Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus

"OBJECTIVE: Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus. METHODS: A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. RESULTS: A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. CONCLUSIONS: These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region."

Low and high doses of rabeprazole vs. omeprazole for cure of Helicobacter pylori infection.

BACKGROUND: Low-dose rabeprazole-based triple therapy was effective for Helicobacter pylori eradication in a few Japanese studies. AIM: To compare the effectiveness of 1-week low-dose and high-dose rabeprazole-based triple therapy with those of omeprazole. METHODS: One hundred and sixty-two H. pylori-infected dyspeptic patients were randomized to receive twice daily for 1 week either rabeprazole 10 mg (R10), rabeprazole 20 mg (R20) or omeprazole 20 mg (O) in combination with amoxicillin 1,000 mg (A) and clarithromycin 500 mg (C). H. pylori status assessment was by the CLO test and histology at entry and by the 13C-urea breath test at 4-6 weeks after cessation of therapy. RESULTS: H. pylori eradication rates in intention-to-treat groups were 85%, 96% and 83% for R10AC, R20AC and OAC, respectively. Eradication rates in per protocol groups were 86%, 96% and 90% for R10AC, R20AC and OAC, respectively. On an intention-to-treat analysis, the R20AC group had a significantly higher eradication rate than did R10AC or OAC (P < 0.05). However, the higher eradication rate with R20AC did not reach statistical significance in the per protocol analysis. Drug intolerance was found in three OAC patients. CONCLUSION: High-dose rabeprazole-based triple therapy is more effective than its low-dose equivalent or omeprazole in eradicating H. pylori infection.

Diagnostic value of endoscopic transampullary biopsy for malignant bile duct stricture.

Bile duct stricture, either benign or malignant, usually presented with jaundice, is a common surgical condition. Clinically the diagnosis is made empirically on the basis of clinical data and a telltale cholangiogram without histologic confirmation. Benign stricture, therefore, might be misinterpreted as malignancy. To obtain tissue confirmation, endoscopic transampullary biopsies were performed in 32 patients with clinically suspected malignant biliary stricture, between August 1997 and July 1998. Of these 32 patients, 16 patients each had biopsy-positive and biopsy-negative for malignancy. In the 16 biopsy-positive patients, 11 underwent exploratory laparotomy, and the other 5 did not. Of the 11 who were explored, 8 had histology confirmed malignancy, surgical biopsy was not feasible in the 3 remaining patients. The 5 patients who were not explored, all died within 5 months after the diagnosis was made. In the 16 biopsy-negative patients, 9 underwent exploratory laparotomy, of which 4 had malignancy confirmed histologically, 2 had no malignancy by histology but subsequently had clinical evidence which suggested malignancy, in the 3 remaining patients surgical biopsy was not feasible, however, their clinical courses suggested a benign condition. Of the 7 patients whose transampullary biopsies were negative, and who were not explored, 5 had a clinical course and evidence suggesting malignancy, of these 5 patients 4 died 1, 2, 3 and 10 months after the diagnosis, and one was lost to follow-up. The 2 remaining patients who had no clinical evidence of malignancy remained alive even 2 years after the follow-up. Of the patients who underwent exploratory laparotomy and surgical biopsy, the sensitivity, specificity, positive predictive value and negative predictive value for transampullary biopsy were 66.7 per cent, 100 per cent, 100 per cent and 31.3 per cent respectively. There were no major complications related to transampullary biopsy per se. The results suggested that transampullary biopsy is an effective and safe procedure for diagnosing malignant bile duct stricture.

The effect of hyperglycaemia on cerebral potentials evoked by rapid rectal distension in healthy humans.

BACKGROUND: Acute hyperglycaemia affects the perception of sensations arising from the gastrointestinal tract. The mechanisms responsible for this effect are unknown. Recordings of cerebral evoked potentials (EPs) can be used to assess the integrity of visceral afferent pathways. Our aim was to determine whether hyperglycaemia affects EPs elicited by rectal distension in healthy humans. MATERIALS AND METHODS: Twelve healthy men, aged 19-31 years, were studied. A manometric catheter, incorporating a rectal balloon, was positioned 7-10 cm from the anal verge. Balloon distensions at both 'low' ( approximately 20 mL) and 'high' ( approximately 28 mL) volumes were performed, in a single-blind, randomized order, during both euglycaemia (4 mmol L-1) and hyperglycaemia (12 mmol L-1). EPs were recorded from a midline scalp electrode (Cz, International 10-20 system) and averaged for each series of 50 distensions. EP latencies and interpeak amplitudes were calculated. RESULTS: Polyphasic EPs were recorded in all but one subject. Although the blood glucose concentration had no significant effect on the latencies of the EP peaks elicited by either 'low'- or 'high'-volume balloon distension, the interpeak amplitude (P1-N1) was greater during hyperglycaemia than during euglycaemia at the 'low' balloon volume (6.3 +/- 1.2 microV vs. 4.8 +/- 1.0 microV, P < 0.05). The blood glucose concentration had no significant effect on the perception of rectal balloon distension. CONCLUSIONS: We conclude that in normal subjects acute hyperglycaemia increases the amplitude of the cerebral EP elicited by rectal balloon distension at low balloon volumes, suggesting that the effects of hyperglycaemia on gastrointestinal sensation may be mediated by central mechanisms.

Roxatidine versus ranitidine in the treatment of duodenal ulcer: a randomized, double blind, controlled, multicenter study in Thailand.

BACKGROUND: Roxatidine acetate is a novel H2-receptor antagonist and several studies have shown that it is effective in healing duodenal ulcers. We evaluated the efficacy of roxatidine in a non-western society with particular different features and its healing of duodenal ulcers was compared in Thailand with that of ranitidine. METHOD: The design was controlled, randomized, double-blind, and multicenter. The study recruited a total of 215 patients who were endoscoped at the start of the trial and then randomized to receive a single capsule of roxatidine acetate, 150 mg, or an identical capsule containing ranitidine, 300 mg, both to be taken at night. Patients were evaluated at 1, 2, and 4 weeks, including endoscopy at the last session, as well as at 6 weeks with repeat endoscopy if the ulcer had not healed. RESULT: Both drugs relieved pain rapidly, usually within a week, and at repeat endoscopy at 4 weeks most ulcers (78%) were healed, 77.0 and 79.5 per cent in ranitidine and roxatidine, and in those patients in whom healing was not completed the healing rate had risen appreciably to 89.8 and 93.8 per cent respectively at 6 weeks. Small ulcers tended to heal quicker than larger ones, but smoking and alcohol intake had no negative effects on the results. CONCLUSION: The study was valid proof that roxatidine, in a single evening dose of 150 mg, was found to be both safe and effective in the rapid healing of duodenal ulcers when compared with 300 mg ranitidine.