Evaluation of the additive effect of domperidone on patients with refractory gastroesophageal reflux disease; a randomized double blind clinical trial

Background: Gastroesophageal reflux disease [GERD] is a common problem with annoying symptoms. It is associated with negative impact on quality of life. Prokinetic agents may be used in combination with acid suppression agents as an adjunctive in patients with GERD refractory to proton pump inhibitors [PPI] therapy, rather than as sole treatment. This study aimed to evaluate the efficacy of combination of PPI with domperidone [a prokinetic agent] compared with PPI alone in the treatment of patients with refractory GERD

Methods: This study was a double blind clinical trial on 29 patients with GERD refractory to PPI during the period of one month. By randomization, the patients were divided into two groups. Group A was treated by pantoprazole 40 mg twice daily and domperidone three times a day for a month, while group B was treated by pantoprazole 40 mg twice daily and placebo three times a day. In this study endoscopy was performed to evaluate the prevalence of erosive esophagitis, non-erosive reflux, and hiatal hernia. Manometry was conducted to study the prevalence of dysmotility. GERD symptom questionnaires including the Gastrointestinal Symptom Rating Scale [GSRS], Carlson Dennett, and the Medical Outcomes Study Short Form-36 health survey [SF36] were used before and after treatment for screening GERD and assessing treatment response

Results: There were 17 [58.62%] women and 12 [41.37%] men. The prevalence of erosive esophagitis and non-erosive reflux, was 10.34% and 89.66%, respectively. There was a significant difference comparing reflux symptoms before and after treatment between the two groups according to reflux and Carlson Dennett questionnaires. At the end of the study, symptoms of reflux significantly improved by treatment. Although, the quality of life questionnaire scores improved by treatment, there was no statistically significant difference in response to treatment between the two groups

Conclusion: In this research, we showed that adding domperidone to PPI could not make any improvement in patients with refractory reflux regarding the quality of life and improving the symptoms

efficacy of levofloxacin-based triple therapy for helicobacter pylori eradication after failure with clarithromycin-containing regimens

Background: Clinical trials and meta-analyses have reported about 20% failure rates in first-line Helicobacter pylori [H. pylori] eradication. This reflects the need for effective second-line eradication regimens

Materials and Methods: 61 patients with H. pylori infection who had failed previous non-bismuth clarithromycin-containing first line therapies entered the study. They were given a 14-day levofloxacin-containing triple regimen consisted of pantoprazole 40 mg, amoxicillin 1gr, and levofloxacin 500mg, each given twice daily. Eight weeks after the treatment, H. pylori eradication was assessed by 14C-urea breath test

Results: All patients completed the study. The eradication rate was 91.8% [95% confidence interval = 84.9% - 98.6%] by both intention to treat and per-protocol analyses. Side effects of therapy were reported by eight patients [13.1%], but they were severe in only two patients [3.2%]

Conclusion: According to the high H. pylori eradication rate and the very low rate of severe adverse effects, levofloxacin-containing triple therapy seems to be a suitable second-line option in case of previous failure by clarithromycin-containing therapies. We suggest further studies with shorter duration of treatment or lower dose of levofloxacin

Role of upper and lower gastrointestinal endoscopy in investigating the etiologies of iron deficiency anemia in postmenopausal women

Background: iron deficiency anemia has been considered as an alarming sign of the possible presence of malignancy in the digestive tract. Inadequate assessment of such affected patients can lead to delay in the diagnosis of gastrointestinal [GI] tumors especially colorectal cancers. Therefore the present study examined the upper and lower GI tract of postmenopausal women with iron deficiency anemia by GI endoscopy

Materials and Methods: women aged over 45 years referred to Gastroenterology Clinic of Imam Khomeini Hospital were asked about their menstruation. Postmenopausal women with the anemia were enrolled. A list of laboratory studies was performed for all included patients. These laboratory studies included complete blood count [CBC], iron profile and stool examination for occult blood. 103 postmenopausal women with iron deficiency anemia according to laboratory tests were interviewed and their clinical and biochemical variables were recorded. All of the study patients underwent esophagogastroduodenoscopy and colonoscopy. The endoscopic findings were recorded regarding the presence of GI lesions causing iron deficiency anemia or the lack of them

Results: a total of 103 patients participated in this study. Endoscopy revealed a source of iron deficiency anemia in 90.3% of the study population. Upper and lower GI tract lesions were found in 73.8% and 51.5% of the patients, respectively. The most frequent lesions in the upper GI endoscopy were severe gastroesophageal reflux disease involving 34 patients [33%] followed by gastric erosions in 31 cases [30.1%] and duodenal ulcer in 15 cases [14.6%]

Conclusion: in postmenopausal women with iron deficiency anemia as in men, it is necessary to examine the GI tract

comparison between hybrid and concomitant regimens for helicobacter pylori eradication: a randomized clinical trial

Background: Helicobacter pylori [H. pylori] is one of the most common bacterial infections worldwide. We designed a study to compare the efficacy of 14-day hybrid regimen with 10-day concomitant therapy for H. pylori eradication in Iran

Methods: 252 patients with naive H. pylori infection were randomly divided to receive either hybrid regimen [pantoprazole 40 mg, and amoxicillin 1 gr twice daily for 14 days, accompanied by clarithromycin 500 mg, and metronidazole 500 mg, twice daily just during the last 7 days] or concomitant regimen [pantoprazole 40 mg, amoxicillin 1 gr, clarithromycin 500 mg, and metronidazole 500 mg, all twice daily for 10 days]. 8 weeks after therapy, 14C- urease breath test was performed to confirm eradication

Results: According to intention to treat analysis, the eradication rates were 87.3% [95% CI: 81.4-93.1] and 80.9% [95% CI: 74-87.8] in hybrid and concomitant groups, respectively [p=0.38]. Per-protocol eradication rates were 89.3% [95% CI: 83.8-94.7] and 83.1% [95% CI: 76.3-89.8], respectively [p=0.19]. The rates of severe side effects were not statistically different between the two groups [4% vs. 8.7%]

Conclusion: 14-day hybrid therapy can be considered as a nearly acceptable regimen with few severe side effects in Iran. However, it seems that the efficacy of this therapy is decreasing as the resistance rates to antibiotics are increasing. We suggest further studies to assess the efficacy of a more prolonged concomitant therapy for H. pylori eradication in Iran

comparison between moderate- and high-dose furazolidone in triple regimens for Helicobacter pylori eradication in Iran

Furazolidone has been used as an alternative for clarithromycin or metronidazole in Helicobacterpylori [H. pylori] eradication regimens. In Iran, 14-day Furazolidone-containing quadruple regimens have shown promising eradication rates, but short-course, low dose therapies are always attractive. Therefore, we designed a study to compare the efficacy of two 10-day triple regimens containing moderate and high dose furazolidone for H. pylori eradication. Two hundred and ten patients with peptic ulcer disease who were naive to H. pylori treatment were included. They were randomized into 2 groups: 105 patients received omeprazole 20mg, amoxicillin 1000mg, and furazolidone 200mg [OAF-400], all twice a day for ten days. And the remaining 105 patients received omeprazole 20mg twice a day, amoxicillin 1000mg twice a day and furazolidone 200mg three times a day for ten days [OAF-600]. Urease breath test was performed 8 weeks after the treatment to confirm H. pylori eradication. The intention-to-treat eradication rate was 76.19% in group OAF-400 and 80.95% in group OAF-600 [p=0.38]. Per protocol eradication rates were 81.63% and 89.47%, respectively [p= 0.11]. Severe adverse effects were reported by 8.6% of the patients in group OAF-400 and 5.7% of the patient in group OAF-600 [p=0.1]. However, the total side effects [including mild, moderate, and severe ones] were significantly more prevalent in the OAF-600 group [p=0.001]. None of our triple furazolidone-based regimens [moderate- and high-dose] could achieve the standard eradication rate, and therefore, cannot be considered as a suitable option for first-line treatment

Acute bleeding in duodenal gastrointestinal stromal tumor

Gastrointestinal stromal tumors [GIST] are the most common mesenchymal tumors of the gastrointestinal tract. The biological pattern of these tumors ranges from benign-appearing small lesions to malignant sarcomas. Only 3%-5% of GISTs are found in the duodenum. A duodenal GIST is a rare source of upper gastrointestinal bleeding. A remarkable percentage of duodenal GISTs are localized in the third and fourth part of the duodenum and may not be noticed on standard upper endoscopy. Push enteroscopy is sometimes advisable to find these lesions. Surgical resection either limited or pancreaticoduodenectomy can be the treatment of choice. In general, adjuvant therapy with imatinib has been proved to extend survival in patients with GIST. The current case, a 24-year-old male, presented with acute upper gastrointestinal bleeding from a submucosal ulcerated tumor located in the distal third part of the duodenum, 3 cm distal from the papilla of Vater. After primary care and blood transfusion in a local hospital, partial resection of the duodenum was performed as a definitive surgical therapy. Histopathology showed a GIST with a diameter of 3 cm and moderately malignant according to tumor grade, and <5 mitoses/10 high power field [HPF]

[Tyrosine kinase domain gene polymorphism of epidermal growth factor receptor in gastric cancer in northern Iran]

Gastric cancer is one of the most common diseases of digestive system with a low 5-year survival rate and metastasis is the main cause of death. Multi-factors, such as changes in molecular pathways and deregulation of cells are involved in the disease development. Epidermal growth factor receptor pathway [EGFR] which is associated with cell proliferation and survival can influence cancer development. EGFR function is governed by its genetic polymorphism; thus, we aimed to study the tyrosine kinase domain gene mutations of the receptor in patients with gastric cancer. In this experimental study, 123 subjects [83 patients with gastric cancer and 40 normal subjects] were investigated in north of Iran for EGFR gene polymorphisms during 1 year. Genomic DNA was extracted by DNA extraction kit according to the manufacture's protocol. Polymerase chain reaction single-stranded conformation polymorphism [PCR-SSCP] and silver staining were performed for investigating EGFR gene polymorphisms. The participants included 72 men and 44 women. Gene polymorphism in exon 18 was present in 10% of the study population but SSCP pattern in exon 19 did not show different migrate bands neither in patients nor in normal subjects. It seems that screening for tyrosine kinas gene polymorphism of epidermal growth factor receptor in patients with gastric cancer and use of tyrosine kinas inhibitors could be useful in the prevention of disease progress and improvement of treatment process for a better quality of life in these patients

High frequency of A2143G mutation in clarithromycin-resistant Helicobacter pylori isolates recovered from dyspeptic patients in Iran

Resistance to clarithromycin in H. pylori isolates is accepted as a main cause of treatment failure in developing countries. We aimed to determine the prevalence of clarithromycin-resistant strains isolated from dyspeptic patients in northern Iran, furthermore we aimed to assess the relationship between clinical outcomes of infection with point mutations. A total of 147 consecutive patients infected with H. pylori were included for determining the status of resistant H. pylori strains. With upper gastroscopy, three antral biopsies were taken from each patient, first section for rapid urea test, second for pathology and third section was used for bacterial culture in microbiologic lab. The antimicrobial susceptibility tests in this examination were agar dilution, in accordance with clinical and laboratory standards institue guidelines. Restriction fragment length polymorphism-PCR [RFLP-PCR] method was applied to determine the frequency of point mutations in 23s rRNA gene. Statistical analysis was performed using SPSS software [15.0] [SPSS, Inc., Chicago, Ill]. Chi-square and Fisher's exact tests were applied to our analysis. A P value less than 5% was considered as statistically significant. Our results showed that there was no point mutation in clarithromycin-susceptible strains of H. pylori. The important findings in our study indicate that A2143G is the most prevalent point mutation [30/32: 93.7%] attributed in clarithromycin resistance among the H. pylori strains. The current study concluded that clarithromycin could still be involved in the empirical treatment of H. pylori infection, although a high frequency of A2143G mutation may increase the concerns regarding treatment failure