Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli.

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

Screening for colorectal cancer: what is the most cost-effective approach?

In Western countries, including Australia, colorectal cancer is the leading cause of cancer mortality in nonsmokers. Development of most colorectal cancers can be prevented by adenoma removal. The current screening strategies of faecal occult blood testing (FOBT), flexible sigmoidoscopy combined with FOBT and colonoscopy are all cost effective. In clinical practice, a range of options should be offered to allow for individual patients' preferences. A public education program is essential to the success of any screening strategy.

Distribution of colorectal adenomas: implications for bowel cancer screening.

OBJECTIVE: To determine the distribution of colorectal adenomas relative to the splenic flexure in an asymptomatic population undergoing colonoscopy, as an indicator of the number of patients with adenomas who would be missed by screening with flexible sigmoidoscopy. DESIGN: Retrospective survey of medical records. SETTING: Private endoscopy centres in Melbourne, Victoria. SUBJECTS: All 1131 asymptomatic individuals who underwent full colonoscopy between 1 January 1995 and 31 December 1997 after referral from a bowel cancer prevention program organised by the endoscopy centres. People referred were aged either 40 years or over with a first-degree relative with bowel cancer, or 50 years or over with marked anxiety about bowel cancer. MAIN OUTCOME MEASURES: Presence and distribution of colorectal adenomas. RESULTS: Polyps were found in 270 individuals (24%) and were confirmed to be adenomas in 138 (12%). These 138 comprised 106 men and 32 women, with mean age 54 years (range, 40-78 years). Most (86%) had a single adenoma. Position of adenomas in relation to the splenic flexure was: distal only in 85 of the 138 people (62%), proximal only in 34 (25%), and both distal and proximal in 19 (14%). CONCLUSIONS: In 25% of asymptomatic people found to have adenomas by this bowel cancer prevention program, the adenomas were found only in the proximal colon, well beyond the reach of the flexible sigmoidoscope. This distribution of adenomas suggests that screening programs cannot rely solely on flexible sigmoidoscopy.

Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective method of feeding via the stomach in situations where oral intake is not possible. Its simplicity has led to its potential use in areas of dubious clinical benefit. Our unit has faced a major increase in referrals for PEG insertion over the last 2 years. For this reason we decided to audit our PEG insertion procedures with regard to indications, complications, outcome and follow up. We studied 168 patients who had an initial PEG insertion during the period 1 February 1996-31 January 1998. The medical records of these patients were reviewed with regard to the procedure, antibiotic use and complications. All patients (or carers or next of kin) were contacted by telephone to provide details regarding late complications and follow up. There were 87 females and 81 males (aged 16-98 years, median age 70 years). At 2 years, 67% were alive. The most frequent indication for PEG insertion was a neurological condition, the commonest being stroke. Most patients received either ticarcillin/clavulanic acid or cephazolin antibiotic prophylaxis before and after the procedure. In six patients (3.6%) infection at the PEG site required intravenous antibiotics. Four of these six patients did not have antibiotic prophylaxis. Only two deaths could be directly related to the procedure. Three died within 7 days of the procedure due to unrelated medical complications. Sixteen patients died within 1 month, the majority of these patients did not leave hospital. One-fifth of the patients (35/168) had their PEG removed due to the re-establishment of oral feeding, with median time of use, 4.3 months. It is a safe, effective feeding method in the elderly, but experience with case selection, the procedure and careful follow up remain essential. The use of prophylactic antibiotics resulted in few significant infections of the PEG site. Up to one-fifth of patients will require their PEG only for a short term.

Heartburn: community perceptions.

BACKGROUND AND AIMS: To determine the prevalence of heartburn in the Australian community, and document factors precipitating it and medications used in treatment. METHODS: Telephone interviews with 1200 individuals aged 18 years or more were conducted one weekend in 1996. Each respondent was asked four questions about heartburn, its severity, factors causing it and current therapy. RESULTS: Fifty-six per cent of respondents reported that they had suffered from heartburn at some time in the past and 37% had symptoms at least once every 4-6 months. The frequency of heartburn increased with age and was more common in men (40.7%) than women (32.6%). There was no difference in frequency between city and rural dwellers, or between white- and blue-collar workers. Almost half the individuals experienced mild pain or discomfort, one-third had moderate discomfort and 15% reported severe pain or discomfort. Women were more likely to report greater problems than men. Aggravating factors included spicy foods, greasy/rich foods, stress, alcohol, overeating, pregnancy, smoking, food allergy and coffee. More than half the respondents relied on antacids to control symptoms, 20% used prescription medications and a similar number did not use any medication. CONCLUSION: Heartburn is common in the Australian community and sufferers attribute symptoms to various lifestyle events, including diet and stress. Antacid usage is the commonest mode of therapy.

Lansoprazole quadruple therapy is effective in curing Helicobacter pylori infection.

BACKGROUND: Quadruple therapy using omeprazole combined with classic bismuth triple therapy has been advocated as optimal therapy for the cure of Helicobacter pylori (H. pylori) infection. We investigated the efficacy of substituting lansoprazole for omeprazole in proton pump quadruple therapy. MATERIALS AND METHODS: In a prospective open study, 219 consecutive patients, with either peptic ulcer disease or biopsy-proven H. pylori-associated gastritis, received seven days of lansoprazole, bismuth, tetracycline and metronidazole after three days of lansoprazole pretreatment. Cure of infection was judged by 14C urea breath test at six weeks after completion of therapy. RESULTS: On an intention to treat basis, 198 of the 219 patients (90%) were confirmed to be cured of H. pylori infection. Compliance was excellent and minimal side effects reported. CONCLUSION: Lansoprazole-based quadruple therapy achieves a very high cure rate in an unselected population of either peptic ulcer patients or those with H. pylori-associated gastritis. Recommended regimens should achieve at least 90% cure of infection. Lansoprazole quadruple therapy is effective and compares favorably with other H. pylori treatment regimens.

Gastrointestinal bleeding after cold biopsy.

Cold biopsy of the gastric mucosa is useful in many gastroduodenal disorders. Antral biopsies are done with increasing frequency to confirm Helicobacter pylori infection and to determine the type and content of gastritis. Gastrointestinal bleeding after gastric cold biopsy is rare. We report two patients who developed melena after cold biopsy of the gastric antrum. Repeat gastroscopies excluded lesions other than the biopsied sites as the source of bleeding. Colonoscopies in both cases did not reveal any evidence of lower GI bleed. Relevant medications include amlodipine, in case 1, and brufen, which was used in case 2 but discontinued before biopsy. Literature review has shown the rarity of clinically significant hemorrhage resulting from gastric cold biopsy. Nevertheless, all patients undergoing gastroscopy should be informed of this potential complication.

Sucralfate as an alternative to bismuth in quadruple therapy for Helicobacter pylori eradication.

BACKGROUND: There are persuasive arguments for treating all patients with Helicobacter pylori-associated peptic ulcer disease. However, the choice of therapeutic regimen remains problematical. Bismuth triple therapy produces greater than 80% cure of H. pylori infection, whereas omeprazole and bismuth quadruple therapy has produced cure rates in excess of 90%. Colloidal bismuth is not available in many countries, hence limiting the use of bismuth-based therapeutic regimens. We substituted widely available sucralfate for bismuth in a quadruple-therapy regimen. METHOD: We studied 223 consecutive patients with gastritis or peptic ulcer disease in whom H. pyori infection was confirmed by CLOtest (Delta West Ltd., Bentley, WA, Australia) or histological assessment. Successful therapy was validated by the 14C urea breath test 4 to 6 weeks after therapy. Omeprazole, 20 mg was given twice daily for 10 days. After 3 days of omeprazole sucralfate (1 gm qid), tetracycline (500 mg qid) and metronidazole (400 mg tid) were added for 7 days. RESULTS: Therapy was successful in 194 of 223 patients (87%). Compliance was excellent, with only two patients being unable to tolerate therapy. Side effects were minimal and included nausea, vomiting, headache, and vaginal moniliasis. At 6 months' follow-up, 10 of 210 patients (5%) who were previously documented as "cured" had a positive breath test. CONCLUSIONS: The wide availability of sucralfate in many countries makes it a possible alternative to bismuth for use in proton pump quadruple-therapy regimens, achieving a reasonable cure rate for H. pylori infection.

Helicobacter pylori eradication: therapy other than with bismuth or proton-pump inhibitors.

Antibiotics alone do not achieve Helicobacter (H. pylori) eradication perhaps because of reduced activity in an acid environment. Some reports suggest that ranitidine combined with amoxicillin and metronidazole is highly successful in eradicating H. pylori, but other have found less success with H2-antagonists. Studies have shown that sucralfate is equally as effective as omeprazole when combined with clarithromycin and metronidazole in achieving H. pylori eradication. Similarly, sucralfate triple therapy (substituted for bismuth) may provide cost efficient treatment. Whilst immunization to protect against Helicobacter infection seems attractive, a large amount of animal work needs to be done before the necessary tedious human trials. Future trends in H. pylori eradication may involve 1-week therapy combining proton-pump inhibitors, bismuth or sucralfate and two antibiotics. It is hoped that such regimens will be simple, effective, relatively inexpensive and free of side effects.

Helicobacter pylori and gastric neoplasia: evolving concepts.

There is evidence that Helicobacter pylori infection is associated with gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma and possibly with non-ulcer dyspepsia. Eradication therapy for confirmed H. pylori infection may therefore become mandatory in patients with non-ulcer dyspepsia severe enough to warrant endoscopy and in first-degree relatives of patients with gastric cancer. However, routine treatment of asymptomatic carriers awaits confirmation of the association with cancer.

Influence of initial therapy on outcome of peptic ulcer.

Histamine 2 (H2) receptor antagonists, proton pump inhibitors, prostaglandin analogues, colloidal bismuth and sucralfate have all proved safe and effective in the initial treatment of peptic ulcer. Yet, most ulcers will recur when treatment is stopped. Continuous maintenance with H2 antagonists results in low symptomatic relapse, complications occur rarely, and such treatment is safe. An alternative is Symptomatic Self Care (on-demand therapy), which provides an economic option for patients with no concomitant disease or previous complications. Meta-analyses suggest a higher relapse rate after H2 antagonist therapy than that following sucralfate or bismuth. Whilst improved morphology and/or functional status of the gastro-duodenal mucosa ('quality of healing') has been claimed, the difference has not been explained. Successful prolonged eradication of Helicobacter pylori leads to a very low relapse rate, but more effective, predictable and safer eradication regimens are needed.

Long-term strategies for peptic ulcer.

Commonly when treatment is stopped most peptic ulcers recur. The prevention of ulcer recurrence by continuous long-term therapy, usually with H2-receptor antagonists, provides effective and convenient management in patients at risk in order to reduce the chance of relapse, complications, and associated mortality. High relapse rates of peptic ulcer suggest the need for continuous H2-antagonists in elderly patients, those receiving NSAID, aspirin or anticoagulants, those with coexistent medical conditions and those with previous haemorrhage or perforation. Patients suitable for intermittent therapy include those who are < 60 years, with no previous ulcer complications, no coexistent medical conditions and few recurrences. Long-term H2-antagonists have an enviable safety profile and are cost effective. Despite this, the possibility of permanent cure of peptic ulcer by Helicobacter pylori eradication suggests that long-term therapy may not be needed. We face the exciting prospect of placing peptic ulcer into the annals of history.