure due to different postoperative anatomy. ERCP success is determined mainly by great personal experience and skillfulness of the endoscopist. ERCP performed lege artis in patients with Billroth II gastrectomy is a highly effective and safe method where the success rate reached can be almost the same as in a normal anatomical situation.

Endoscopie par capsule - expérience initiale en république tchèque : étude rétrospective multicentrique

RésuméIntroductionL’endoscopie par capsule (EC) utilisant le système Given Imaging, est disponible en République tchèque depuis fin 2002.Buts et méthodesLe but de cette étude rétrospective a été d’évaluer l’expérience existante de la capsule endoscopique dans cinq centres de gastroentérologie de notre pays. Soixante dix-huit EC ont été colligées (de novembre 2003 à avril 2004) concernant 38 hommes et 40 femmes (âge moyen: 54 ans). L’EC était indiquée comme dernière étape dans l’algorithme diagnostique.RésultatsLa totalité de l’intestin grêle a pu être investiguée dans 54 cas sur 78 (69 %). Les angiodysplasies ont été le plus fréquemment retrouvées (16 patients), puis la maladie de Crohn (8 patients) et enfin, les tumeurs du grêle (7). L’EC a été suivie d’un geste chirurgical chez 15 patients, d’une entéroscopie per opératoire chez 9 patients et un traitement médical a été initié ou modifié chez 26 patients. Une rétention de la capsule a été observée dans 5 cas (6 % et une impaction dans le grêle dans 3 cas); un échec technique a été rapporté dans 5 cas (6 %).ConclusionL’EC est une méthode complémentaire qui n’entre pas en compétition avec les autres outils diagnostiques d’investigation du grêle. L’EC est particulièrement précieuse en cas de saignement GI obscur. Cependant, notre expérience reste jusqu’à présent, assez limitée.SummaryIntroductionCapsule endoscopy (CE), using a Given Imaging system, is available in the Czech Republic since late 2002.Aims and methodsThe aim of this retrospective study was to evaluate the existing experience with CE in five gastroenterology centers in the Czech Republic. Seventy-eight CE were reviewed (Nov 2002 – Apr 2004), 38 men, 40 women (mean age 54). CE was indicated as the last step in diagnostic algorithm.ResultsThe entire small bowel was investigated in 54/78 cases (69 %). The most frequent findings were angiodysplasias (16 patients), Crohn’s disease (8) and small bowel tumours (7). CE was followed by surgery (15 pts), intraoperative enteroscopy (9 pts) and medical treatment was introduced or changed in 26 pts. Capsule retention was found in 5 cases (6 %; small bowel impaction in 3 cases), technical failure was noticed 5 times (6 %).ConclusionCE is complementary, not competing with other diagnostic tools in the investigation of the small bowel. CE is helpful namely in obscure GI bleeding. However, the existing experience is limited so far.

Dietary habits of colorectal neoplasia patients in comparison to their first-degree relatives

AIM To compare the dietary habits between colorectal neoplasia patients, their first-degree relatives, and unrelated controls. METHODS From July 2008 to April 2011, we collected epidemiological data relevant to colorectal cancer from patients with colorectal neoplasias, their first-degree relatives, and also from a control group consisting of people referred for colonoscopy with a negative family history of colorectal cancer and without evidence of neoplasia after colonoscopic examination. The first-degree relatives were divided into two groups following the colonoscopic examination: (1) patients with neoplasia or (2) patients without neoplasia. Dietary habits of all groups were compared. A χ (2) test was used to assess the association between two dichotomous categorical variables. RESULTS The study groups consisted of 242 patients with colorectal neoplasias (143 men, 99 women; mean age: 64 ± 12 years) and 160 first-degree relatives (66 men, 94 women; mean age: 48 ± 11 years). Fifty-five of the first-degree relatives were found to have a neoplastic lesion upon colonoscopy, while the remaining 105 were without neoplasia. The control group contained 123 individuals with a negative family history for neoplastic lesions (66 men, 57 women; mean age: 54 ± 12 years). Two hypotheses were tested. In the first, the dietary habits of first-degree relatives with neoplasia were more similar to those of patients with neoplasia, while the dietary habits of first-degree relatives without neoplasia were similar to those of the control group. In the second, no sex-related differences in dietary habits were expected between the particular groups. Indeed, no significant differences were observed in the dietary habits between the groups of patients, controls and first-degree relatives with/without neoplastic lesions. Nevertheless, statistically significant sex-related differences were observed in all groups, wherein women had healthier dietary habits than men. CONCLUSION In all groups examined, women had healthier dietary habits than men. Modification of screening guidelines according to sex may improve the efficiency of screening programs.

Pancreatic pain@@@Schmerz bei Pankreaserkrankungen

SummaryPain is a common symptom of many diseases. Recently, the pain has been classified and analyzed exactly. Its particular components/types are described to the maximum of their depths and details. That is why each particular pain present in a specific disease (pancreatopathies included) has to be treated according to the presence of the specific type of pain. In diseases of pancreas, there are nociceptive, neuropathic, and inflammatory components of pain participating, frequently. Especially long-lasting, not well-controlled pain sets off the process of neuromodulation. The recent pioneering applications/administrations of various neuromodulatory therapeutic approaches represent the promising discoveries for the treatment of long-term, severe, drug-resistant pain syndromes, including chronic pancreatitis. In this article, we summarized the characteristics of pain, the therapeutic strategy, and algorithms of analgesic treatment (in general and applied for pancreatopathies), including new therapeutic trends and approaches.ZusammenfassungSchmerz ist ein unspezifisches Symptom vieler Erkrankungen. Schmerz kann in seinen Qualitäten und Ursachen näher untersucht und klassifiziert werden. Die spezifischen Schmerzursachen und Schmerzkomponenten können mittlerweile detailliert erfasst werden. Auf Grund dessen muss jede Art von Schmerz bei einer Erkrankung, so auch bei Erkrankungen des Pankreas, spezifisch nach dem jeweiligen Schmerztyp behandelt werden. Bei Pankreaserkrankungen liegen regelmäßig nozizeptive, neuropathische und inflammatorische Schmerzkomponenten vor und spielen zusammen als Schmerzursachen eine Rolle. Langanhaltende und schlecht kontrollierte Schmerzzustände führen zu einer Neuromodulation. Rezente Neuerungen bei der Applikation und im Einsatz von verschiedenen neuromodulatorischen Schmerzmedikamenten stellen neue Therapieansätze dar, die die Hoffnung geben, auch bei schweren, lang anhaltenden und mit konventioneller Schmerztherapie schlecht kontrollierbaren Schmerzsyndromen Erfolge zu erzielen, so auch bei der chronischen Pankreatitis. Im vorliegenden Artikel werden die Schmerzkomponenten, die Therapiestrategien sowie die Algorithmen der Schmerztherapie im allgemeinen und speziell für Pankreaserkrankungen dargestellt. Dies beinhaltet auch neue therapeutische Ansätze und Entwicklungen.

Crohn's disease - genetic factors and progress of the disease

BACKGROUND AND OBJECTIVES Crohns disease is a multifactorial inflammatory disease affecting mainly the gastrointestinal tract. The genetic factors that are involved in the disease include mainly three mutations of the gene NOD2/CARD15 (R702W, G908R, 3020insC). The aim of this study was to determine the relationship between the presence of these variants and disease phenotype. MATERIAL AND METHODS 70 patients with Crohns disease were examined for the presence of the above-mentioned mutations. The researchers used the medical records to retrospectively obtain clinical data and together with the information obtained prospectively according to the protocol they analysed the connection between gene mutations and disease phenotype. RESULTS At least one mutation was found in 22 patients with Crohns disease (32%), four patients were found to have two different mutations (composed heterozygotes - 6%) and six patients (9%) were homozygotes for the 3020insC gene. No significant differences were found between the groups with wild-type form and the mutated form of the NOD2 / CARD15 gene with respect to age at the time of diagnosis, form of the disease or localization according to the Montreal classification. CONCLUSION Mutations of the NOD2 / CARD15 gene did not significantly affect the frequency of reoperations, homozygotes with 3020insC gene mutations, however, represented a high risk group. The phenotype was not related significantly to the presence of the examined mutations.