Prevalence of esophagitis in H. pylori-positive peptic ulcer disease and the impact of eradication therapy.

BACKGROUND/AIMS: There have been recent reports of reflux esophagitis apparently occurring de novo after cure of H. pylori in peptic ulcer disease. The possibility that this phenomenon might be explained, at least in part, by unmasking of coexistent disease has not been assessed. The aim of this study was to assess the prevalence of esophagitis in H. pylori-positive peptic ulcer disease and examine the short-term impact of H. pylori therapy on the esophagus. METHODOLOGY: Esophagitis was systematically graded and the presence of hiatal hernia was noted in 244 peptic ulcer patients (duodenal 223; gastric 21) before and at least four weeks after triple therapy. H. pylori status was assessed using CLO test and histology, and esophagitis grade was assigned without knowledge of H. pylori status. RESULTS: Of the 244 patients, 49 (20%) had esophagitis which was grade 2 or more in over two-thirds. The prevalence of esophagitis was similar in duodenal and gastric ulcer patients. The presence of hiatal hernia was strongly associated with the finding of esophagitis (P < 0.001). Of 241 patients evaluable after therapy, 215 (89%) were H. pylori-negative and 26 remained H. pylori-positive. Esophagitis tended to improve or remain stable after H. pylori therapy and worsened in only 2 of the 49 patients (4%). Of 192 patients with a normal esophagus at baseline endoscopy, 14 (7%) showed evidence of esophagitis after therapy. The presence of hiatal hernia, but not cure of H. pylori, was significantly associated with the development of esophagitis. CONCLUSIONS: Our results indicate that esophagitis can coexist with peptic ulcer disease and persists after cure of H. pylori. Development of de novo esophagitis seems uncommon in the short-term after H. pylori therapy. Esophagitis in peptic ulcer disease is strongly associated with the presence of hiatal hernia.

Lansoprazole triple therapy for Helicobacter pylori--is 5 days enough?

BACKGROUND: Seven-day proton pump inhibitor triple therapy is currently the treatment of choice for Helicobacter pylori infection. It is unclear whether triple therapy for less than 7 days might preserve efficacy while at the same time improving patient acceptability and compliance. AIM: To evaluate the Helicobactericidal efficacy, ulcer healing capacity and patient acceptability of a 5-day lansoprazole-based triple therapy regimen. METHODS: Sixty-nine consecutive patients with H. pylori-positive peptic ulcer received lansoprazole 30 mg twice daily in combination with metronidazole 400 mg twice daily and clarithromycin 250 mg twice daily for 5 days. Ulcer healing medication was not continued after the 5-day regimen. H. pylori status was assessed before and at least 4 weeks after therapy by rapid urease test and histology. Adverse events and compliance were assessed by direct questioning. RESULTS: All 69 patients attended for repeat endoscopy and 63 were H. pylori-negative after therapy giving a cure rate of 91%, (95%, Cl: 85-98%). Of the 59 patients with active ulcers, 58 were healed at repeat endoscopy giving an ulcer healing rate of 98% (95% Cl: 92-100%). All patients fully complied with therapy and mild adverse events, mainly gastrointestinal, were reported by 11 patients (16%). CONCLUSIONS: Five-day lansoprazole triple therapy is an effective regimen for H. pylori infection which combines a high cure rate and ulcer healing efficacy with the advantages of excellent patient acceptability and compliance.

Eradication of Helicobacter pylori: the results of a pilot study of 3, 5 & 7 day triple antibiotic regime with bismuth for one month.

In a prospective study designed to assess the effect of duration of antibiotic therapy on the helicobactericidal and ulcer healing efficacy of bismuth therapy, groups of patients, 10 in each group, with H. pylori-positive duodenal ulcer received a triple therapy regimen consisting of colloidal bismuth subcitrate 120 mg 4 times daily for 28 days with metronidazole 400 mg 3 times daily and tetracycline 500 mg 3 times daily for the first 3, 5 or 7 days of therapy. H. pylori infection was assessed by urease test, culture and histology performed before and 4 or more weeks after completion of therapy. Three patients (30 per cent) were H. pylori-negative after therapy in the 3 day compared with 5 (50 per cent) in the 5 day and 9 (90 per cent) in the 7 day treatment groups (3 vs 7, P = 0.01; 5 vs 7, P = 0.14). Healed ulcers were seen in 7 (70 per cent) of the 3 day, in 6 (60 per cent) of the 5 day, and in 10 (100 per cent) of the 7 day treatment groups (5 vs 7, P = 0.04). Bismuth triple therapy incorporating metronidazole and tetracycline for 7 days is associated with superior H. pylori eradication and ulcer healing rates than bismuth triple incorporating antibiotics for 3 or 5 days.

One week triple therapy for Helicobacter pylori: does high-dose clarithromycin confer additional benefit?

BACKGROUND: Clarithromycin, a new acid stable macrolide antibiotic with proven efficacy against Helicobacter pylori, has been widely incorporated into eradication regimens but its optimal dosage schedule remains controversial. The standard dose of clarithromycin is 250 mg twice daily. METHODS: In a prospective study designed to evaluate the helicobactericidal efficacy, patient acceptability, and ulcer healing efficacy of a triple therapy regimen incorporating high dose clarithromycin, 100 consecutive patients with H. pylori-positive peptic ulcer received omeprazole 20 mg twice daily in combination with metronidazole 400 mg twice daily and clarithromycin 500 mg twice daily for seven days. H. pylori status was assessed before and at least 4 weeks after therapy by rapid urease test and histology. Adverse events and compliance were assessed by direct questioning. RESULTS: Only two patients failed to attend for repeat endoscopy, leaving 98 evaluable patients. Of these, 94 were H. pylori-negative after therapy, giving an intention-to-treat eradication rate of 94% (95% confidence interval, 89%-99%). The ulcer healing rate was 92% (86%-98%), and ulcer healing was significantly associated with H. pylori eradication (p < 0.01). Adverse events were reported by 33% of patients of which nausea was the commonest (14%). Noncompliance with therapy was significantly associated with H. pylori treatment failure (p < 0.001). CONCLUSIONS: Seven day triple therapy incorporating high dose clarithromycin effectively eradicates H. pylori and heals ulcers, but it is disadvantaged by a relatively high rate of adverse events. In view of these findings and the fact that no direct comparison to date has shown increased efficacy from high dose clarithromycin, we would recommend continued use of low dose clarithromycin when combined with omeprazole and a nitroimidazole.

Effect of Helicobacter pylori eradication on peptic ulcer healing.

In a prospective study designed to assess the effect of Helicobacter pylori eradication on peptic ulcer healing, 85 consecutive patients with H. pylori-positive peptic ulcer disease were treated with a triple therapy regimen consisting of colloidal bismuth subcitrate 120 mg four times daily for 28 days, with metronidazole 400 mg three times daily and tetracycline 500 mg three times daily for the first seven days of treatment. H. pylori status was assessed by CLO test and histology at least four weeks after completing therapy. Of 75 patients (88%) H. pylori-negative after therapy, 69 (92%) had healed ulcers compared with only five of 10 patients (50%) who remained H. pylori-positive (p = 0.003). Cigarette smoking had no significant effect on ulcer healing. Our results suggest that H. pylori eradication may accelerate ulcer healing and provide further evidence that an effective helicobactericidal regimen is the treatment of choice in H. pylori-positive peptic ulcer.

Helicobacter pylori and gastro-oesophageal reflux disease--a prospective study.

In a prospective evaluation of the relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease (GORD), 93 consecutive patients (47 female: 46 male: mean age, 46 years: range 13-93) with symptoms and endoscopic evidence of GORD were studied. A total of 50 patients (54%) were H. pylori-positive on gastric antral biopsies. No significant correlation was detected between H. pylori status and grade of oesophagitis. The prevalence of H. pylori infection showed a gradual increase with age. Of 64 patients with a hiatal hernia, 28 (44%) had histological evidence of H. pylori infection of the hernia mucosa; 27 of these patients (96%) had associated H. pylori in the gastric antrum. Of the 36 patients whose hiatal hernia was H. pylori-negative, only 6 (17%) had antral H. pylori (P < 0.001). Of the 8 patients found to have Barrett's oesophagus, only 1 had H. pylori detected on the Barrett's mucosa. Our results do not support the presence of a significant association between H. pylori infection and GORD.

Esophagoatrial fistula.

The author describes a case of esophagoatrial fistula--an extremely rare condition. A 79-year-old-man had had epigastric pain for 4 weeks. Physical and roentgenographic examinations disclosed atrial fibrillation with a systolic murmur and an ulcer of the lower esophagus which, on histologic examination, was benign. No specific treatment was recommended. The patient died suddenly 3 months later from massive gastrointestinal hemorrhage which, at autopsy, was found to be due to an esophagoatrial fistula. A review of the literature showed that this case differed from others previously reported in that the duration of symptoms up to the time of death was only 4 months and the patient had no embolism.