Comparison of oral versus intravenous proton pump inhibitors in preventing re-bleeding from peptic ulcer after successful endoscopic therapy

Background: Proton pump inhibitors [PPIs] are now widely prescribed for the management of patients with acute upper gastrointestinal bleeding; although its optimal dose and route of administration has remained a controversial issue. The aim of this study was to assess the clinical effectiveness of high dose oral versus intravenous [IV] PPI after successful endoscopic therapy in patients with bleeding peptic ulcer disease

Methods: 178 patients with active upper gastrointestinal bleeding due to a peptic ulcer with stigmata of high risk for re-bleeding entered the study. After successful endoscopic hemostasis, they were randomized to receive either high dose oral pantoprazole [80 mg stat and 80 mg twice daily for 3 days] or high dose intravenous pantoprazole [80 mg IV infusion within 30 minutes and 8 mg per hour for 3 days]. After the 3rd day, the patients in both groups received oral pantoprazole 40 mg twice daily for one month. The end points were comparing the rate of re-bleeding or mortality, and the need for blood transfusion or surgery during the first month between the two groups

Results: There were not significant statistical differences between the two groups in the volume of blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates. However, the rates of re-bleeding were 2.3% [2:88] in the IV group and 3.3% [3:90] in the oral group [p = 0.6]

Conclusion: According to our findings, it seems that high dose oral PPI can be a good alternative to high dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding. Due to the lower cost and the availability of oral PPIs, their use can be economically much more affordable

Eradication of helicobacter pylori in Iran: a review

Helicobacter pylori [H. pylori] infection is one of the most common bacterial infections, affecting almost half of the world's population. It is associated with peptic ulcer disease, gastric adenocarcinoma, and lymphoma. In Iran, the prevalence of H. pylori infection has been reported to be between 36% and 90% in different geographic regions. Several studies have assessed the efficacy of different therapeutic options for first line and second-line H. pylori eradication in Iran; however, the results are conflicting. Therefore, we conducted a review to evaluate different studies in order to select the best options and to provide recommendations for H. pylori eradication in Iran. Accordingly, we searched through PubMed to obtain relevant randomized clinical trials published in English language up to June 2017. According to our study, among first-line eradication regimens, bismuth-based furazolidone-or clarithromycin-containing quadruple therapies, hybrid regimen, and concomitant therapy seem to be appropriate options. Also, 10- or 14-day clarithromycin-containing triple therapy can be used if local H. pylori resistance to clarithromycin is known to be less than 15%. For second-line H. pylori eradication, bismuth-based quadruple therapies and 14-day levofloxacin-based triple therapy can be used, provided that antibiotics other than those used in the first-line regimen are used. Third-line H. pylori eradication regimens have not been addressed in Iranian studies. However, most guidelines recommend treatment according to the results of culture and susceptibility testing. Although we limited our investigation to H. pylori eradication regimens in Iran, the results are transferrable to any region as long as the patterns of antibiotic resistance are the same

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

comparison between hybrid therapy and standard triple therapy for helicobacter pylori eradication in patients with uremia: a randomized clinical trial

Background: The prevalence of peptic ulcer disease in hemodialysis patients is more than the general population. They are also more prone to complications including upper gastrointestinal bleeding. The aim of this study was to compare the efficacy of 14 days hybrid regimen with 14 days triple therapy for Helicobacter pylori [H. pylori] eradication in hemodialysis patients

Methods: Forty hemodialysis patients with naïve H.pylori infection were randomized to receive either hybrid regimen [pantoprazole 40 mg + amoxicillin 500 mg, both twice a day during the first 7 days, followed by pantoprazole 40 mg + amoxicillin 500 mg + clarithromycin 500 mg + tinidazole 500 mg, all twice a day, for the second 7 days, or standard triple therapy including pantoprazole 40 mg, clarithromycin 500 mg, and amoxicillin 500 mg, all twice a day for 14 days. H.pylori eradication was assessed by fecal H.pylori antigen test 8 weeks after the treatment

Results: All the patients completed the study. According to both intention to treat and per-protocol analyses, H.pylori eradication rates were 100% [95% confidence interval [CI]: 100] in those who received hybrid therapy and 70% [95% CI: 69.4 - 70.8] in those who were treated by standard triple therapy [p=0.02]. Severe adverse effects were not reported by any patient; however, mild adverse effects were more frequent in those who received standard triple therapy [p<0.05]

Conclusion: Hybrid regimen could achieve ideal H.pylori eradication rates with low rates of adverse effects

Effects of clarithromycin-containing quadruple therapy on helicobacter pylori eradication after nitroimidazole-containing quadruple therapy failure

Background: Several large clinical trials and meta-analyses have shown about 20% failure to eradicate Helicobacter pylori [H.pylori], necessitating investigations for second-line treatments. The aim of this study was to evaluate the effects of clarithromycin-containing quadruple regimen after nitroimidazole-containing quadruple therapy failure

Methods: Thirty two patients who had failed 10-day H.pylori treatment with omeprazole, amoxicillin, bismuth subcitrate, and metronidazole [OABM] regimen and 31 patients who had failed 10-day treatment with omeprazole, amoxicillin, bismuth subcitrate, and furazolidone [OAMF] regimen entered the study. They all received omeprazole [20 mg], amoxicillin [1 gr], bismuth subcitrate [240 mg] and clarithromycin [500 mg] twice a day for 10 days. Eight weeks after treatment, H. pylori eradication was assessed by 14C-urea breath test

Results: Totally 61 patients completed the study. According to intention to treat [ITT] analysis, eradication rates by second-line OABC regimen were 84.37% [95% CI= 71.7-96.9%] in OABM group and 77.41% [95% CI= 62.71-92.11%] in OABF group [p=0.756]. Per-protocol [pp] eradication rates were 87.09% [95% CI= 75.2-98.8%] and 82.75% [95% CI= 79.4-96%], respectively [p=0.638]. Also the cumulative eradication rates by OABC regimen were 80.9% [95% CI= 71.2-90.6%] and 85% [95% CI= 75.9-94%] according to ITT and PP analyses, respectively. Severe side effects were reported in 3.1% of the patients

Conclusion: Regarding ideal eradication rate [>80%] and very low adverse effects, it seems that clarithromycin-containing quadruple therapy can be an encouraging regimen after nitroimidazole-containing regimen failure

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

Significance of response to hepatitis b recombinant vaccine in subjects with isolated antibody to hepatitis b core antigen

It is important to differentiate whether isolated anti-HBc is due to false positive results or the prior exposure to hepatitis B virus, because individuals with false-positive anti-HBc can benefit from vaccination and their blood can be safely transfused. To distinguish between these two conditions, we evaluated the serologic response to hepatitis B vaccine. Ninety subjects with isolated anti-HBc [cases] and 100 subjects with totally negative hepatitis B serologic markers [controls]] were recruited to receive three doses of hepatitis-B [HB] vaccine. Thirty days after the first dose of the vaccine, anti-HBs titers were checked and individuals with anti-HBs titer >50 mlU/mL did not receive additional doses of the vaccine. However, others completed the vaccination course, and another blood sample was collected 30 days after the third dose to measure anti-HBs level. Nineteen [21.1%] cases and three [3%] controls had no sero-conversion [anti-HBs titers <10 mlU/mL] 30 days after the third dose [p<0.000l]. Primary response, defined as the development of anti-HBs antibody titers >10 mlU/mL 30 days after the third dose, was observed in 43 [47.8%] cases and 92 [92%] controls [p<0.000l]. Also, 31.1% of cases developed anti-HBs titers > 50 mlU/mL 30 days after the first dose of vaccine, but the rate was significantly lower [5%] in the control group [P<0.0001]. Furthermore, half of the individuals with positive isolated anti-HBc developed protective levels of anti-HBs after three doses of HB vaccination. More than 75% of individuals with positive isolated anti-HBc can benefit from vaccination and can be included in donor pool. Also, one fifth seemed to have occult HBV infection. So HB vaccination may be used as a diagnostic tool for clarifying the situation of the subjects with isolated anti-HBc

Large bowel obstruction after colonoscopy; a case report

Postpolypectomy bleeding and perforation are the major complications of colonoscopy. This report presents a rare case of colon obstruction immediately after colonoscopy. A 56-year-old man underwent colonoscopy because of 6 months lower abdominal pain. Colonoscopy revealed diverticulosis and multiple small sessile polyps in sigmoid colon. Biopsy samples were taken from the polyps and the procedure was continued up to cecum. Soon after the procedure, the patient complained of colicky abdominal pain accompanied by diaphoresis. In physical examination, the abdomen seemed distended and bowel sounds were high-pitched. There was no abdominal tenderness or guarding. Plain and upright abdominal radiography showed multiple colonic air-fluid levels. Immediately, the patient underwent second colonoscopy, but passage of scope through sigmoid colon [at the site of biopsies] was somewhat hard because of edema and spasm. The colonoscope proceeded gently up to cecum and decompressed the entire colon by suctioning the air that was entrapped in proximal parts. By second colonoscopy and further conservative treatments, the patient's condition improved without any surgical procedure and was discharged after 24 hours

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

Target antigens for perinuclear antineutrophil cytoplasmic antibodies in Iranian patients with ulcerative colitis

Patients with ulcerative colitis [UC] carry autoantibodies such as perinuclear antineutrophil cytoplasmic antibodies [p-ANCA]. The aim of the present study was to evaluate the target antigens for p-ANCA in Iranian patients with UC. p-ANCA target antigens including elastase, lactoferrin, cathepsin G, myeloproxidase, lysozyme, and bactericidal permeability increasing protein [BPI] were determined in 113 patients with UC using enzyme-linked immunosorbent assay [ELISA]. 59.2% of the patients were positive for at least one antigen and p-ANCA directed against lactoferrin, elastase, lysozyme, cathepsin G, Bactericidal permeability increasing protein, and myeloproxidase in 31.5%, 25.9%, 8.3%, 7.4%, 5.6%, and 0% of the patients, respectively. The highest prevalence of p-ANCA was observed against lactoferrin and elastase. Also, myeloproxidase was not an antigen for p-ANCA among our patients

HLA-DQ2 and HLA-DQ8 genotyping in a sample of Iranian celiac patients and their first-degree relatives

Recent studies have shown a critical role for HLA-DQ2 and HLA-DQ8 in the pathogenesis of celiac disease. No study has been performed on the prevalence of these two HLA types in Iranian celiac patients. We enrolled 24 celiac patients and 37 first-degree relatives in whom the diagnosis of celiac was excluded by sero-logic tests. HLA typing for HLA-DQ2 [DQB1*02], HLA-DQ8 [DQB1*03], HLA-DQ B1*05 and HLA-DQ B1*06 was performed using polymerase chain [PCR] reaction. Twenty two [91.7%] celiac patients and twenty seven [73%] controls were positive for the HLA-DQ2 and/or HLA-DQ8 heterodimers. There was no significant difference between the two groups p=0.068]. However, celiac patients were statistically more positive for homozygote HLA-DQ2, whereas non-celiac participants were more positive for homozygote HLA-DQ8 [p<0.05]. The total prevalence of HLA-DQ2 and/or HLA-DQ8 allels did not significantly differ between the two groups. Hence, first-degree relatives of celiac patients appear to be more susceptible for developing celiac disease. On the other hand, the higher prevalence of homozygote HLA-DQ2 in celiac patients shows its stronger role in disease pathogenesis. Further studies on larger populations are needed in Iran.

incidence and outcome of pregnancy-related biliary sludge/stones and potential risk factors

Diseases of the gall bladder have been reported to be the most common cause for non-obstetrical hospitalizations during the first year postpartum. Therefore we designed a prospective study to evaluate the incidence and natural outcome of pregnancy-related biliary sludge and stones, and to define the potential risk factors in a population of pregnant women in Sari, Iran. A total of 380 pregnant women were scheduled for three ultrasound assessments: 1] during the first trimester of pregnancy [9 - 12 weeks], 2] during the early third trimester [26 - 32 weeks], and 3] during the fourth to sixth weeks postpartum. The incidence of biliary sludge, new stones and progression from sludge to stones in addition to the probable risk factors were analyzed with the t-test and chi-square test as appropriate [SPSS software, version 15]. According to the first ultrasonography, 14 [3.7%] participants had evidence of biliary sludge and 3 [0.7%] had gallstones. Among those with normal baseline ultrasound findings, 28 [7.7%] developed biliary sludge and 7 [1.9%] formed stones by their second ultrasound examination [P < 0.05]. Among the 14 participants with biliary sludge in their first ultrasound assessment, 1 [7.1%] developed gall stone and sludge remained in the other 13 as seen on the third trimester ultrasound results. According to the third ultrasound [performed postpartum], out of 41 participants with prior biliary sludge, 16 [39%] had no evidence of sludge, 22 [53.7%] had persistent sludge, and 3 [7.3%] developed stones. Out of 11 participants with prior gallstones, 1 had a normal ultrasound postpartum, but stones persisted in the other 10 [P < 0.05]. In those with stones, 9.1% underwent cholecystectomies postpartum. The incidence of sludge and stones significantly correlated with the number of pregnancies and higher age at pregnancy. Since the annual rate of pregnancy is high in Iran, pregnancy-related biliary disorders are important in this country. According to our results, the number of parities and age at pregnancy are potentially modifiable risk factors for lowering pregnancy-related biliary disorders

[Evaluation of therapeutic effect of capsaicin pomade [Caspian 0.03%] in hemodialysis related pruritus]

Pruritus is one of the common problems in hemodialysis patients with end stage renal disease. Approximately, 60% of these patients suffer from this condition. There are several causes for pruritus, thus, various treatments are applied in order to control it. The aim of this study was to evaluate the therapeutic effect of capsaicin on pruritus, compared with placebo, in hemodialysis patients. This randomized double blind cross over clinical trial study, was performed on 34 hemodialysis patients with uremic pruritus in 1386. All patients were divided in two groups. One group received Caspian 0.03%, while the other, placebo for four weeks. Treatment was stopped for two weeks and continued as cross over technique. Pruritus scores were analyzed with Paired t-test and Repeated measurement ANOVA. In this study, the difference between Mean of pruritus score before capsian treatment and in weeks following 1 to 4 was statistically significant [P=0.0001]. In placebo group, the difference between pruritus score before treatment and in weeks 1 to 4 was statistically significant [P=0.0001]. There was no significant difference before treatment in two groups, however, after each week, the difference was significant [P=0.0001]. Repeated measurement test showed that reduction in pruritus severity in capsian group was more than placebo group, during treatment period [P=0.0001]. Although our study indicated the appropriate effects of Capsian in pruritus, the placebo also has a good effect in controlling hemodialysis related pruritus. Our placebo had emollient property; therefore, we can apply it to control the pruritus in these patients

[ epidemiologic and clinical-pathologic characteristics of coloretal cancers from 1999 to 2007 in Sari, Iran]

Each year, about 50,000 new cases of cancer occur in Iran and the most common being the gastrointestinal [GI] tract [38%]. Colorectal cancers account for the 3[rd] and 4[th] most prevalent cancers in Iranian men and women, respectively. Since genetic and environmental factors lead to differences in colorectal cancer occurrence in different geographic regions and races, we designed a study to assess characteristics of this cancer, in the Guilak race of Mazandaranian people. The records of all colorectal cancer patients who were referred to in a private GI clinic or admitted in hospitals and were studied during 1999 to 2007. Data was analyzed using SPSS software, Chi- Square and T-Tests. 296 cases of colorectal cancers [CRCs] were enrolled in the study. There were 2 cases of colon lymphoma and 1 case of cervical cancer with metastasis to colon. The remaining 293 patients had colorectal Aden carcinoma, of which 152 were males and 141 were females. The mean age of patients was 52.6 +/- 15.2 years. 98 patients [33.5%] were under 45 years of age. A total of 70 cases [24%] had familial history of CRC. Moreover, 47% of patients under 45 years had positive familial history for CRC, of whom 43 patients [14.6%] were classified as having Hereditary Non- Polyposis Colorectal Cancer [HNPCC]. 125 patients had rectal, while 168 cases had colon cancers. Right- sided colon cancers were 2 times more prevalent than the left- sided involvements. In addition, right- sided colon cancers were relatively more prevalent in those with positive familial history of CRC. Importantly, about half of all patients showed advanced stages of the disease [Lymph node involvement or distal metastases] at the time of diagnosis. Regarding the younger age of involvement, the significant positive familial history, the more prevalent proximal colon cancers and advanced stages of the disease at the time of diagnosis, we recommend to design screening programs for earlier detection of CRCS in this geographic region