Svante Sjöstedt

Curing Helicobacter pylori Infection in Patients with Duodenal Ulcer Does Not Provoke Gastroesophageal Reflux Disease

Background. It has been suggested that the incidence of gastroesophageal reflux disease (GERD) increases after successful eradication of Helicobacter pylori infection. We present data on development of GERD from a controlled study of H. pylori eradication in 165 duodenal ulcer patients.

Prospective randomised comparison of adjustable gastric banding and vertical banded gastroplasty for morbid obesity

OBJECTIVE To compare the clinical results of adjustable gastric banding and vertical banded gastroplasty for morbid obesity. DESIGN Prospective randomised trial. SETTING University hospital, Sweden. PATIENTS 59 morbidly obese patients, listed for obesity surgery. INTERVENTIONS Adjustable gastric banding (n = 29) or vertical banded gastroplasty (n = 30). MAIN OUTCOME MEASURES Weight loss, complications, need for revisional surgery, reflux symptoms and the patients own evaluation. RESULTS Five years after surgery the mean (SEM) weight reduction for adjustable gastric banding was 43 (3.0) kg and for vertical banded gastroplasty 35 (4.8) kg. One patient in each group died of unrelated causes during follow-up and 3 and 2 patients, respectively, were lost to follow-up. One patient in the vertical banded group required reoperation for an anastomotic leak on the third postoperative day. A total of 3 patients in the adjustable group required reoperation and 11 in the vertical banded group. CONCLUSIONS Adjustable gastric banding carries a smaller risk of reoperation than vertical banded gastroplasty and the weight reduction is in the same order of magnitude.

Bovine anti-Helicobacter pylori antibodies for oral immunotherapy

Background: Passive immunization with orally administered antibodies against specific pathogens has previously been successfully used therapeutically in both animal and human studies. We employed a similar strategy for experimental treatment of mice infected with the gastric pathogen Helicobacter pylori. Methods: An anti- H. pylori bovine colostral hyperimmune immunoglobulin preparation (BIC) was generated and its efficacy was tested in different in vitro experiments, such as binding to the Lewis b blood group antigen, inhibition of adherence of H. pylori to human gastric mucosa tissue sections in situ and in a haemagglutination assay. The BIC preparation was also given in the drinking water to H. pylori -infected mice. Results: An inhibition of 95% of the binding of H. pylori to Lewis b glycoconjugate was observed in vitro. Furthermore, a blocking activity of almost 90% was observed when the BIC was preincubated with H. pylori bacteria. Finally, the BIC preparation inhibited the haemagglutination of H. pylori and human red blood cells. Seven of 40 (17.5%) mice remained infected in the treatment group as compared with 25 of 45 (55.5%) in the control group. Hence, the cure rate was 66%, P = < 0.001. The mean number of colonies in the antibody-treated mice where eradication was not successful was also reduced ( P < 0.05). In trials using FVB/N transgenic Lewis b expressing mice, a cure rate of 50%-66% was observed. Conclusion: Bovine colostral antibodies against H. pylori can be generated in high titres, inhibit binding in vitro and can eradicate or reduce the number of bacteria in infected mice.

Long-term effects of eradication of Helicobacter pylori on relapse and histology in gastric ulcer patients: a two-year follow-up study

Background: The main purpose of this study was to compare omeprazole (ome) plus two antibiotics (OMC) with omeprazole plus placebo (OP) with regard to gastric ulcer relapse for a period of 2 years in patients who were Helicobacter pylori-positive at inclusion. Methods: Using double-blind randomization 125 patients with gastric ulcer were treated with either OMC (ome 20 mg b.i.d., metronidazole 400 mg b.i.d., clarithromycin 250 mg b.i.d.) (n = 64) or OP (ome 20 mg and placebo) (n = 61) for 1 week, followed by ome 20-40 mg o.d. until healing was confirmed endoscopically after 4, 8 or 12 weeks. Endoscopy and H. pylori diagnostics using culture, histology and serology were performed 6, 12 and 24 months after treatment or at symptomatic relapse. At inclusion, 35% of the OMC group and 38% of the OP group were taking non-steroidal anti-inflammatory drugs (NSAIDs). Nine percent (11/125) of the ulcers were malignant. Results: The prevalence of H. pylori was 82% and the eradication rate 88% in the OMC group and 3% in the OP group. More than 90% of the ulcers were healed after 12 weeks. After 2 years, 76% of patients in the OMC group were in remission compared with 28% in the OP group (ITT) (P < 0.001). Sixty percent of patients in the OMC group that continued to take NSAIDs were in remission after 2 years compared with none in the OP group. Atrophy but not intestinal metaplasia decreased after treatment. Conclusions: Gastric ulcers are mainly caused by H. pylori, and relapse is effectively prevented by H. pylori eradication, even in patients on NSAIDs.

Adenocarcinoid of the Liver Arising Within an Area of Hamartoma With Predominant Bile Duct Component

Malignant transformation in bile duct hamartomas has been previously reported in very rare instances. Here, we describe a unique case of a neuroendocrine tumor of the liver arising within an area of unusually large hamartoma with predominant bile duct component, hitherto unreported and distinct from the conventional von Meyenburg complex. The tumor was apparently secreting gastrin and chromogranin, with associated gastrinoma syndrome over several years. The histologic picture was reminiscent of a moderately differentiated adenocarcinoid, with positive mucin staining in a signet ring pattern. Tumor cells showed positive staining for neuron-specific enolase, chromogranin A, gastrin, and serotonin. Staining for pancreatic hormone peptides was negative. Resection of the tumor was apparently curative, with complete resolution of the patients symptoms.

Structured Diagnostic and Treatment Approach Versus the Usual Primary Care Approach in Patients With Gastroesophageal Reflux Disease: A Cluster-randomized Multicenter Study.

Goals: To compare the clinical outcomes of gastroesophageal reflux disease (GERD) patients treated with an implemented new structured pathway (NSP) or according to existing local clinical practices [old clinical pathway (OCP)]. Background: GERD is a major challenge at the primary care level. Study: Primary care centers (n=24) were cluster randomized to handle patients suffering from symptoms suggestive of GERD according to the NSP (n=97) or the OCP (n=134). In the NSP, the GerdQ questionnaire score was used both for diagnosis and management including treatment. We used validated questionnaires to evaluate disease symptoms, quality of life, and costs at inclusion and at follow-up 2 to 6 months later. Results: On the basis of the Reflux Disease Questionnaire, 56% of the patients treated with the NSP reported total symptom relief at the follow-up compared with 33% in the OCP group (P=0.0013). The reflux symptoms after treatment affected daily activities to a lesser extent in the patients in the NSP group compared with the OCP group (10% vs. 13%, respectively, P=0.01). The utility score of the EuroQoL-5D questionnaire improved more in the NSP group than in the OCP group (0.05 vs. 0.02, respectively, P<0.001). The patients in the NSP group had an approximately 50% lower average total cost for GERD-related health care resources compared with the OCP group [301 Swedish Kronor (SEK) vs. 588 SEK, respectively, NS]. Conclusions: The management of GERD patients in primary care centers using a structured clinical pathway and the results of the GerdQ improves the clinical outcome compared with prevailing local routines (NCT00842387).

Effects of Structured Follow-Up and of More Effective Acid Inhibitory Treatment in the Management of GORD Patients in a Swedish Primary-Care Setting

AbstractBackground: Despite the high prevalence of gastro-oesophageal reflux disease (GORD) and the documented impact of GORD symptoms on individual health-related quality of life (HR-QOL) and on socioeconomic factors, structured management of GORD has had a low priority in Swedish routine primary health care. Objective: The primary objective of this study (IMPROVE) was to evaluate the effects of a structured follow-up and management regimen for primary-care GORD patients with symptomatic breakthrough despite standard proton pump inhibitor (PPI) treatment. Patients received either an increased dose of current PPI treatment or were switched to the more effective acid inhibitor esomeprazole. Methods: GORD patients with symptomatic breakthrough despite standard PPI treatment were identified through medical records and by a postal survey using the GERD Impact Scale (GIS) questionnaire. Patients rated the severity and frequency of GORD symptoms, general health status (EuroQol Group 5-Dimension Self-Report Questionnaire) and the impact of GORD symptoms on work productivity (Work Productivity and Activity Impairment) before and 4 weeks following randomization to open-label treatment with either increased acid suppressive therapy or an adjusted, higher dosage of the PPI previously used. The patients’ valuation, in monetary terms, of the treatment they received pre-study versus the treatment given during the study was documented through willingness-to-pay (WTP) questions. Results: Following more effective acid suppression, 66.3% of the study population experienced complete relief of heartburn, with no difference between the groups; HR-QOL was restored to a level comparable to that of a normal Swedish population and ability to work efficiently was significantly improved. Access to a better acid suppressive treatment was highly valuable to the patients in terms of WTP. Conclusion: An improved GORD management strategy including structured follow-up of treatment given and initiation of more effective acid inhibitor therapy when symptoms persist will be of great benefit to GORD patients.

Two-year follow-up of patients with duodenal ulcer after treatment with omeprazole and amoxycillin/placebo

We randomized in a double-blind controlled study 165 patients (102 males), mean age 55 (range 22-80) years, 45% smokers, with active duodenal ulcer to receive either omeprazole 40rag bid and amoxycillin 750 mg bid (O/A) or omeprazole 40rag bid and placebo (O/P) for two weeks. Endoscopic healing was assessed after 2 weeks. Patients not healed received another two weeks of omeprazole 20rag om. Endoscopy and Helicobacter pylori (HP) status assessed by culture, histology and serology were done before treatment and 6, 12, and 24 months after treatment and at ulcer relapse. In the case of a first relapse patients received a second course with the active treatment. Patients with a second relapse reached a study end-point. Results, Ulcer healing after 2 weeks was 78% in the O/A group (n=ll0) and 78% in the O/P group (n=55). 31132 patients not healed at 2 weeks healed after open treatment with omeprazole. Five patients (3%) were HP negative or had uncertain HP status at entry and were excluded from the analysis of HP eradication. The intention-to-treat analysis showed that 41% and 2% (p < 0.001) became HP negative in the O/A and O/P groups, respectively. Ulcer relapse occurred in 34% of the patients in the O/A group and 87% in the O/P group (p < 0.001). The figure shows time to relapse in relation to treatment and HP status after treatment.