Sergio Peyre

High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: A multicentre, randomized study

BACKGROUND:The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain.METHODS:Patients with actively bleeding ulcers and those with nonbleeding visible vessel or adherent clot were treated with epinephrine injection and/or thermal coagulation, and randomized to receive intravenous PPIs according to an intensive regimen (80 mg bolus followed by 8 mg/h as continuous infusion for 72 h) or a standard regimen (40 mg bolus daily followed by saline infusion for 72 h). After the infusion, all patients were given 20 mg PPI twice daily orally. The primary end point was the in-hospital rebleeding rate, as ascertained at the repeat endoscopy.RESULTS:Bleeding recurred in 28 of 238 patients (11.8%) receiving the intensive regimen, and in 19 of 236 (8.1%) patients receiving the standard regimen (P = 0.18). Most rebleeding episodes occurred during the initial 72-h infusion: 18 (7.6%) and 19 events (8.1%) in the intensive and standard groups, respectively (P = 0.32). Mean units of blood transfused were 1.7 ± 2.1 in the intensive and 1.5 ± 2.1 in the standard regimen group (P = 0.34). The duration of hospital stay was <5 days for 88 (37.0%) and 111 patients (47.0%) in the intensive and standard groups (P = 0.03). There were fewer surgical interventions in the standard versus intensive regimen (1 vs 3). Five patients in each treatment group died.CONCLUSIONS:Following endoscopic hemostasis of bleeding ulcers, standard-dose PPIs infusion was as effective as a high-dose regimen in reducing the risk of recurrent bleeding. (ClinicalTrials.gov number, NCT00374101).

Digestive Endoscopy Is Not a Major Risk Factor for Transmitting Hepatitis C Virus

Context Controversy persists regarding the risk for transmission of hepatitis C virus (HCV) as a result of digestive-tract endoscopy. Contribution This prospective study of HCV-negative patients who underwent gastroscopy with the same endoscopes as HCV-positive patients showed no transmission of infection on follow-up 6 months later. Biopsy with reusable or disposable forceps did not increase the risk for HCV infection. Blood donors who were HCV negative without endoscopic exposure showed a few conversions to infected status an average of 2.5 years later. Implications The risk for HCV transmission by endoscopy is extremely low when standard instrument-cleaning techniques are used. The Editors Health carerelated procedures have been implicated in the transmission of a consistent proportion of contemporary hepatitis C virus (HCV) infections. The role of major surgical operations, such as cardiovascular, gynecologic, and orthopedic procedures, is well established. However, the role of less invasive procedures, such as digestive endoscopy, remains a matter of debate. A claim from a retrospective French study (1) that digestive endoscopic procedures are a major cause of HCV transmission among blood donors has not been substantiated by other authors (2, 3); acquisition of HCV through endoscopy has in fact been rarely reported in recent years (4, 5). Nevertheless, endoscopy as a vehicle for HCV transmission has been suspected since 1996, when blood banks in France and Italy suspended donors who reported a history of recent digestive endoscopy from donating blood for 6 months and up to 1 year, respectively. It is therefore important to establish whether digestive endoscopy represents a real risk and, if so, to define its magnitude. We conducted a prospective study among outpatients referred to 3 endoscopic units in northwestern Italy from 1999 to 2002. The patients entering the study were tested for antibody to HCV (anti-HCV) at baseline and 6 months after endoscopy. The incidence of HCV infection in this cohort was compared with that in blood donors recruited in the same area and during the same time period; these donors had not undergone any digestive endoscopic procedure. Methods Endoscopy Cohort Between January 1999 and December 2002, all of the outpatients referred for upper digestive endoscopy to 3 endoscopic units in northwestern Italy (1 secondary referral center and 2 tertiary referral centers) were asked to participate in this study. Eligibility criteria were age older than 18 years and indication for gastroscopy. We restricted the procedure to gastroscopy in order to obtain a high rate of invasive procedures (for example, gastric biopsy). We excluded patients if they were hospitalized, had previously undergone endoscopic procedures, were known anti-HCV carriers, or had to undergo additional endoscopic procedures other than gastroscopy. However, to identify the potentially infective population, we retrospectively looked for known HCV carriers who underwent gastroscopy in the 3 centers between January 1999 and December 2002. Of 11348 patients fulfilling the inclusion criteria, 9188 (81.0%) agreed to participate and gave written consent. They completed a questionnaire about risk factors for HCV infection during the past 6 months, and a serum sample was obtained from each immediately before endoscopy. Mild sedation with midazolam and hyoscine butylbromide was administered to each patient by using disposable syringes and vials. Gastroscopies were done by using various types of endoscopes, including fiberscopes and video endoscopes (Olympus GIF-Q20, GIF-Q30, GIF-IT30, GIF-IT140, Olympus Europe, Hamburg, Germany). Biopsies were performed with disposable biopsy forceps (Radial Jaw 3, Boston Scientific Microvasive, Natick, Massachusetts) in one center and reusable biopsy forceps (FB-24U-1, Olympus Europe) in another center; the third center used reusable forceps (EN-62143, Pescetto, Genova, Italy) in 1999 and disposable forceps (Max Capacity, Boston Scientific Microvasive) after 1999. Each patient was invited to attend a follow-up visit 6 months after endoscopy in order to obtain a serum sample for determining anti-HCV; at this visit, the patient was asked to complete the HCV questionnaire again. To reduce the risk for false-negative results, potentially immunodeficient patients (those undergoing hemodialysis or receiving immunosuppressive treatment) were also tested for HCV RNA by polymerase chain reaction (PCR). All patients who did not attend the follow-up visit were recontacted by telephone. Among patients in the endoscopy cohort, we identified an at-risk subset of patients: Overall, 912 endoscopic procedures (732 gastroscopies performed on known HCV carriers and 180 gastroscopies performed on newly discovered HCV carriers) were considered potentially infective. When we considered that each endoscope was used 3 times during the endoscopic session and assumed that the anti-HCVpositive patient was the first, second, or third at random, the number of exposed patients per HCV-infectedpatient-day was 0, 1, or 2, with equal probability (the mean of those numbers is 1). Blood Donors Cohort Using a computerized database, we retrospectively identified all 51645 consecutive blood donors at 2 transfusion centers in Torino and Pinerolo between January 1999 and December 2002 who were negative for HCV. Of these, 415 (0.8%) reported previous digestive endoscopy; the blood bank database did not record invasive procedures performed during endoscopy (such as biopsy and polypectomy). These 415 donors were asked to repeat the serologic and virologic HCV tests: 329 (79.3%) agreed, and 86 declined. Of the 51230 blood donors who did not undergo endoscopic procedures during the observation period, 38 280 (74.7%) were tested again after a mean of 2.49 years (range, 6 months to 4 years); the remaining 12 950 blood donors could not be contacted by telephone for retesting or declined to be retested. Retested blood donors found to be newly positive for anti-HCV completed a structured questionnaire aimed at investigating risk factors for HCV infection, including endoscopic procedures, travel history, sexual activity, and potential parenteral exposures to blood or blood products (previous blood, platelet, or plasma transfusions; administration of coagulation factor concentrates; intravenous drug use; tattooing; acupuncture therapy; ear piercing; and major or minor surgery). Cleaning and Disinfection Method The instruments used for the known HCV carriers were not handled differently from those used for the HCV-negative patients; they were not removed from the general instrument pool, were disinfected in the same way as the others, and were then used promptly to perform endoscopy on the HCV-negative patients. Moreover, endoscopic procedures in known HCV carriers were not postponed at the end of the session but were performed according to the list of scheduled appointments. All units participating in this study adhered to the international guidelines for cleaning and disinfection practices in digestive endoscopy (6-10) and reprocessing endoscopic accessories (11); written protocols were available in each center. The staff involved in disinfection procedures consisted of trained nurses who were unaware of the ongoing study. At the end of the endoscopic procedure, the staff manually cleaned the instrument, including brushing the channels; each internal channel was flushed with detergent, rinsed with water, and blown through with air. The endoscopic units used 3 different automated washer-disinfectors (DSD-91E, Medivators, Minneapolis, Minnesota; Circlean MC-12, Shoei, Tokyo, Japan; and ETD2, Olympus Europe), but the reprocessing cycle was similar: 1) The units were immersed in 2% glutaraldehyde for 20 minutes, and internal channels were flushed with the same solution; 2) the units were rinsed internally and externally with drinking-quality water to remove all traces of disinfectant; and 3) the units were dried externally and each channel was flushed with air. Before the first endoscopy of each day, all endoscopes were disinfected in a washer-disinfector. After use, reusable biopsy forceps were immersed in enzymatic detergent solutions; next, they were cleaned first manually and then by a medical-grade ultrasonic cleaner. After rinsing and drying, the forceps were sterilized by autoclave at 134 C for at least 5 minutes. Finally, the sterilized devices were stored in sterile packaging in a closed cupboard where they were protected from dust, humidity, and temperature fluctuations. Laboratory Methods We tested for anti-HCV by using a third-generation enzyme immunoassay (Ortho HCV EIA-3, Ortho Diagnostic Systems, Raritan, New Jersey). Anti-HCV immunoreactivity was confirmed with a third-generation immunoblot assay (RIBA-3, Chiron Corp., Emeryville, California, and Ortho Diagnostic Systems). We measured HCV RNA by using PCR (Cobas Amplicor 2.0, Roche Diagnostic Systems, Branchburg, New Jersey); the sensitivity of this assay was 1000 copies/mL. Statistical Analysis We estimated person-years of observation and incidence rates of anti-HCV seroconversion for both cohorts. We used the difference between the incidence rates to compare the 2 cohorts. For the endoscopy cohort, we also measured the risk for anti-HCV seroconversion 6 months after the procedure, using the number of persons as denominators. Further analyses were limited to subgroups of the endoscopy cohort: 1) 6132 patients who underwent biopsy (biopsy cohort) and 2) 912 patients who underwent endoscopy later in the same day as and with the same instruments used in HCV-positive patients (at-risk cohort). Because we could not identify with certainty each patient in the at-risk cohort, we estimated that number with a rough but conservative approach. If we assume that each endoscope was used approximately 3 times during an ordinary endoscopic session and that at least 1 HCV carrier would be seen at

The importance of endoscopic ultrasonography in the management of low-grade gastric mucosa-associated lymphoid tissue lymphoma

Background : Anti‐Helicobacter pylori therapy has been reported to cause regression of low‐grade gastric mucosa‐associated lymphoid tissue lymphoma in a high percentage of patients. However, in some patients, these lesions persist despite antibiotic treatment.

The Effect of the Eradication of helicobacter pylori Infection on Hemorrhage Because of Duodenal Ulcer

The cost of a recurrently bleeding duodenal ulcer (DU) is very high, both from a human and an economic point-of-view. Helicobacter pylori infection plays an important role in the pathogenesis of DU disease and its complications, such as bleeding. Cure of H. pylori infection is recommended in patients with DU and its complications, although in the latter case, the most efficient management is not yet a defined issue. In particular, acid secretion inhibitors may not contribute to long-term cure. Our aims were to ascertain whether the recurrence of bleeding because of DU could be prevented by H. pylori eradication and whether long-term inhibition of gastric acid output is needed to prevent recurrence. Eighty-four patients (65 men; mean age, 55.1 years), who had bled because of recurrent DU, were followed after the cure of H. pylori infection. None of the patients were on therapy with nonsteroidal antiinflammatory drugs. Successful cure of H. pylori was determined by gastroscopy, histology, and serology performed at 3, 6, 12, 24, and 48 months after the eradication treatment. A 13C urea breath test was performed when the results of serology were unclear and also at recurrence of DU or bleeding. After the antibiotic treatment, 46 patients stopped all medications, whereas 38 continued long-term therapy with histamine type 2 receptor antagonists. During a mean follow-up period of 47.2 months (range, 37–65 months), recurrence of DU at endoscopy was observed in three patients in each group (p = 0.56), but none bled again. We conclude that H. pylori eradication prevents DU recurrence and rebleeding, that reinfection rate by H. pylori after cure was nil at 4 years, and that long-term inhibition of acid secretion may not improve outcome after cure of H. pylori, even in patients whose DU was complicated by hemorrhage.

4757 Role of endoscopic ultrasonography in therapeutic decision making and in following-up gastrointestinal submucosal tumors and extraluminal compressions.

Purpose: EUS has been proved to be the best method to diagnose upper GI ST and to differentiate them from EC.However no follow-up studies are available up to now. The aim of our work was to compare prospectively histopathological data of tumors removed by surgery to EUS results and to perform a follow-up of ST identified by EUS. Methods: 269 consecutive patients (pts) (143 men, mean age 58,9 years) suspected of having upper GI ST or EC at routine endoscopy, underwent EUS with a rotating sector scanner (Olympus GF-UM2/UM3/UMQ130). Histological data available for 53 pts (47 underwent surgery, 2 had a polipectomy and 4 had a biopsy) were compared to EUS diagnosis. Furthermore we followed-up other 108 pts with ST by EUS or endoscopy. Results: performing EUS in 269 pts, we found 289 lesions (in 5 pts no lesion was confirmed by EUS). 206 lesions were diagnosed as ST mostly due to leiomyoma (118) and lipoma (20) and 69 as EC mostly due to vascular structures (25) and gallbladder (11); 5 resulted intramucosal lesions and 4 could not be better defined by EUS. In 6/6 cases of EC EUS diagnosis was confirmed at surgery. In 46 cases of SL we have histological diagnosis on resected specimens. EUS diagnosis was histologically confirmed in 33/41 (80.4%) and a good agreement was found about tumor size. 82 pts underwent EUS follow-up (mean 23.1±18.5 months) without showing any critical change in tumor size or echopattern. 31 pts remained asymptomatic with lesions unchanged at endoscopic follow-up.CT, US or barium radiography gave no additional information. Conclusions: EUS represent a major adjunct to the available imaging armamentarium for diagnosing and differentiate ST from EC. It is also the most cost-effective method for following-up GI ST. No significant changes were demonstrated in ST size or echopattern in the medium/long period even in tumors greater than 3 cm. Furthermore EUS has shown a good accuracy in predicting the nature of ST and EC as compared to histopathology and can be of value in identifying the best candidates to surgery.