Optimised empiric triple and concomitant therapy for Helicobacter pylori eradication in clinical practice: the OPTRICON study.

BACKGROUND: Empiric triple therapy for Helicobacter pylori should be abandoned when clarithromycin resistance rate is >15-20%. Optimisation of triple therapy (high-dose acid suppression and 14-day duration) can increase eradication rates by 10%. AIM: To compare the efficacy and safety of optimised triple (OPT-TRI) and nonbismuth quadruple concomitant (OPT-CON) therapies. METHODS: Prospective multicentre study in 16 Spanish centres using triple therapy in clinical practice. In a 3-month two-phase fashion, the first 402 patients received an OPT-TRI therapy [esomeprazole (40 mg b.d.), amoxicillin (1 g b.d) and clarithromycin (500 mg b.d) for 14 days] and the last 375 patients an OPT-CON treatment [OPT-TRI therapy plus metronidazole (500 mg b.d)]. RESULTS: Seven-hundred seventy-seven consecutive patients were included (402 OPT-TRI, 375 OPT-CON). The OPT-CON therapy achieved significantly higher eradication rates in the per-protocol [82.3% (95% CI = 78-86%) vs. 93.8% (91-96%), P < 0.001] and intention-to-treat analysis [81.3% (78-86%) vs. 90.4% (87-93%), P < 0.001]. Adverse events (97% mild/moderate) were significantly more common with OPT-CON therapy (39% vs. 47%, P = 0.016), but full compliance with therapy was similar between groups (94% vs. 92%, P = 0.4). OPT-CON therapy was the only significant predictor of successful eradication (odds ratio, 2.24; 95% CI: 1.48-3.51, P < 0.001). The rate of participating centres achieving cure rates ≥ 90% favoured OPT-CON therapy (OPT-TRI 25% vs. OPT-CON 62%). CONCLUSIONS: Empiric OPT-CON therapy achieved significantly higher cure rates (>90%) compared to OPT-TRI therapy. Addition of metronidazole to OPT-TRI therapy increased eradication rates by 10%, resulting in more mild adverse effects, but without impairing compliance with therapy.

Daño hepático y enfermedad celíaca / Liver damage and celiac disease

La enfermedad celiaca (EC) es una causa importante de elevaciónde transaminasas: entre un 5 y un 10% de los pacientes con elevacióncrónica, criptogénica, de las transaminasas presentan EC y, alcontrario, la EC puede estar asociada a diferentes enfermedades hepáticas.En efecto, un amplio abanico de patología hepática puedeasociarse a EC, tanto en niños como en adultos, que pueden resumirseen: a) daño hepático mínimo caracterizado por la ausencia desíntomas o signos clínicos asociables a una enfermedad hepática crónicay con cambios histológicos no específicos que desaparecen despuésde la introducción de una dieta sin gluten; b) hepatopatías deetiología autoinmune, incluyendo la hepatitis autoinmune, la colangitisesclerosante primaria y la cirrosis biliar primaria, en las que la respectivaevolución no está influenciada por la introducción de dieta singluten; y c) insuficiencia hepática grave y cirrosis hepática criptogénicadescompensada, potencialmente tratables con la dieta sin gluten.Todas estas patologías están condicionadas por diferentes factoresindividuales y por una predisposición genética. La progresióny la reversibilidad del daño hepático en los diferentes cuadrospatológicos, pueden estar condicionadas por la exposición al gluteny la edad, precoz o tardía, en la cual ha sido introducido en ladieta. Hay suficiente evidencia clínica para recomendar un atentocribado cruzado tanto para el diagnóstico del daño hepático asintomáticoen los pacientes con EC como para el diagnóstico de laEC en los pacientes con daño hepático criptogénico

Celiac disease (CD) is an important cause of serum aminotransferaseelevation: between 5 and 10% of patients with persistentand cryptogenetic transaminase elevation may have CD. Infact, a wide spectrum of liver injuries in children and adults maybe related to CD, particularly: a) mild parenchymal damage characterizedby absence of any clinical signs or symptoms suggestingchronic liver disease, and by non-specific histological changes reversibleon a gluten-free diet; b) chronic liver damage with autoimmuneetiology, including autoimmune hepatitis, primary sclerosingcholangitis, and primary biliary cirrhosis, which may beassociated with CD but are generally unaffected by gluten withdrawal;and c) severe liver failure and decompensated cryptogeneticliver cirrhosis, potentially treatable with a gluten-free diet.Such different types of liver injuries may represent one same disorderwhere individual factors, such as genetic predisposition,precocity, and duration of exposure to gluten may influence reversibilityof liver damage. A rigorous cross-checking for asymptomaticliver damage in CD individuals and, conversely, for CD inany cryptogenic liver disorder, including end-stage liver failure, isrecommended

Prognostic value of hepatic venous pressure gradient for in-hospital mortality of patients with severe acute alcoholic hepatitis.

BACKGROUND: Hepatic venous pressure gradient (HVPG) has prognostic value in complications and survival of patients with liver cirrhosis. However, the relationship between HVPG and the outcome of acute alcoholic hepatitis (AAH), as well as the specific features of portal hypertension syndrome in this setting, have not been defined. AIMS: To evaluate the prognostic value of HVPG and to analyse the degree of portal hypertension and hyperdynamic circulation in patients with severe AAH. METHODS: Early measurements of HVPG were performed in 60 patients with severe AAH, and compared with the haemodynamic findings of 37 and 29 liver transplantation candidates with alcoholic or viral end-stage cirrhosis respectively. RESULTS: Twenty-three patients (38%) died during hospitalization. Portal hypertension and hyperdynamic circulation were more severe in AAH patients. HVPG was greater in non-survivors [26.9 (7.4) vs. 19.4 (5.2) mmHg, P < 0.001]. Only 4/31 (13%) patients with HVPG 22 (P < 0.001). Encephalopathy (OR 9.4; CI 1.4-64.8), Model for End-Stage Liver Disease (MELD) score > 25 (OR 7.4; CI 1.4-39.9) and HVPG > 22 mmHg (OR 6.7; CI 1.1-39.9) were independently associated to in-hospital mortality. CONCLUSIONS: Early measurement of HVPG provides important prognostic information on the short-term outcome of patients with severe AAH. In addition, MELD score also seems to be a strong prognostic factor in these patients.

[Liver damage and celiac disease]. / Daño hepático y enfermedad celíaca.

Celiac disease (CD) is an important cause of serum aminotransferase elevation: between 5 and 10% of patients with persistent and cryptogenetic transaminase elevation may have CD. In fact, a wide spectrum of liver injuries in children and adults may be related to CD, particularly: a) mild parenchymal damage characterized by absence of any clinical signs or symptoms suggesting chronic liver disease, and by non-specific histological changes reversible on a gluten-free diet; b) chronic liver damage with autoimmune etiology, including autoimmune hepatitis, primary sclerosing cholangitis, and primary biliary cirrhosis, which may be associated with CD but are generally unaffected by gluten withdrawal; and c) severe liver failure and decompensated cryptogenetic liver cirrhosis, potentially treatable with a gluten-free diet. Such different types of liver injuries may represent one same disorder where individual factors, such as genetic predisposition, precocity, and duration of exposure to gluten may influence reversibility of liver damage. A rigorous cross-checking for asymptomatic liver damage in CD individuals and, conversely, for CD in any cryptogenic liver disorder, including end-stage liver failure, is recommended.

[Liver abscess and Crohn' disease. Report of 3 cases]. / Absceso hepático y enfermedad de Crohn. Presentación de 3 casos.

Liver abscess is a rare complication of Crohn's disease. Its prevalence and mortality are higher in patients with Crohn's disease than in the general population. Owing to its nonspecific clinical presentation, which may be mistaken for reactivation of Crohn's disease or be masked by simultaneous steroid therapy, a high index of suspicion is required for an early diagnosis and prompt treatment. We report 3 cases of Crohn's disease complicated with liver abscess in which the only common features were the absence of clinical or even endoscopic activity of Crohn's disease at diagnosis and the presence of an anastomotic leak due to right ileocolectomy in the previous year. In all patients, outcome was satisfactory with antibiotic therapy and percutaneous catheter drainage.