Rhonda A. Cole

Prospective validation of the Baylor bleeding score for predicting the likelihood of rebleeding after endoscopic hemostasis of peptic ulcers.

Endoscopic therapy is effective in securing hemostasis for bleeding ulcers, but bleeding recurs in 10% to 30% of patients. Prospective identification of patients at increased risk for rebleeding is requisite to reducing rebleeding rates. We previously developed a three-component scoring system that identifies patients at increased risk for rebleeding. In the present study, we prospectively validated our scoring system. Forty-seven men ranging in age from 23 to 95 years in whom endoscopic therapy for bleeding ulcers was successful were studied. Patients with pre-endoscopy scores greater than 5 or postendoscopy scores greater than 10 were stratified as high-risk, and patients with pre-endoscopy scores of 5 or less and post-endoscopy scores of 10 or less as low-risk. Twenty-six patients were categorized as high-risk and 19 as low-risk. All patients were followed until discharged from the hospital. The rebleeding rate for high-risk patients was 31% (8 of 26), compared with 0 for low-risk patients (p < .05). We conclude that our scoring system accurately predicts patients at increased risk for rebleeding after successful endoscopic therapy of bleeding ulcers.

Metronidazole, omeprazole and clarithromycin: An effective combination therapy for Helicobacter pylori infection

Background: Successful treatment of Helicobacter pylori infection results in cure of peptic ulcer disease. Multidrug regimens are needed to cure this infection. We studied the effectiveness and side effect profile of two antibiotics active against Helicobacter pylori, metronidazole and clarithromycin, combined with omeprazole.

Visceral abdominal obesity measured by CT scan is associated with an increased risk of Barrett's oesophagus: a case-control study

Objective Abdominal obesity has been associated with increased risk of Barretts oesophagus (BE) but the underlying mechanism is unclear. We examined the association between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) and the risk of BE. Design A case-control study among eligible patients scheduled for elective oesophagastroduodenoscopy (EGD) and in a sample of patients eligible for screening colonoscopy recruited at the primary care clinic. All cases with definitive BE and a random sample of controls without BE were invited to undergo standardised mid-abdomen non-contrast computerised axial tomography images, which were analysed by semiautomated image segmentation software. The effect of VAT and SAT surface areas and their ratio (VAT to SAT) on BE were analysed in logistic regression models. Results A total of 173 BE cases, 343 colonoscopy controls and 172 endoscopy controls underwent study EGD and CT scan. Participants with BE were more than twice as likely to be in the highest tertile of VAT to SAT ratio (OR: 2.42 (1.51 to 3.88) and adjusted OR 1.47 (0.88 to 2.45)) than colonoscopy controls, especially for those long (≥3 cm) segment BE (3.42 (1.67 to 7.01) and adjusted OR 1.93 (0.92 to 4.09)) and for white men (adjusted OR 2.12 (1.15 to 3.90)). Adjustment for gastroesophageal reflux disease (GERD) symptoms and proton pump inhibitors (PPI) use attenuated this association, but there was a significant increase in BE risk even in the absence of GERD or PPI use. Conclusions Large amount of visceral abdominal fat relative to subcutaneous fat is associated with a significant increase in the risk of BE. GERD may mediate some but not all of this association.

Waist-to-Hip Ratio, but Not Body Mass Index, Is Associated With an Increased Risk of Barrett's Esophagus in White Men

BACKGROUND & AIMS Abdominal obesity increases the risk of gastroesophageal reflux disease (GERD) and also might contribute to the development of Barretts esophagus (BE), although results are inconsistent. We examined the effects of waist-to-hip ratio (WHR) and body mass index (BMI) on the risk of BE and investigated whether race, GERD symptoms, or hiatus hernia were involved. METHODS We conducted a case-control study using data from eligible patients who underwent elective esophagogastroduodenoscopy; 237 patients had BE and the other 1021 patients served as endoscopy controls. We also analyzed data and tissue samples from enrolled patients who were eligible for screening colonoscopies at a primary care clinic (colonoscopy controls, n = 479). All patients underwent esophagogastroduodenoscopy, completed a survey, and had anthropometric measurements taken. WHR was categorized as high if it was 0.9 or greater for men or 0.85 or greater for women. Data were analyzed with logistic regression. RESULTS There was no association between BMI and BE. However, more patients with BE had a high WHR (92.4%) than endoscopy controls (79.5%) or colonoscopy controls (84.6%) (P < .001 and P = .008, respectively). In adjusted analysis, patients with BE were 2-fold more likely to have a high WHR than endoscopy controls (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.1-3.5), this association was stronger for patients with long-segment BE (OR, 2.81; 95% CI, 1.0-7.9). A high WHR was associated significantly with BE only in whites (OR, 2.5; 95% CI, 1.2-5.4), but not in blacks or Hispanics. GERD symptoms, hiatus hernia, or gastroesophageal valve flap grade could not account for the association. CONCLUSIONS High WHR, but not BMI, is associated with a significant increase in the risk of BE, especially long-segment BE and in whites. The association is not caused by GERD symptoms or hiatus hernia.

Profiling Lipoxygenase Metabolism in Specific Steps of Colorectal Tumorigenesis

Lipoxygenases (LOX) are key enzymes for the oxidative metabolism of polyunsaturated fatty acids into biologically active products. Clinical data on comparative levels of various LOX products in tumorigenesis are lacking. Therefore, we examined the profiles of several LOX products (5-LOX, 12-LOX, 15-LOX-1, and 15-LOX-2) by liquid chromatography/tandem mass spectrometry in the major steps of colorectal tumorigenesis (normal, polyp, and cancer) in a clinical study of 125 subjects (49 with normal colon, 36 with colorectal polyps, and 40 with colorectal cancer) who underwent prospective colorectal biopsies to control for various potential confounding factors (e.g., diet, medications). Mean 13-hydroxyoctadecadienoic acid (13-HODE) levels were significantly higher in normal colon [mean, 36.11 ng/mg protein; 95% confidence interval (95% CI), 31.56-40.67] than in paired colorectal cancer mucosa (mean, 27.01 ng/mg protein; 95% CI, 22.00-32.02; P = 0.0002), and in normal colon (mean, 37.15 ng/mg protein; 95% CI, 31.95-42.34) than in paired colorectal polyp mucosa (mean, 28.07 ng/mg protein; 95% CI, 23.66-32.48; P < 0.001). Mean 13-HODE levels, however, were similar between the left (mean, 37.15 ng/mg protein; 95% CI, 31.95-42.35) and the right normal colon (mean, 32.46 ng/mg protein; 95% CI, 27.95-36.98; P = 0.09). No significant differences with regard to 12- or 15-hydroxyeicosatetraenoic acid or leukotriene B4 levels were detected between normal, polyp, and cancer mucosae. 15-LOX-1 inhibited interleukin-1β expression. This study establishes that reduced 13-HODE levels are a specific alteration in the LOX product profile associated with human colorectal tumorigenesis. Cancer Prev Res; 3(7); 829–38. ©2010 AACR.

Detection of Helicobacter pylori by rapid urease tests: is biopsy size a critical variable?☆☆☆★★★

BACKGROUND The variables responsible for false-positive and false-negative rapid urease tests are largely unexplored. OBJECTIVES We compared the results of rapid urease testing with jumbo cup forceps (3.3 mm diameter) and tiny cup forceps (1.8 mm diameter) with two rapid urease tests. METHODS Antral biopsies were obtained. The order of forceps and rapid urease tests was randomized. Biopsies were also taken for Genta staining. RESULTS One hundred and two patients were studied; 59 had Helicobacter pylori infection. There were 22 false-negative tests (8 CLOtest, 16 hpfast) and 5 false-positive tests (3 CLOtest, 2 hpfast). All 5 false-positive tests were among those positive only in the second 12 hours. There was no difference in results with the jumbo and tiny cup forceps. Five percent to nine percent (average, 6.6%; 95% confidence interval, 4.4% to 9.6%) of tests with any of the combinations gave an erroneous categorization of H. pylori status. There were no clinical or statistical differences in H. pylori categorizations by CLOtest or hpfast. CONCLUSION The diagnostic yield for detecting H. pylori infection by rapid urease tests is not adversely affected by small biopsy size, possibly because tiny biopsies obtain superficial tissue where H. pylori reside.

Helicobacter pylori-negative gastritis: prevalence and risk factors.

OBJECTIVES:Recent studies using histology alone in select patients have suggested that Helicobacter pylori-negative gastritis may be common. The objective of this study was to investigate the prevalence of H. pylori among individuals with histologic gastritis.METHODS:Subjects between 40 and 80 years underwent elective esophagogastroduodenoscopy at a VA Medical Center. Gastric biopsies were mapped from seven prespecified sites (two antrum, four corpus, and one cardia) and graded by two gastrointestinal pathologists, using the Updated Sydney System. H. pylori-negative required four criteria: negative triple staining at all seven gastric sites, negative H. pylori culture, negative IgG H. pylori serology, and no previous treatment for H. pylori. Data regarding tobacco smoking, alcohol drinking, nonsteroidal anti-inflammatory drug, and proton pump inhibitor (PPI) use were obtained by questionnaire.RESULTS:Of the 491 individuals enrolled, 40.7% (200) had gastritis of at least grade 2 in at least one biopsy site or grade 1 in at least two sites. Forty-one (20.5%) had H. pylori-negative gastritis; most (30 or 73.2%) had chronic gastritis, five (12.2%) had active gastritis, and six (14.6%) had both. H. pylori-negative gastritis was approximately equally distributed in the antrum, corpus, and both antrum and corpus. Past and current PPI use was more frequent in H. pylori-negative vs. H. pylori-positive gastritis (68.2% and 53.8%; P=0.06).CONCLUSIONS:We used multiple methods to define non-H. pylori gastritis and found it in 21% of patients with histologic gastritis. While PPI use is a potential risk factor, the cause or implications of this entity are not known.

Influence of endoscopic biopsy forceps characteristics on tissue specimens: results of a prospective randomized study

BACKGROUND A large variety of endoscopic biopsy forceps are commercially available. However, little is known regarding the influence of forceps characteristics such as disposability, size, shape, and presence of a needle on the adequacy of the specimens for histologic diagnosis. Our aim was to analyze in a prospective, randomized, pathologist-blinded study the performance of different biopsy forceps. METHODS Twelve biopsy forceps were tested, 6 each at upper endoscopy and colonoscopy. Two biopsy specimens were obtained with each forceps, for a total of 12 specimens per patient. The tissue samples were examined for the following parameters: weight (mg), size (mm3), depth, crush artifact, sheering effect, and adequacy of the specimens for histologic information (0 = inadequate, 1 = suboptimal, and 2 = adequate). RESULTS Fifty-five patients undergoing routine upper or lower gastrointestinal endoscopy were included in the study, and a total of 624 tissue samples were available for analysis. Overall, disposable forceps provided specimens of greater size and depth. At upper endoscopy, alligator-shaped forceps improved the depth of the sample as did the absence of a needle within the cup. These factors, however, had no impact on the specimens obtained at colonoscopy. When the adequacy of the specimens was assessed for histologic diagnosis, no significant difference was noted between any of the individual forceps, although collectively oval-shaped forceps were superior to alligator-shaped forceps at colonoscopy. CONCLUSIONS The biopsy forceps currently available in the market are equally efficient in providing histologic diagnosis. The primary consideration when selecting an endoscopic biopsy forceps, therefore, should be the cost and ease of use and not any perceived advantage in performance.

Simplified 13C-urea breath test for detection of Helicobacter pylori infection.

OBJECTIVE:The U.S. standard 13C-urea breath test (13C-UBT) has proven to be extremely reliable but entails several complicated performance requirements and a test period of approximately 1 h. The aim of this study was to compare the standard 13C-UBT with a simplified version embodying modifications of test meal, duration of fasting, amount of 13C-urea, method of breath collection, and duration of test.METHODS:This was a randomized, three-way, crossover study of the standard U.S. 13C-UBT, which contains 125 mg of 13C-urea and a pudding test meal. The final breath sample is taken 30 min after urea ingestion. This test was compared with a formulation containing 75 mg of 13C-urea, a 2.5-g citric acid test meal (UBT-Lite), and a final breath sample taken by direct exhalation into tubes 15 min after urea ingestion. We also compared the effect of prior meals versus fasting on the test outcome with the UBT-Lite.RESULTS:A total of 259 subjects were enrolled in the trial, and 249 completed all three urea breath tests. There was excellent agreement between the three versions of the UBT with >98% of subjects having concordant results. Using predetermined criteria, there was substantial equivalence between the tests. Neither solid and/or liquid food up to 1 h before performing the UBT-Lite affected outcome.CONCLUSION:The UBT-Lite formulation of the 13C-UBT proved to be an improved version of the U.S. standard 13C-UBT offering less expensive ingredients, shorter test duration, and a simplified breath test collection method, without sacrificing accuracy.

An objective end point for dilation improves outcome of peptic esophageal strictures: a prospective randomized trial

BACKGROUND The usual end point for defining success of dilation is subjective (relief of dysphagia). In most patents thus managed strictures recur. We asked whether an objective end point would improve outcome. METHODS After dilation to 15 mm, patients were randomized into subjective and objective groups. In subjective group patients, end point for dilation was alleviation of dysphagia; in objective group patients, passing the 12 mm barium pill test. Objective group patients who failed underwent redilation until they passed the pill or failed three times. During Part 1 of the study, patients received ranitidine, during Part 2 they received omeprazole. RESULTS In part 1, dysphagia was alleviated in 7 of 8 subjective group patients. Only 2 of 10 objective group patients passed the pill test and no additional patients passed after 3 sessions, although most had no dysphagia. In Part 2, 19 subjective groups and 15 objective group patients were studied. End point was not achieved in 3 objective group patients. Over long-term follow-up, objective group patients had less recurrent dysphagia (p = 0.02) and required fewer redilation sessions (p < 0.05). Overall, the pill test correlated with the presence or absence of dysphagia (P < 0.001). Predictive value of passing the pill 1 week after dilation for the absence of dysphagia was 100%, but of failing the pill test and the presence of dysphagia was only 18%. CONCLUSIONS Achieving an objective end point reduces stricture recurrence and the need for subsequent dilation. Initial subjective improvement does not predict long-term success.