Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding.

OBJECTIVES: To evaluate the effect of Helicobacter pylori (H. pylori) eradication on ulcer bleeding recurrence in a prospective, long-term study including 1,000 patients. METHODS: Patients with peptic ulcer bleeding were prospectively included. Prior non-steroidal anti-inflammatory drug (NSAID) use was not considered exclusion criteria. H. pylori infection was confirmed by rapid urease test, histology, or (13)C-urea breath test. Several eradication therapies were used. Subsequently, ranitidine 150 mg o.d. was administered until eradication was confirmed by (13)C-urea breath test 8 weeks after completing therapy. Patients with therapy failure received a second, third, or fourth course of eradication therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy and were controlled yearly with a repeat breath test. NSAID use was not permitted during follow-up. RESULTS: Thousand patients were followed up for at least 12 months, with a total of 3,253 patient-years of follow-up. Mean age 56 years, 75% males, 41% previous NSAID users. In all, 69% had duodenal ulcer, 27% gastric ulcer, and 4% pyloric ulcer. Recurrence of bleeding was demonstrated in three patients at 1 year (which occurred after NSAID use in two cases, and after H. pylori reinfection in another one), and in two more patients at 2 years (one after NSAID use and another after H. pylori reinfection). The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16-1.16%), and the incidence rate of rebleeding was 0.15% (0.05-0.36%) per patient-year of follow up. CONCLUSION: Peptic ulcer rebleeding virtually does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved. However, NSAID intake or H. pylori reinfection may exceptionally cause rebleeding in H. pylori-eradicated patients.

Normal values in ambulatory oesophageal pH monitoring at two levels in Spain.

AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Absence of cardiovascular autonomic dysfunction and vagal pancreatic impairment in idiopathic achalasia of the oesophagus.

Extra-oesophageal autonomic dysfunction in idiopathic achalasia is not well documented, due to contradictory results reported. We aimed to study the cardiovascular and pancreatic autonomic function in patients with idiopathic achalasia. Thirty patients with idiopathic achalasia (16M/14F; 34.5 +/- 10.8 years) and 30 healthy volunteers (13M/17F; 34.8 +/- 10.7 years) were prospectively studied. Age >60 years and conditions affecting results of autonomic evaluation were excluded. Both groups underwent the sham feeding test and plasmatic levels of pancreatic polypeptide (PP) were determined by radioimmunoassay (basal, at 5, 10, 20 and 30 min). Cardiovascular parasympathetic (deep breathing, standing, Valsalva) and sympathetic function (postural decrease of systolic blood pressure, Handgrip test) were assessed. Statistical comparison of basal and increase levels of PP and parasympathetic/sympathetic cardiovascular parameters was performed between groups. Basal levels of PP were similar in controls and patients and maximum increase of PP during sham feeding test. A similar rate of abnormal cardiovascular tests was found between groups (P > 0.05). E/I ratio was the mostly impaired parameter (patients: 36.7% vs controls: 20%, P = 0.15, chi-squared test). Autonomic cardiovascular tests and pancreatic response to vagal stimulus are not impaired in patients with primary achalasia of the oesophagus.

Oesophageal motility disorders in type 1 diabetes mellitus and their relation to cardiovascular autonomic neuropathy.

The relationship between cardiovascular autonomic neuropathy (CVAN) and oesophageal dysfunction in diabetes mellitus has not been well established because reports are contradictory. The aim of this study was to assess oesophageal function and its correlation with CVAN in type 1 diabetic patients without oesophageal symptoms. Forty-six type 1 diabetic patients without oesophageal symptoms (DG) and 34 healthy volunteers (CG) were studied. Both groups underwent CVAN tests and oesophageal manometry and pH-metry. Differences between groups regarding results of cardiovascular autonomic tests and oesophageal studies were statistically analysed. Compared with the CG, the DG group showed insufficient lower oesophageal sphincter (LOS) relaxation and a higher percentage of simultaneous waves (P < 0.01). Patients with CVAN (n = 22) showed a higher prevalence of pathological simultaneous contractions (>10%), and the prevalence of simultaneous waves related to the degree of autonomic neuropathy was: 9% of patients without CVAN, 7% of those suspected to have it and 50% of patients with CVAN (P < 0.001). Factors associated with the presence of pathological simultaneous waves (>10%) were the presence of CVAN and duration of diabetes (P < 0.05, logistic regression analysis). Increase in simultaneous waves and impaired relaxation of LOS are more frequent in diabetic patients with CVAN.

Prevalence of silent fecal and urinary incontinence in women from the town of Teruel.

OBJECTIVES: To study the prevalence of fecal (FI) and urinary incontinence (UI) in women from Teruel (Spain), as well as the clinical conditions associated with these disorders. METHODS: We studied prospectively women with an age range of 20-64 years who were randomly selected from the population seen in a primary care center because of medical disorders not related to incontinence. Patients with functional or cognitive impairment were excluded. Medical and obstetric antecedents, as well as the type and frequency of incontinence symptoms were collected in a questionnaire. RESULTS: Out of 115 women, 103 completed the study (mean age: 41+/-12 years range 20-64). UI was present in 34.9% (stress 33%, urge 14%, mixed 47%), FI in 14 (13.6%) (flatus 57%, liquid stools 43%), and 10 (9.7%) displayed both disorders. Age > 42 years and body mass index more or equal of 25 were associated with FI and UI; pregnancy was only associated with UI, but the group of women with more or equal of 2 vaginal deliveries showed a higher frequency of FI (p < 0.05, Chi squared test). In the multivariate analysis, only the presence of UI was associated with FI (OR 6.0; CI 95% 1.7-21). Association of FI and UI was more frequent in women older than 42 years (OR 16.7, CI 95% 1.9-141). No statistical differences were found when smoking, exercise, and type of childbirth were compared between the presence/absence of FI or UI. CONCLUSIONS: Urinary and fecal incontinence are frequent in women, and the coexistence of both disorders is not uncommon. Age, overweight and parity are associated with the presence of fecal and/or urinary incontinence.

Prevalencia de la incontinencia anal y urinaria silentes en mujeres de la ciudad de Teruel / Prevalence of silent fecal and urinary incontinence in women from the town of Teruel

Objetivos: conocer la prevalencia de la incontinencia anal (IA)y urinaria (IU), así como los factores asociados, en mujeres con capacidad social autónoma en la ciudad de Teruel. Métodos: estudio prospectivoa leatorizado en 115 mujeres (20-64 años) que acudieron a un centro de asistencia primaria por motivos independientes de IA o IU, sin alteraciones físicas ni psíquicas que pudieran condicionar la existencia de incontinencia. Resultados: completaron el estudio 103 mujeres (89,5%): 34,9% presentaban IU (33% de esfuerzo, 14% de urgencia y 47% mixta); 14 (13,6%) referían IA (57% a gases y 42,9% a heces líquidas) y 10 (9,7%) presentaban IA e IU. En el análisis univariante, la edad > 42 años y el índice de masa corporal > 25 se asocian con la IA y con la IU; la existencia de embarazos a término, con la IU, y la existencia de dos o más partos vaginales se correlaciona con la IA (p < 0,05). La IA se relaciona con la presencia de IU (OR 6,0; IC 95%: 1,7-21,0). No encontramos asociación con tipo de parto, hábitos tabáquico o enólico ni práctica deportiva. La doble incontinencia (IA y IU) se asocia con la edad mayor de 42 años (OR 16,7, IC 95%: 1,9-141,1). Conclusiones: en la mujer, la incontinencia urinaria, así como a gases y heces líquidas, es frecuente. La asociación de ambas (IU e IA) no es infrecuente. La edad, el sobrepeso y el mayor número de partos vaginales se asocian con la presencia de disfunción anal y/o urinaria

Objectives: to study the prevalence of fecal (FI) and urinary incontinence (UI) in women from Teruel (Spain), as well as the clinical conditions associated with these disorders. Methods: we studied prospectively women with an age range of 20-64 yrs. who were randomly selected from the population seen in a primary care center because of medical disorders not related to incontinence. Patients with functional or cognitive impairment were excluded. Medical and obstetric antecedents, as well as the type and frequency of incontinence symptoms were collected in a questionnaire. Results: out of 115 women, 103 completed the study (mean age: 41±12 yrs. range 20-64). UI was present in 34.9% (stress 33%, urge 14%, mixed 47%), FI in 14 (13.6%) (flatus 57%, liquid stools 43%), and 10 (9.7%) displayed both disorders. Age > 42 yr. and body mass index >=25 were associated with FI and UI; pregnancy was only associated with UI, but the group of women with >=2 vaginal deliveries showed a higher frequency of FI (p < 0.05, Chi squared test). In the multivariate analysis, only the presence of UI was associated with FI (OR 6.0; CI 95% 1.7-21). Association of FI and UI was more frequent in women older than 42 yr. (OR 16.7, CI 95% 1.9-141). No statistical differences were found when smoking, exercise, and type of childbirth were compared between the presence/absence of FI or UI. Conclusions: urinary and fecal incontinence are frequent in women, and the coexistence of both disorders is not uncommon. Age, overweight and parity are associated with the presence of fecal and/or urinary incontinence

Unstimulated salivary flow rate, pH and buffer capacity of saliva in healthy volunteers.

OBJECTIVES: To assess the salivary flow rate, pH, and buffer capacity of healthy volunteers, and their relationships with age, gender, obesity, smoking, and alcohol consumption, and to establish the lower-end value of normal salivary flow (oligosialia). METHODS: A prospective study was conducted in 159 healthy volunteers (age > 18 years, absence of medical conditions that could decrease salivary flow). Unstimulated whole saliva was collected during ten minutes, and salivary flow rate (ml/min), pH, and bicarbonate concentration (mmol/l) were measured using a Radiometer ABL 520. The 5 percentile of salivary flow rate and bicarbonate concentration was considered the lower limit of normality. RESULTS: Median salivary flow rate was 0.48 ml/min (range: 0.1-2 ml/min). Age younger than 44 years was associated with higher flow rates (OR 2.10). Compared with women, men presented a higher flow rate (OR 3.19) and buffer capacity (OR 2.81). Bicarbonate concentration correlated with salivary flow rate. The lower-end values of normal flow rate and bicarbonate concentration were 0.15 ml/min and 1.800 mmol/l, respectively. The presence of obesity, smoking, and alcohol consumption did not influence salivary parameters. CONCLUSIONS: In healthy volunteers, salivary flow rate depends on age and gender, and correlates with buffer capacity. Obesity, smoking, and alcohol use do not influence salivary secretion.

Dental and periodontal lesions in patients with gastro-oesophageal reflux disease.

OBJECTIVE: Dental erosion has been considered an extraesophageal manifestation of gastro-oesophageal reflux disease, but few reports have studied the relationship between this disease and other periodontal or dental lesions. The aim of this study was to investigate the prevalence of dental and periodontal lesions in patients with gastro-oesophageal reflux disease. PATIENTS AND METHODS: A total of 253 subjects were prospectively studied between April 1998 and May 2000. Two study groups were established: 181 patients with gastro-oesophageal reflux disease and 72 healthy volunteers. Clinical assessment, including body mass index and consumption of tobacco and alcohol, was performed in all subjects, as well as a dental and periodontal examination performed by a dentist physician, blind as to the diagnosis of subjects. Parameters evaluated were: (a) presence and number of dental erosion, location and severity, according to the Eccles and Jenkins index [Prosthet Dent 1979;42:649-53], modified by Hattab [Int J Prosthes 2000;13:101-71; (b) assessment of dental condition by means of the CAO index; and (c) periodontal status analysed by the plaque index, the haemorrhage index, and gingival recessions. RESULTS: Clinical parameters were similar in both groups (p > 0.05). Age was statistically associated with the CAO index, presence of dental erosion, and gingival recession (p < 0.001, Student's t-test). Compared with the control group, the percentage of dental erosion was significantly higher in the gastro-oesophageal reflux disease group (12.5 vs. 47.5%, p < 0.001, chi2-test), as was the number and severity of dental erosions (p < 0.001, Student's t-test). Location of dental erosion was significantly different between groups. Age was not statistically related to either the amount or severity of dental erosion. CAO and periodontal indices were similarly distributed between groups. CONCLUSIONS: Dental erosion may even be considered as an extraesophageal manifestation of gastro-oesophageal reflux disease. The fact that the prevalence of caries and periodontal lesions is similar in patients with gastro-oesophageal reflux disease and in healthy volunteers suggests a lack of relationship with gastro-oesophageal reflux disease.

Prospective evaluation of magnetic resonance cholangiopancreatography in patients with biliary disease: comparative study with conventional ultrasonography and endoscopic retrograde cholangiopancreatography diagnostic algorithm.

BACKGROUND: Magnetic resonance cholangiopancreatography is an accurate technique that can replace invasive diagnostic methods of the biliary and pancreatic duct. AIMS: Our aim was to assess sensitivity and specificity of magnetic resonance cholangiopancreatography and ultrasonography using the results of endoscopic retrograde cholangiopancreatography as reference, and to establish a diagnostic algorithm under which circumstances magnetic resonance cholangiopancreatography can replace endoscopic retrograde cholangiopancreatography. PATIENTS: Eighty-three patients with suspicion of biliary disease based on clinical, biochemical and ultrasonography findings were studied. METHODS: Ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were performed, comparing the results of the techniques for the determination of their sensitivity and specificity. RESULTS: Sensitivity and specificity results obtained by magnetic resonance cholangiopancreatography were: 100 and 92.8% when dilated ducts were detected (n=61); 97.4 and 97.2% in the diagnosis of choledocholithiasis (n=38); 100 and 96.7% in malignant lesions (n=14) and 81.8 and 98.4% when biliary ducts were normal. The percentage of images of diagnostic quality was 97.6%. Sensitivity and specificity achieved by ultrasonography was: 100 and 57.1% in detection of dilatation, 71 and 97.2% in choledocholithiasis, 92.8 and 96.7% in malignancy and 66.6 and 96.8% in normal ducts. CONCLUSIONS: Magnetic resonance cholangiopancreatography is a technique with high sensitivity and specificity in the evaluation of biliary ducts. Thus, magnetic resonance cholangiopancreatography may replace diagnostic endoscopic retrograde cholangiopancreatography for purely diagnostic purposes, following an initial clinical and ultrasonographic exam.

Valoración del tiempo de tránsito colónico en los pacientes con estreñimiento crónico idiopático / Measurement of colonic transit time in patients with chronic idiopathic constipation

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Outpatient management of upper digestive hemorrhage not associated with portal hypertension: a large prospective cohort.

OBJECTIVES: To evaluate the safety of outpatient management of upper GI hemorrhage (UGIH) not associated with portal hypertension. METHODS: A prospective cohort of 983 subjects who went to the Accident & Emergency Department (A&ED) of a University hospital in Valencia (Spain), for UGIH not associated with portal hypertension during 1994 to 1997 were evaluated. After evaluation in the A&ED, 216 patients (22%) were discharged and referred for outpatient follow-up, but 15 patients could not be located thus, reducing the follow-up to 201 subjects. The main outcome measures were rebleeding within 10 days, emergency surgery within 15 days, and mortality for any cause during the 30 days after the initial hemorrhaging episode. RESULTS: UGIH in subjects under outpatient care were less severe than those subjects in the hospitalized group. Hemorrhaging recurred in 7.3% of inpatients versus 0.5% of outpatients (p < 0.01); emergency surgery was required in 5.6% of the hospitalized patients and 0.5% of the outpatients (p < 0.01); a total of 20 deaths occurred in the hospitalized group (2.6%), while three (1.5%) occurred in outpatients (p = 0.26). After adjusting for several significant risk factors, outpatient management was not associated with outcomes that were worse. CONCLUSIONS: Treatment under an outpatient regime is a safe alternative for a large percentage of selected patients with UGIH not associated with portal hypertension.

Activity of Crohn's disease assessed by colour Doppler ultrasound analysis of the affected loops.

The aim of this study was to evaluate with colour Doppler ultrasound the vascular changes in the wall of the loops affected by Crohn's disease, and to establish whether these changes reflects clinical or biochemical activity of Crohn's disease. Seventy-nine patients with Crohn's disease (44 with active disease and 35 inactive patients) were studied with frequency- and amplitude-encoded duplex Doppler sonography. A group of 35 healthy volunteers were also included. The exam consisted of the search for colour signals in the walls of the loops affected by Crohn's disease, classifying the degree of vascularity with a simple scoring system into three groups: absence of colour signal (score of 0); weak or scattered colour signals (score of 1); and multiple colour signals or clear identification of vessels in the loops walls (score of 2). Doppler curves were obtained of the detected vessels with measurement of the resistive index (RI). There was a visible increase in the gut walls' vascularity in the active patients compared with those with inactive disease. The mean RI was statistically significantly lower in the gut wall vessels of the patients with active illness than that obtained in the inactive patients. Colour Doppler ultrasound is a useful tool in the assessment of activity in Crohn's disease.

Comentario / Commentary

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[Outpatient care of upper gastrointestinal hemorrhage not related to portal hypertension]. / Seguridad del control ambulatorio de la hemorragia digestiva alta no relacionada con hipertensión portal.

BACKGROUND: The handling of upper gastrointestinal hemorrhage (UGH) usually includes the hospitalization of all patients, regardless of severity and prognosis. The aim of this paper is to assess the security of the outpatient control of some UGH, after their assessment in the hospital emergency room. PATIENTS AND METHODS: Prospective cohort of 533 patients who attended over 1994 and 1995 hospital emergency room for an episode of UGH not linked to portal hypertension. After clinical and endoscopical assessment in the emergency department, 422 cases (79%) were admitted and 111 (21%) discharged for outpatient care. An analysis is presented of the characteristics of both groups, their clinical outcomes and a multivariate analysis to assess the factors associated with the decision to admit the patient. RESULTS: Outpatients were young, with less comorbidity and better haemodynamic status than hospitalized patients. Most of outpatient cases UGH was due to gastroduodenitis, oesophagitis and Mallory-Weiss syndrome, as opposed to the greater importance of peptic ulcer in those admitted. All outpatients presented clean lesions or haematic remains. 25 (5.9%) hospitalized patients presented rebleeding, vs. only 1 (0.9%) outpatient (p < 0.05). When more severity cases were excluded from hospital group, the differences were not significant. All cases with active bleeding, severe haemodynamic repercussion or without endoscopy were admitted. For the remainder, the decision to admit was associated with the presence of bleeding stigmata, haemodynamic repercussion, some causes of hemorrhage, older age, and urea levels. CONCLUSIONS: Although the scarce sample do not permit definitive conclusions, results guide towards that a substantial part of UGH not linked to portal hypertension may be monitored without hospitalizing the patient, thereby minimizing care costs and increasing the productive capacity of the hospital, without increasing risks for the patient.

Predictors of morbidity and mortality after the first episode of upper gastrointestinal bleeding in liver cirrhosis.

BACKGROUND/AIMS: Upper gastrointestinal (GI) bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. The aim of this study was to determine the independent predictors of morbidity, mortality, and survival after the first episode of GI bleeding in patients with liver cirrhosis. METHODS: In a retrospective study of 403 cirrhotic patients who were admitted in the period January 1982 to December 1994 because of a first episode of GI hemorrhage, epidemiological factors, bleeding-related variables and cirrhosis-related variables that may be associated with hepatic and extrahepatic complications, mortality at 48 h and 6 weeks, and survival up to 30 June 1996 were assessed. RESULTS: Forty-five percent of patients developed hepatic and/or extrahepatic complications, with a mortality rate of 7.4% at 48 h and 24% at 6 weeks. Renal failure, rebleeding, hepatocellular carcinoma, and hepatic encephalopathy were independent predictors of mortality. The Kaplan-Meier method showed a median survival of 30.9+/-4.5 months (95% confidence interval 22 to 39.7 months). The cumulative percentage of survivors was 60.2% at 1 year, 33.6% at 5 years, and 14% at 10 years. In a Cox's multiple regression analysis, age, hepatic encephalopathy, hepatocellular carcinoma, Child-Pugh grade, and renal failure were independently associated with long-term survival. CONCLUSIONS: The first episode of GI bleeding in patients with liver cirrhosis is associated with high morbidity and mortality. Renal failure, rebleeding, hepatocellular carcinoma, and hepatic encephalopathy were independent risk factors for early death.