Medical treatment of uncomplicated diverticular disease of the colon: any progress?

Clinical evidence supports a therapeutic approach to uncomplicated, symptomatic diverticular disease of the colon by means of increased fiber intake and cyclic administration of the non absorbable antibiotic agent rifaximin polymorph-alpha. Alternate treatments such as mesalazine and probiotics have been recently proposed but no definitive conclusions on their efficacy can be drawn until larger, randomized placebo-controlled studies will be available.

Probiotic agents in the treatment of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is characterized by abdominal pain and alterations in bowel habits. Several pathogenetic factors, such as altered intestinal motility, visceral hypersensitivity, serotonin system abnormalities and psychic disturbances have been identified. Recently, a pathogenetic role of intestinal microflora has been shown in IBS: viral or bacterial infection can trigger post-infectious IBS; some patients have small intestinal bacterial overgrowth; the composition of patients' enteric flora is altered; and minimal inflammatory changes, consistent with the pro-inflammatory role of bacteria, have been demonstrated. Probiotics may, therefore, offer a rational therapeutic approach to IBS. The data available on the use of probiotics in IBS are still limited and results of controlled clinical trials are contradictory because they have been performed using different species, dosages, treatment durations and end-points for results evaluation. A critical evaluation of the therapeutic role of the various probiotics in IBS is presented in this article.

Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomised controlled trial.

BACKGROUND: It has been speculated that midazolam may be effective in reducing the required dose of propofol during sedation. AIM: To evaluate the sparing effect of midazolam during target-controlled propofol infusion. METHODS: Two hundred-seventy patients undergoing upper endoscopic ultrasound were randomised to receive sedation with propofol plus placebo (group A) or plus midazolam (group B). Outcome parameters were the procedure duration, the discharge time and the satisfaction of patients, operator and nurse about the quality of sedation. RESULTS: The mean propofol dose administered was 364+/-207 mg in group A and 394+/-204 mg in group B. Mean procedure duration (group A: 32+/-17 min, group B: 35+/-22 min) and discharge time (group A: 39+/-30 min, group B: 38+/-24 min) were similar in both groups. No severe complications were observed. The quality of sedation was judged satisfactory for all patients by both the endoscopist and the nurse assistant without any difference between the two groups. No patient remembered the procedure or reported it as unpleasant. CONCLUSIONS: Target-controlled propofol infusion provides safe and effective sedation; premedication with low dose of midazolam does not reduce the total amount of propofol administered. Further studies are needed to compare propofol alone with propofol co-administered with opioid.

Helicobacter pylori seroprevalence in Crohn's disease: lack of influence by pharmacological treatment.

BACKGROUND/AIMS: Helicobacter pylori infection has a low prevalence in Crohn's disease, possibly because of sulphasalazine therapy. We investigated Helicobacter pylori seroprevalence in patients with Crohn's disease never treated with sulphasalazine in order to assess the possible role of antibiotic treatment. METHODOLOGY: Two groups of patients with Crohn's disease (group I: subjects treated with ciprofloxacin, metronidazole or both during the last six months; Group II: subjects who were not given antibiotics during the last six months) and a control group of 30 patients with irritable bowel syndrome were considered. IgG anti-H. pylori levels were measured in all patients. RESULTS: Serology was positive respectively in 16.6%, 13.3% and 36.6% of cases in the three groups. CONCLUSIONS: Our findings confirm the Helicobacter pylori infection is infrequent in Crohn's disease. Neither sulphasalazine nor antibiotics appear to play a role.

Review article: alternative antibacterial agents for Helicobacter pylori eradication.

Standard eradication therapies against Helicobacter pylori appear to be effective in most cases, but in clinical practice a failure rate higher than the 5-10% reported in clinical trials is often observed. Among the various reasons responsible for therapeutic failure, antibiotic resistance is becoming a major issue in some countries. A range of different antibacterial agents is currently under investigation: several macrolides, new fluoroquinolones, furazolidone and rifabutin. Although not formally tested in refractory cases, azithromycin, spiromycin, levofloxacin and furazolidone represent the most promising antibacterial agents for possible inclusion in eradication regimens. Rifabutin has been evaluated in H. pylori infections resistant to standard therapies. Although very effective, the drug is expensive and its use should be restricted to the most difficult cases to avoid the development of rifabutin resistance in Mycobacterium spp.

Long-term follow-up and serologic assessment after triple therapy with omeprazole or lansoprazole of Helicobacter-associated duodenal ulcer.

We assessed both the effectiveness of two Helicobacter pylori (Hp) eradication triple therapies and the usefulness of serology in the follow-up. Fifty patients with active or scarred duodenal ulcer were randomized to lansoprazole or omeprazole for 1 to 4 weeks, with clarithromycin 250 mg twice a day and tinidazole 500 mg twice a day for the first week. Endoscopies were scheduled before treatment, after 8 weeks, and after I year. H. pylori status was determined before therapy by rapid urease test and histology and during the follow-up by histology and culture. Serology was determined at baseline and at 6 and 12 months. The regimens were equally effective in inducing ulcer healing (95.8% vs. 87.5%) and eradicating Hp with no recurrences at 12 months. Among 44 patients eradicated, a significant reduction of immunoglobulin G (IgG) titer occurred at 6 (p < 0.0001) and 12 months (p < 0.0001). If a titer reduction of more than 30% was taken as an indicator for Hp eradication, the specificity of enzyme-linked immunosorbent assay was 75% at 6 and 95.4% at 12 months with a 100% sensitivity. Either lansoprazole or omeprazole combined with antibiotics are effective in eradicating Hp. Serology is useful for monitoring Hp eradication provided that an appropriate percent reduction in IgG titer is used after more then 6 months after therapy.

Saccharomyces boulardii in maintenance treatment of Crohn's disease.

The possible role of Saccharomyces boulardii, a nonpathogenic yeast with beneficial effects on the human intestine, in the maintenance treatment of Crohn's disease has been evaluated. Thirty-two patients with Crohn's disease in clinical remission (CDAI < 150) were randomly treated for six months with either mesalamine 1 g three times a day or mesalamine 1 g two times a day plus a preparation of Saccharomyces boulardii 1 g daily. Clinical relapses as assessed by CDAI values were observed in 37.5% of patients receiving mesalamine alone and in 6.25% of patients in the group treated with mesalamine plus the probiotic agent. Our results suggest that Saccharomyces boulardii may represent a useful tool in the maintenance treatment of Crohn's disease. However, in view of the product's cost, further controlled studies are needed to confirm these preliminary data.

Celecoxib versus diclofenac in long-term management of rheumatoid arthritis: randomised double-blind comparison.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclo-oxygenase (COX), which leads to suppression of COX-1-mediated production of gastrointestinal-protective prostaglandins. Gastrointestinal injury is a common outcome. We compared the efficacy, safety, and tolerability of long-term therapy with celecoxib, a COX-1 sparing inhibitor of COX-2, with diclofenac, a non-specific COX inhibitor. METHODS: 655 patients with adult-onset rheumatoid arthritis of at least 6 months' duration were randomly assigned oral celecoxib 200 mg twice daily or diclofenac SR 75 mg twice daily for 24 weeks. Anti-inflammatory and analgesic activity and tolerability were assessed at baseline, every 4 weeks, and at week 24. We assessed gastrointestinal safety by upper-gastrointestinal endoscopy within 7 days of the last treatment dose at centres where the procedure was available. Analysis was by intention-to-treat. FINDINGS: 430 patients underwent endoscopy (celecoxib n=212, diclofenac n=218). The two drugs were similar in management of rheumatoid arthritis pain and inflammation. Gastroduodenal ulcers were detected endoscopically in 33 (15%) patients treated with diclofenac and in eight (4%) in the celecoxib group (p<0.001). The rate of withdrawal for any gastrointestinal-related adverse event, most commonly abdominal pain, diarrhoea, and dyspepsia, was nearly three times higher in the diclofenac-treated group than in the celecoxib group (16 vs 6%; p<0.001). INTERPRETATION: Celecoxib showed sustained anti-inflammatory and analgesic activity similar to diclofenac, with a lower frequency of upper gastrointestinal ulceration or gastrointestinal adverse events, and tolerability was better.

Gastric mucosal defences in the elderly.

BACKGROUND: Elderly subjects are more prone to develop gastric injury, but human data on the state of mucosal protective mechanisms are scarce. The aim of the study was to assess gastric mucus and bicarbonate secretion as well as local microcirculation in elderly patients. METHODS: Fasting gastric juice was collected in 45 elderly patients and in 45 control subjects devoid of endoscopic gastric abnormalities. Total mucoproteins, 'mucoprotective index' (as qualitative expression of mucus secretion) and gastric bicarbonate (Feldman's method) were measured. In addition in 24 elderly patients, and in a matching group of younger subjects, gastric mucosal blood flow was measured by laser Doppler flowmetry. RESULTS: Mucus and bicarbonate production was significantly reduced (p < 0.01) in elderly patients, the quality of mucus secretion being unaltered. Gastric mucosal perfusion was also significantly decreased (p < 0. 01) in aged subjects. CONCLUSION: In the elderly gastric mucosal defences are impaired. This is in keeping with a reduced gastric prostaglandin biosynthesis and may account for the higher susceptibility of the mucosa to damaging agents. The possible role of atrophic gastritis and Helicobacter pylori infection as independent confounding factors remains to be determined.