Zahid A. Saeed

Effect of Treatment of Helicobacter pylori Infection on the Long-term Recurrence of Gastric or Duodenal Ulcer: A Randomized, Controlled Study

OBJECTIVE To determine the effect of treating Helicobacter pylori infection on the recurrence of gastric and duodenal ulcer disease. DESIGN Follow-up of up to 2 years in patients with healed ulcers who had participated in randomized, controlled trials. SETTING A Veterans Affairs hospital. PARTICIPANTS A total of 109 patients infected with H. pylori who had a recently healed duodenal (83 patients) or gastric ulcer (26 patients) as confirmed by endoscopy. INTERVENTION Patients received ranitidine, 300 mg, or ranitidine plus triple therapy. Triple therapy consisted of tetracycline, 2 g; metronidazole, 750 mg; and bismuth subsalicylate, 5 or 8 tablets (151 mg bismuth per tablet) and was administered for the first 2 weeks of treatment; ranitidine therapy was continued until the ulcer had healed or 16 weeks had elapsed. After ulcer healing, no maintenance antiulcer therapy was given. MEASUREMENTS Endoscopy to assess ulcer recurrence was done at 3-month intervals or when a patient developed symptoms, for a maximum of 2 years. RESULTS The probability of recurrence for patients who received triple therapy plus ranitidine was significantly lower than that for patients who received ranitidine alone: for patients with duodenal ulcer, 12% (95% CI, 1% to 24%) compared with 95% (CI, 84% to 100%); for patients with gastric ulcer, 13% (CI, 4% to 31%) compared with 74% (44% to 100%). Fifty percent of patients who received ranitidine alone for healing of duodenal or gastric ulcer had a relapse within 12 weeks of healing. Ulcer recurrence in the triple therapy group was related to the failure to eradicate H. pylori and to the use of nonsteroidal anti-inflammatory drugs. CONCLUSIONS Eradication of H. pylori infection markedly changes the natural history of peptic ulcer in patients with duodenal or gastric ulcer. Most peptic ulcers associated with H. pylori infection are curable.

Treatment of helicobacter pylori reduces the rate of rebleeding in peptic ulcer disease

BACKGROUND We evaluated whether therapy designed to eradicate Helicobacter pylori infection resulted in a reduction in rebleeding in patients with peptic ulcer disease. Patients presenting because of major upper gastrointestinal hemorrhage from peptic ulcer and whose ulcers healed in a study in which they were randomized to receive ranitidine alone or triple therapy plus ranitidine were followed up regularly with endoscopy. No maintenance anti-ulcer therapy was given after ulcer healing. METHODS Patients received ranitidine, 300 mg, or ranitidine plus triple therapy. Triple therapy consisted of tetracycline, 2 g; metronidazole, 750 mg; and bismuth subsalicylate, 5 or 8 tablets (151 mg bismuth per tablet), and was administered for the first 2 weeks of treatment; ranitidine therapy was continued until the ulcer had healed or 16 weeks had elapsed. After ulcer healing, no maintenance antiulcer therapy was given. Development of ulcer recurrence with or without recurrent upper gastrointestinal bleeding was evaluated. RESULTS Thirty-one patients with major upper gastrointestinal bleeding from peptic ulcer were studied; 17 received triple therapy and 14 ranitidine alone. Major rebleeding occurred significantly (p = 0.031) more often in those in the ranitidine group (28.6%), compared with none (0%) in the triple therapy group. CONCLUSION Eradication of H. pylori infection reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease.

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

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.

Endoscopic stent placement for internal and external pancreatic fistulas

Stents have been effectively used for various pancreatic conditions. Pancreatic fistulas, however, have traditionally been considered a surgical disease, and if the fistula does not respond to conservative measures, an operation is usually performed. Stents were placed endoscopically in five consecutive patients who presented with pancreatic fistulas that did not respond to conservative management. Fistulas resolved in all patients after endoscopic stent placement, and after 14-30 months of follow-up, none has recurred. The cases comprise two patients with pancreaticocutaneous fistula and one each with pancreaticopleural, pancreaticoperitoneal, and pancreaticocholedochal fistula. The need for an operation can be obviated in many patients with internal and external pancreatic fistulas.

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.

Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy

Endoscopic variceal ligation has been developed as an alternative to endoscopic sclerotherapy. We report a series of 12 men with a history of bleeding esophageal varices who were treated with endoscopic variceal ligation after they had failed sclerotherapy. Hemostasis was achieved in all 10 patients who were bleeding at the time of initial endoscopy and again in those who subsequently re-bled. Over a follow-up period of up to 22 months, varices have been and remain eradicated in five patients; in four others, a reduction in grade was noted before death (two patients), liver transplant, or loss to follow-up (one patient each); two patients died before they could be re-evaluated, while in the remaining patient, no reduction in variceal grade was noted before loss to follow-up. No complication was recorded after 35 endoscopic treatment sessions involving a total of 245 rubber band ligations. Our results indicate that endoscopic variceal ligation may be used with success in patients who fail sclerotherapy.

A Randomized Comparison of Dilatation Alone Versus Dilatation Plus Laser in Patients Receiving Chemotherapy and External Beam Radiation for Esophageal Carcinoma

Most patients with carcinoma of the esophagushave advanced disease at presentation. Since cure isusually not possible, the goal of treatment is thepalliation of dysphagia. Palliative modalities include bougies, balloons, stents, tumor probe, laser,surgery, chemotherapy, and radiation. In recent years,combined chemotherapy and radiation has shown promisingresults. However, the relief of dysphagia is slow and frequently incomplete. We compared theeffectiveness of dilatation alone versus dilatation plusNd-YAG laser therapy for the relief of dysphagia whileassessing the role of chemotherapy and radiation as an adjunct to surgery. Fifteen patients withsquamous cell carcinoma of esophagus who were deemed fitfor intensive chemotherapy and radiation were randomizedto receive either dilatation alone (N = 7) or dilatation plus laser (N = 8); theend-point for initial success was the passage of a 45French Savary dilator, and the relief of dysphagia. Atentry, 13 of these 15 patients were judged potentially resectable. However, after chemotherapy andradiation, only 3 of 13 (20%) patients could be offeredsurgery; the remainder were considered too poor asurgical risk. Follow-up was for 30 months, or until death. Further dilatations were performed asneeded for relief of dysphagia. No difference wasobserved between the laser plus dilatation and thedilatation alone group with respect to the degree ofdysphagia, weight record, quality of life index (Karnofskyscore), or mortality rate. Our results indicate that inpatients undergoing chemotherapy and radiation foresophageal carcinoma, dilatation alone provides adequate palliation of dysphagia, and in thesepatients, chemotherapy and radiation is a poor adjunctto surgical treatment.

TREATMENT OF BENIGN ESOPHAGEAL STRICTURES : WHERE DO WE GO FROM HERE ?

Dilatation has been used for the treatment of benign esophageal strictures since at least the sixteenth century (1). Over the ensuing 400 years there have been continued improvements in the material and design of bougies that have resulted in the mercuryfilled rubber bougies, over-guidewire metal olives, and tapered polyvinyl dilators in use today. The more recent introduction of balloon dilators, and electrosurgical incision therapy, have added theoretically more efficient therapeutic choices (2, 3). Reports have described high degrees of success, irrespective of the device used, and following dilatation virtually all patients report improvement in their ability to swallow (4-9).

Technology Assessment Status Evaluation—Balloon Dilation of Gastrointestinal Tract Strictures: November, 1994

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.