Effect of omeprazole, rabeprazole, and rebamipide on the accuracy of urea breath test in patients with Helicobacter pylori infection

Background: The urea breath test (UBT) has been widely used for H. pylori eradication after treatment. The breath test could be adversely affected by various factors including proton pump inhibitors (PPIs) that are also used in the therapy for H. pylori infection. Objective: Determine the effect of omeprazole, rabeprazole and the mucoprotective agent rebamipide, on the UBT. Methods: Fifty-six patients with dyspepsia and positive for H. pylori by rapid urease test were enrolled. They were classified into three groups: Group 1 (n=25) received omeprazole 20 mg once daily, group 2 (n=13) received rabeprazole 20 mg once daily, and group 3 (n=18) received rebamipide 100 mg three times a day. All patients received a 14-day course of their medications. UBT was performed on day 0 as a baseline and on day 14 in all patients. In patient with negative results of UBT on day 14, the UBT was performed in consecutive week until the test became positive. Results: Fifty-six patients (20 men and 36 women) participated in the study. Their mean age was 46.77±14.3 years. False negative rate after 14-day treatment in omeprazole, rabeprazole and rebamipide group were 20.0%, 30.8%, and 0% respectively. There was a significant difference between 13C level in patients with negative and positive UBT results (2.7±0.7 vs.22.9±3.7/mL, p=0.025). The reversal of false negative to true positive tests occurred within two weeks after discontinuation of omeprazole and rabeprazole. Conclusion: Proton pump inhibitors had an effect on the accuracy of H. pylori detection using UBT. Rabeprazole revealed a higher false negative rate in the UBT than omeprazole. The mucoprotective drug, rebamipide, did not influence negative results in the UBT.

Efficacy of octreotide in the control of acute upper gastrointestinal bleeding.

To evaluate the efficacy and safety of octreotide in the control of acute upper gastrointestinal (GI) bleeding and prevention of rebleeding, the Gastroenterology Unit, Chulalongkorn University Hospital, conducted a prospective open study in patients with acute upper GI bleeding. All patients with acute upper GI bleeding were given octreotide by intravenous infusion. The patients then had endoscopic confirmation within 24 hours, were divided into variceal and nonvariceal groups, and then randomly allocated to receive either 48 hours of octreotide infusion or 48 hours of octreotide infusion plus 72 hours subcutaneous injection. Efficacy and safety of octreotide were evaluated during the 5 days observation period. Forty-three patients with acute upper GI bleeding were treated with octreotide infusion. After endoscopy, 16 patients in the variceal group and 22 patients in the non-variceal group were randomized to receive 48 hours infusion or 48 hours infusion plus 72 hours subcutaneous infusion. Failure to control active bleeding occurred in 11 patients (28.9%) and failure to prevent rebleeding was found in 5 patients (13.2%). The results showed that the effect of octreotide infusion in controlling acute upper GI bleeding appeared to be not different between the variceal and non-variceal causes. Subcutaneous injection of octreotide for another 72 hours showed no apparent benefit for the prevention of rebleeding.

Long-term effect of interferon therapy on incidence of cirrhosis and hepatocellular carcinoma in Thai patients with chronic hepatitis B.

The aim of this study was to assess the long-term effects of interferon (IFN) therapy on the incidence of disease progression to cirrhosis and hepatocellular carcinoma (HCC) in Thai patients with chronic hepatitis B. Sixty-seven patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B who received IFN therapy were retrospectively analyzed. The average duration of follow-up was 59.4+/-30.9 months (ranging from 20 to 119 months). Seventy-two untreated patients with comparable clinical data and mean duration of follow-up served as a control group. During follow-up, 24 (35.8%) treated and 7 (9.7%) untreated patients had a sustained loss of HBeAg. However, none of the treated patients or controls became negative for hepatitis B s antigen (HBsAg). Among treated patients, the response was independent of type and dose of IFN, as well as the presence of steroid priming. In addition, 1 of 24 (4.2%) sustained responders and 6 of 43 (14%) non-responders progressed to cirrhosis whereas 16 of 72 (22.2%) in the control group progressed to such sequelae. The overall incidence of new cirrhosis in sustained responders was significantly lower than in the control group (p=0.04). HCC appeared in 11 cirrhotic patients: 9 (12.5%) in the control group and 2 (4.7%) of the non-responders, whereas none of the sustained responders developed HCC. The average period to detection of HCC was 70.5+/-12.4 months for non-responders and 65.3+/-27.6 months for the control group, with no significant differences between these groups. In conclusion, our data suggest that IFN therapy might prevent the progression of cirrhosis and the development of HCC in patients with chronic hepatitis B. These beneficial effects were particularly observed in those who achieved a sustained virological response to treatment.

Lactose intolerance and intestinal villi morphology in Thai people.

OBJECTIVE: To study the relationship of lactose intolerance and intestinal villi morphology in Thai people. MATERIAL AND METHOD: Subjects for this study were patients with functional dyspepsia who had no history of milk allergy and underwent gastroduodenoscopy. Two mucosal biopsy specimens were taken from beyond the distal end of the second part of the duodenum. The specimens were carefully orientated and were graded according to the following scheme: group I: finger shaped villi; group II: mixed finger and leaf shaped villi; group III: clubbing or blunting shaped villi. All subjects were tested for lactose malabsorption by breath hydrogen analysis after consuming 50 gram lactose. Breath hydrogen concentration was analyzed in samples collected intermittently by end-expiratory technique. A rise in breath hydrogen concentration of 20 PPM over baseline was considered evidence of lactose malabsorption. RESULTS: The twenty-five subjects were twenty females (80.0%) and five males (20.0%) who ranged in age from 18 to 53 years (mean 31 +/- 8.29). Sixteen subjects belonged to the finger shaped villi group (64.0%), five to the mixed finger and leaf shaped villi, group (20.0%) and four to the clubbing or blunting shaped villi group (16.0%). Results of breath hydrogen excretion test identified the prevalence of lactose intolerance in 68 per cent of the subjects: 15/16 (93.75%) of group I; 1/5 (20.0%) of group II and 1/4 (25%) of group III respectively (P<0.001). The symptom of diarrhea after lactose loading was correlated well in patients who had positive breath hydrogen analysis. CONCLUSION: As shown in this study, the lactose intolerance is not related to intestinal villi morphology. It is implied that primary lactase deficiency is more common in Thai people than secondary lactase deficiency.

The combined treatment of interferon alpha-2a and thymosin alpha 1 for chronic hepatitis C: the 48 weeks end of treatment results.

The efficacy and safety of IFN alpha 2a and Thymosin alpha1 combination therapy in patients with chronic hepatitis C were determined. Twelve chronic hepatitis C patients (9 M, 3F), with positive HCV-RNA and histology compatible with chronic hepatitis C were included in this open, prospective study. Each patient received a combination therapy of IFN alpha 2a 3 mU s.c. TIW and Thymosin alpha1 1.6 mg s.c. twice a week for 52 weeks. Up to the present, 11 patients are still being followed-up after the end of 52 weeks' treatment. One patient dropped out after 32 weeks of follow-up due to noncompliance. Responses to treatment were evaluated by measuring serum HCV-RNA levels determined by RT-PCR. and serum amino transferases at the end of 48 weeks of treatment (end of treatment response: ETR). There were 8 naive and 4 previously IFN treated patients with partial response with a mean age of 45.0 +/- 10.1 (mean +/- SD). The mean duration from diagnosis until treatment was 25.1 +/- 22.9 months. The mean AST, ALT, and HCV-RNA levels before treatment were 79.5 +/- 36.8 U/L, 128.3 +/- 68.5 U/L, and 3.9+1.9 x 10(5) copies/ml respectively. Serum AST, ALT, and HCV-RNA levels were significantly lower at week 24 and 48 after treatment compared to before treatment (p<0.05). Of 11 cases, complete HCV-RNA clearance at week 24 was noted in 33.3 per cent, whereas, normal alanine aminotransferase values (ALT < 40 U/L) were observed in 41.7 per cent of patients. Complete HCV-RNA clearance and normal alanine aminotransferase at week 48 were seen in 45.5 per cent of the patients. At the end of week 48, complete response occurred in 4 of 5 naive patients. Minor side effects were observed during treatment with this combination therapy and these included myalgia (33.3%), mild form of alopecia (33.3%), and weight loss (8.3%). In patients with chronic hepatitis C, Interferon alpha 2a and Thymosin alpha1 combination therapy produced a good response rate especially in naive patients with acceptable safety profile. The sustained response will be determined after the completion of follow-up for another 6 months.

Adenocarcinoma of the pancreas: the clinical experience of 45 histopathologically proven patients, a 6 year study.

A retrospective study of 45 cases of adenocarcinoma of the pancreas at Chulalongkorn University Hospital from 1993 to 1998 was reviewed by clinical and histopathological criteria. Male and female ratio was 25:20. The mean age of the patients was 59.5 +/- 10.0 years. The common presenting symptoms and signs were epigastric discomfort (80.0%), weight loss (60.0%) and jaundice (51.1%). Twenty four patients (53.3%) were screened for a tumor marker (CA 19-9) and 87.5 per cent of these had high level of CA 19-9 (> 37 IU/ml). Thirty five patients (77.8%) had tumors located in the head of the pancreas. Most of the cases were investigated by using radiological imaging (ultrasonography or computerized tomography of the abdomen). Thirty five histopathological data (77.8%) were made by the operation, and the rest (22.2%) were performed by a fine needle aspiration from the pancreatic mass or liver metastasis. Whipple operation and the bypass procedure were the most common surgical procedures in our studies. Twenty five patients (55.6%) had post treatment complications from all modalities consisting of gastrointestinal bleeding, respiratory failure and infection. However, the mortality rate within 30 days postoperatively was 8.11 per cent which was due to blood loss during the operation and infections. The post treatment mortality rate from all modalities was 33.3 per cent. The average duration from the diagnosis until death was 82.3 days.

Current status of gastric cancer in Thai patients.

To determine the current status in various aspects of gastric cancer in Thai patients, we retrospectively reviewed the records of 119 patients with histologically proven gastric cancer in King Chulalongkorn Memorial Hospital during the five-year period from 1994 to 1998. There were 72 males (60.5%) and 47 females (39.5%) with ages ranging from 22 to 91 years (mean age 60.2+/-15.1 years). Among these, 20 patients (16.8%) were younger than 40 years. The duration of symptoms prior to first presentation averaged 20 weeks and dyspepsia and weight loss were the most common complaints. Lesion location was lower third in 40.3 per cent, middle third in 31.9 per cent, upper third in 15.1 per cent and entire stomach in 3.4 per cent of patients. Adenocarcinoma was the most common histological finding (91.6%), followed by lymphoma and leiomyosarcoma (3.4% each). Helicobacter pylori infection was detected in 17 of 25 (68%). The TMN staging was as follows: stage II, 5.9 per cent; stage III, 9.2 per cent; and stage IV, 68.9 per cent. (the stage was unknown in 16%). The overall 1-year, 2-year and 5-year survival rates were 51.6 per cent, 17.5 per cent and 4.4 per cent, respectively. Management was surgical treatment in 58.9 per cent (total gastrectomy 14.5%, subtotal gastrectomy 33.3% and palliative bypass surgery in 11.1%). Systemic chemotherapy was the primary modality of therapy in 16.8 per cent and was adjuvant therapy in 18.5 per cent. The median survival time of resectable cases was 1.00+/-0.53 years, significantly longer than that of unresectable cases (0.11+/-0.03 years) (p=0.0025). However, the administration of chemotherapy did not improve the survival rate. It is concluded that, in Thailand, gastric cancer continues to be an important health problem and is generally associated with a poor prognosis.

Hemobilia: four case reports and review of the literature.

In this report, we present four cases of hemobilia. Hemobilia occurs when conditions produce an abnormal communication between blood vessels and bile ducts. Although iatrogenic procedures as causes of hemobilia have been reported with increasing frequency, non-iatrogenic etiologies are still quite rare. We, therefore, report 4 cases of hemobilia secondary to different etiologies found in our institution from 1996 to 1998, that are non-iatrogenic. The first patient was a case of congenital aneurysm, the second pseudoaneurysm from trauma, the third cholangiocarcinoma and the fourth hepatocellular carcinoma. The classical triad consists of melena, jaundice and abdominal pain. Direct observation of blood flowing from the Ampulla of Vater by endoscopy was the initial diagnostic procedure in all four cases. Diagnosis was confirmed by ultrasonography, computerized tomography, angiography or surgery. Transcatheter selective embolization as a noninvasive treatment for hepatic aneurysm/pseudoaneurysm is emphasized.

Pseudomelanosis duodeni: association with hypertension and chronic renal failure: case report.

We present the first reported case with typical endoscopic and histological findings from Thailand. An 80-year-old man presented with chronic periumbilical abdominal pain for 3 months and melena for one week. He had had hypertension for 17 years, chronic renal failure for 4 years and gouty arthritis for 3 years. Panendoscopy was done and showed diffusely scattered small black and brown pigmentation over the stomach and duodenum. Tissue biopsies from the black pigmented lesions were taken for further microscopic and histochemical evaluation. Histological finding and special histochemical stains, Fontana stain, revealed mild chronic inflammation with accumulation of hemosiderin pigment in the lamina propria of the stomach and duodenal villi. This condition is called Pseudomelanosis duodeni. The literature of this condition was also reviewed.

Fibrolamellar hepatocellular carcinoma in a Thai man who presented with hypoglycemia: case report and review of literature.

We present a case of fibrolamellar hepatocellular carcinoma (FLHCC) in a 22 year old Thai man whose presenting symptom was hypoglycemic coma with right hemiparesis. The serum marker for hepatitis B virus (HBsAg) was positive and serum AFP was very high (over 100,000 IU/ml). The abdominal ultrasonography revealed a solitary heterogenic mass, size 5.5 x 6.5 cm in the right lobe. Chest X-ray showed multiple lung metastases. Ultrasound-guided needle liver biopsy was performed and typical histologic features of FLHCC in non-cirrhotic liver were diagnosed. The patient's comatose state and neurological deficits recovered rapidly after glucose administration. Unfortunately, the tumor mass could not be resected on account of far-advanced stage with metastases. Here, we also review of the literature concerning FLHCC in many aspects.

A risk scoring system to predict outcome of non-variceal upper gastrointestinal bleeding in Thai patients.

The purpose of this study was to determine the predictors for poor outcome in patients with upper gastrointestinal bleeding (UGIB) by constructing a risk-scoring system based on retrospective data analysis and validating the scoring system prospectively. In the first phase of the study, 264 patients with acute non-variceal UGIB were retrospectively reviewed, and likely predictors of poor outcome, including major re-bleeding, need for emergency surgery to control bleeding and hospital death, were ranked into a risk scoring system. In the second phase, this scoring system was prospectively validated in 107 patients. The characteristics of the retrospective and the prospective groups were not significantly different. Four predictors of outcome were found to be significant, namely concurrent illnesses, the presence of at least one disease (score 1), heart rate above 110 beat/min (score 1), blood transfusion over 6 units (score 2) and the presence of visible vessels on endoscopic examination (score 1). Patients with a total score of less than 2 had good outcome whereas scores of 2 or more were associated with a poor outcome. The accuracy of the test was 82.5 per cent. The positive and negative predictive values were 46.3 per cent and 92.7 per cent respectively. The likelihood ratio was 4.5. It is concluded that the risk scoring system constructed in this study represents a good predictor of poor clinical outcome in patients presenting with non-variceal UGIB.

Caffeine clearance study in hepatocellular carcinoma.

The purpose of this study was to evaluate hepatic metabolic capacity in cirrhotic patients with hepatocellular carcinoma (HCC). We compared plasma caffeine clearance, calculated by two point analysis, between patients with cirrhosis alone and cirrhosis complicated with HCC. These two groups were comparable with regards to age, sex, and the severity of liver disease, graded by Child-Pugh score as compensated and decompensated cases. From our result, caffeine clearance in compensated cases was clearly higher than that of decompensated cases in both groups studied, particularly in the HCC group (p = 0.001). The mean value of caffeine clearance in HCC patients correlated well with the tumor staging as classified by Okuda's criteria. There was also a reversal correlation between tumor size and the clearance tested in compensated cases of HCC (p = 0.046), but this finding was not detected in decompensated cases (p > 0.05). We conclude that the determination of caffeine clearance can serve as a useful parameter for the assessment of hepatic functional reserve in cirrhotic patients complicated with HCC, and may be a useful predictor for survival outcome.