Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan.

A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

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."

The corpus-predominant gastritis index may serve as an early marker of Helicobacter pylori-infected patients at risk of gastric cancer.

BACKGROUND: To eradicate Helicobacter pylori before the occurrence of precancerous changes is important to prevent gastric carcinogenesis. AIM: To validate whether the corpus-predominant gastritis index (CGI) can serve as an early marker to identify the H. pylori-infected patients at risk of gastric carcinogenesis. METHODS: This study enrolled 188 subjects, including 43 noncardiac gastric cancer patients, 63 of their first-degree relatives and 82 sex- and age-matched duodenal ulcer patients as controls. All received endoscopy to provide topographic gastric specimens to test for H. pylori infection and its related histological features, translated into the operative link on gastritis assessment (OLGA), operative link on gastric intestinal metaplasia assessment (OLGIM) stages, and the presence of CGI. Spasmolytic polypeptide-expressing metaplasia (SPEM) was assessed by immunohistochemistry staining of trefoil factor 2. RESULTS: Gastric cancer patients had higher prevalence of CGI and OLGIM stage II-IV, but not OLGA stage II-IV, than the controls (P = 0.001, OR = 3.4[95% CI: 1.4-8.1] for CGI; OR = 5.0[95% CI: 2.0-12.8] for OLGIM). In patients with the combined presence of CGI and OLGIM stage II-IV, the risk of gastric cancer increased to 9.8 (P < 0.001). The first-degree relatives of the gastric cancer patients had a higher rate of the presence of CGI, but not OLGA or OLGIM stage II-IV than the duodenal ulcer controls (P = 0.001). Of the first-degree relatives, the presence of CGI increased the risk of SPEM (P = 0.003, OR = 5.5[95% CI: 1.8-17.0]). CONCLUSION: The corpus-predominant gastritis index, which is highly correlated to SPEM, may serve as an early marker to identify the H. pylori-infected patients at a higher risk of gastric cancer.

Tumor length assessed by miniprobe endosonography can predict the survival of the advanced esophageal squamous cell carcinoma with stricture receiving concurrent chemoradiation.

There were tumor strictures commonly encountered in the esophageal squamous cell carcinoma (ESCC) to limit the conventional echoendoscope for exact tumor staging and size measurements. This study evaluated the role of miniprobe endosonography (EUS) to predict the survival of ESCC patients after concurrent chemoradiation therapy (CCRT). This study prospectively enrolled ESCC patients to receive high-frequency miniprobe EUS for the assessments of the tumor size and tumor-node-metastasis (TNM) stage. For the patients defined with advanced stages to receive CCRT as initial therapy, the tumor size parameters assessed by EUS were analyzed for their correlation with the treatment response and the patients' survivals. Fifty-four patients, >96% with advanced TNM stage III or IV, were enrolled with a medium follow-up of 320.5 days. Almost all of the 54 cases had partial or complete stricture of the esophageal lumens due to the tumor obstructions at enrollment. The overall median survival was 18.6 months, and the 1- and the 2-year survival rates were 64.9 and 45.2%, respectively. Patients with initial tumor length <6 cm assessed by the pre-CCRT EUS had a better survival than those with length ≥6 cm (median survival: >56.5 months vs. 11.5 months, P= 0.006). The patients with initial tumor length <6 cm had a higher rate of downstage than those with tumor length ≥6 cm after the first course of CCRT (80.0% vs. 16.7%, P= 0.035). Multivariate Cox regression confirmed the initial tumor length (hazard ratio [HR]= 1.21, P= 0.034) as well as the presence of distal metastasis are both independent predictors of the survival in ESCC patients receiving CCRT. For the ESCC patients, commonly with tumor stricture, the miniprobe EUS to assess tumor length before CCRT can predict the treatment response and the survivals.

Different roles of host and bacterial factors in Escherichia coli extra-intestinal infections.

Many host and bacterial factors contribute to the development of different Escherichia coli extra-intestinal infections. The aim of this study was to evaluate the roles of host and bacterial factors in different extra-intestinal E. coli infections. A total of 221 E. coli isolates collected from urine, bile and peritoneal fluid were included in this retrospective study. Four main phylogenetic groups of E. coli, 14 genetic determinants, static biofilm formation and antimicrobial resistance data were assessed, as well as the immunological status of the hosts. Group B2 was the most common phylogenetic group (30%), especially in cases of asymptomatic bacteriuria (ABU), urinary tract infection (UTI), acute appendicitis/gastrointestinal perforation, and spontaneous bacterial peritonitis (SBP), and was associated with elevated prevalence of papG III, fimH, sfa, iha, hlyA, cnf1, ompT and usp. Phylogenetic group A was most common in the isolates from asymptomatic bacteriocholia, biliary tract infection, and peritoneal dialysis (PD)-related peritonitis. There was similarity with respect to both phylogenetic groups and virulence factors in strains from faeces and ABU, and in strains from faeces and SBP/PD-related peritonitis. Host characteristics were important in patients with ABU, UTI, and SBP/PD-related peritonitis. Immunocompetence of hosts was associated with a relatively high prevalence of papG II, afa and iha, and relatively low antimicrobial resistance to fluoroquinolones. This study demonstrates that, in most E. coli extra-intestinal infections, phylogenetic group B2 was predominant and was more virulent than the three other phylogenetic groups in the Taiwanese population studied. The diverse patterns of host and bacterial factors demonstrate that there were different host and bacterial factors dominating in different extra-intestinal E. coli infections.

Mixed infections of Helicobacter pylori: tissue tropism and histological significance.

Mixed infections with Helicobacter pylori facilitate interstrain gene transfer and the maintenance of genetic diversity for adaptation to the gastric environment, but whether mixed infections with histological significance and tissue tropism occur in the human stomach is still unclear. Helicobacter pylori was isolated from the antrum and the corpus of 30 dyspeptic patients. Four to eight colonies were randomly collected from each site. The genetic diversity of each isolate was evaluated by comparing random amplified polymorphic DNA banding patterns. The prevalence of mixed infections was 23.3% (7/30), and different dominant strains were isolated from the antrum and the corpus specimens. In the 23 patients infected with a single strain, the acute inflammation (AI) score, chronic inflammation (CI) score, atrophy (AT) score and lymphoid follicle (LF) score of the antrum were usually higher than those of the corpus (p 0.05). Moreover, the patients with mixed infections had marginally higher CI and HPD scores than those with single-strain infection (p 0.062 and p 0.095, respectively) in the corpus and had a significantly higher rate of appearance of intestinal metaplasia (IM) in the antrum (p 0.005). These data show that H. pylori tissue tropism was found in the human stomach, and suggest that mixed infections could change the histological features in the antrum and in the corpus, and that they could be associated with the appearance of IM in the antrum.

The presence of dental disease can be a risk factor for recurrent Helicobacter pylori infection after eradication therapy: a 3-year follow-up.

BACKGROUND AND STUDY AIM: We investigated whether dental disease might be associated with a higher recurrence of Helicobacter pylori infection after successful eradication by triple therapy. PATIENTS AND METHODS: Consecutive patients with successful H. pylori eradication, defined by negative results for both histology and (13)C-urea breath test (UBT) performed 6 weeks after triple therapy, were enrolled in the study. Each patient was scheduled for serial UBT and dental assessments at the end of the first, second, and third years. Patients were categorized into a "dental disease" group or "no dental disease" group at the first-year follow-up. Patients in the dental disease group whose dental disease had been cured during the second- and third-year follow-up periods, were transferred to a "dental treatment" group. RESULTS: The first-year H. pylori recurrence rate was higher in the 159 patients with dental disease than in those 200 patients without dental disease (13.2 % vs. 3.5 %, P < 0.001; relative risk [95 %CI], 4.2 [1.7 - 10.1]). At both the second-year and the third-year follow-up, the annual H. pylori recurrence rates were higher in the dental disease group than in the no dental disease group or dental treatment group (second year, 18.4 % vs. 2.8 % or vs. 5.7 %, P < 0.001; third year, 20 % vs. 3.8 % or vs. 6.3 %, P < 0.001). CONCLUSION: The presence of dental disease could predispose to recurrent H. pylori infection after successful eradication. Dental surveillance and care after H. pylori eradication is a rational step for preventing recurrence of H. pylori, especially in those with dental diseases.

Esomeprazole 40 mg twice daily in triple therapy and the efficacy of Helicobacter pylori eradication related to CYP2C19 metabolism.

AIM: To determine whether an increased dosage of esomeprazole 40 mg twice daily in triple therapy improved the Helicobacter pylori eradication rate for patients with different genotypes of S-mephenytoin 4'-hydroxylase (CYP2C19). METHODS: Two hundred H. pylori-infected dyspeptic patients were randomized to receive clarithromycin 500 mg twice daily and amoxicillin 1 g twice daily plus either omeprazole 20 mg or esomeprazole 40 mg twice daily for 1 week. Six weeks later, the success of H. pylori eradication was defined. The genotyping of CYP2C19 in each patient was defined as homologous, heterologous extensive metabolizer or poor metabolizer. RESULTS: The age, gender, drug compliance and proportion of CYP2C19 genotypes were similar between the two groups. The H. pylori eradication rates were also similar between the omeprazole group and the esomeprazole group (intention-to-treat analysis: 79% vs. 86%, P > 0.05; per-protocol analysis: 85% vs. 94%, P > 0.05). For patients classified as homologous extensive metabolizers, the per-protocol H. pylori eradication rate was significantly higher in the esomeprazole group than in the omeprazole group (93% vs. 76%, P < 0.05). CONCLUSION: Esomeprazole 40 mg twice daily for triple therapy may improve the H. pylori eradication compared to omeprazole-based therapy, but only for homologous extensive metabolizers of CYP2C19.

Computerized diagnosis of Helicobacter pylori infection and associated gastric inflammation from endoscopic images by refined feature selection using a neural network.

BACKGROUND AND STUDY AIM: We investigated whether analysis of endoscopic images using a refined feature selection with neural network (RFSNN) technique could predict Helicobacter pylori-related gastric histological features. PATIENTS AND METHODS: A total of 104 dyspeptic patients were prospectively enrolled for panendoscopy and gastric biopsy for histological evaluation using the updated Sydney system. The endoscopic images of each patient were analyzed to obtain 84 image parameters. The significant image parameters from 30 randomly selected patients (15 with and 15 without H. pylori infection) associated with histological features were used to develop the RFSNN model. This was then used to test the sensitivity and specificity of the image parameters obtained from the remaining 74 patients for the prediction of the presence of H. pylori infection and related histological features. RESULTS: The RFSNN technique had a sensitivity of 85.4 % and a specificity of 90.9 % for the detection of H. pylori infection. Moreover, RFSNN was highly accurate (> 80 %) in predicting the presence of gastric atrophy, intestinal metaplasia and the severity of H. pylori-related gastric inflammation. CONCLUSIONS: RFSNN is an effective computerized technique for assessing the presence of H. pylori infection and related gastric inflammation and precancerous lesions. By using RFSNN to analyze endoscopic images, a comprehensive evaluation of the stomach may be done, thus avoiding the need for invasive but localized biopsy sampling for histological examination.

Quadruple therapy containing amoxicillin and tetracycline is an effective regimen to rescue failed triple therapy by overcoming the antimicrobial resistance of Helicobacter pylori.

AIM: To identify optimal antibiotics for second-line quadruple therapy of Helicobacter pylori after failed 1-week triple therapy. METHODS: One hundred patients were enrolled in this study after the failure of 1-week triple therapy. They were randomized to receive 1-week quadruple therapy consisting of amoxicillin, omeprazole and bismuth salts, plus either metronidazole or tetracycline. Before quadruple therapy, the H. pylori culture of each patient was tested for metronidazole resistance or clarithromycin resistance by E-test. Six weeks later, an endoscopy or 13C-urea breath test was used to define the success of H. pylori eradication. RESULTS: The H. pylori eradication rates by intention-to-treat and per protocol analysis were higher in the tetracycline group than in the metronidazole group (intention-to-treat: 78% vs. 58%, P < 0.05; per protocol: 89% vs. 67%, P < 0.05). In the metronidazole group, but not in the tetracycline group, the per protocol eradication rate of quadruple therapy was lower for the infected isolates with metronidazole resistance than for those without metronidazole resistance (77% vs. 33%, P < 0.05). CONCLUSION: Quadruple therapy, including tetracycline and amoxicillin, improves the H. pylori eradication rate after failed triple therapy.

Host gastric Lewis expression determines the bacterial density of Helicobacter pylori in babA2 genopositive infection.

BACKGROUND AND AIMS: We tested if host gastric Lewis antigens and the babA2 genotype of Helicobacter pylori correlated with clinicohistological outcome. METHODS: We enrolled 188 dyspeptic patients (45 with duodenal ulcer, 45 with gastric ulcer, and 98 with chronic gastritis) with H pylori infection, proved by culture and gastric histology, reviewed by the updated Sydney system. Gastric expression of Lewis (Le) antigens Le(a), Le(b), Le(x), and Le(y) was determined immunochemically to determine intensity (range 0-3). The corresponding 188 H pylori isolates were screened for babA2 genotype by polymerase chain reaction. RESULTS: All H pylori isolates had a positive babA2 genotype. We identified Le(a) in 33.5%, Le(b) in 72.9%, Le(x) in 86.2%, and Le(y) in 97.4% of biopsies from these 188 patients. Patients who expressed Le(b) had a higher H pylori density than those who did not express Le(b) (p<0.001). Among 139 patients who expressed Le(b), H pylori density increased with a higher Le(b) intensity (p<0.05). Gastric atrophy decreased with Le(b) intensity and thus resulted in lower H pylori density in the antrum (p<0.05). For the 49 patients without gastric Le(b) expression, H pylori density was positively related with Le(x) and Le(a) expression (p<0.05). CONCLUSIONS: Taiwanese H pylori isolates are 100% babA2 genopositive. Gastric Le(b) as well as Le(x) intensity may be major determinants of H pylori density. While lacking gastric Le(b) expression, Le(x) and Le(a) were closely related to H pylori colonisation.

The selection of triple therapy for Helicobacter pylori eradication in chronic renal insufficiency.

AIM: To establish a triple therapy regimen for Helicobacter pylori eradication in patients with chronic renal insufficiency. METHODS: Eighty-eight patients with chronic renal insufficiency and H. pylori infection were evenly randomized into two groups receiving 1-week lansoprazole, 30 mg, clarithromycin, 500 mg, and either amoxicillin, 750 mg, or metronidazole, 500 mg, twice daily. The adverse events and compliance with triple therapy were reviewed at the week 1 visit. Patients provided stool samples at week 6 to assess the success of H. pylori eradication by H. pylori-specific stool antigen. The serum creatinine levels were monitored at enrollment, at weeks 1, 2 and 6 and on any unscheduled visit after triple therapy. RESULTS: The success of H. pylori eradication was higher in the lansoprazole-clarithromycin-metronidazole group than in the lansoprazole-clarithromycin-amoxicillin group (intention-to-treat analysis: 84% vs. 66%, P < 0.05: per protocol analysis: 93% vs. 76%, P < 0.05). Complete drug compliance was also better in the lansoprazole-clarithromycin-metronidazole group than in the lansoprazole-clarithromycin-amoxicillin group (77% vs. 52%, P < 0.05). Patients in the lansoprazole-clarithromycin-metronidazole group had a lower risk of acute renal failure than those in the lansoprazole-clarithromycin-amoxicillin group (2% vs. 18%, P < 0.05; relative risk, 0.128, 95% confidence interval, 0.016-0.979). CONCLUSIONS: Triple therapy with metronidazole and clarithromycin, but not amoxicillin, can be used for H. pylori eradication in patients with chronic renal insufficiency, because it is more effective, well tolerated and less likely to cause deterioration of renal function.

Impact of supplement with Lactobacillus- and Bifidobacterium-containing yogurt on triple therapy for Helicobacter pylori eradication.

AIM: To test whether supplements of Lactobacillus- and Bifidobacterium-containing yogurt (AB-Yogurt) affect the success of Helicobacter pylori eradication. METHODS: One hundred and sixty H. pylori-infected patients were randomized into a triple-plus-yogurt group or a triple-only group, receiving 1 week of triple therapy with and without supplements of AB-Yogurt, respectively. In the triple-plus-yogurt group, AB-Yogurt was continued for 4 weeks after triple therapy. Eight weeks later, patients were assessed for the success of H. pylori eradication. The stool samples of 22 randomly selected patients, 11 from each group, were provided on enrolment, at the first week and at the fifth week for evaluation of the percentage of Bifidobacterium in anaerobes. RESULTS: By intention-to-treat analysis, the triple-plus-yogurt group had a higher H. pylori eradication rate than the triple-only group (91% vs. 78%, P < 0.05). The per protocol H. pylori eradication rates were similar for both groups (93.5% vs. 89%, P = N.S.). Only patients supplemented with AB-Yogurt showed restoration of the percentage of Bifidobacterium in the anaerobes of stools at the fifth week to the level in the stools on enrolment. CONCLUSIONS: Supplement with AB-Yogurt can improve the intention-to-treat eradication rates of H. pylori, and can restore the depletion of Bifidobacterium in stools after triple therapy.

Impact of intravenous omeprazole on Helicobacter pylori eradication by triple therapy in patients with peptic ulcer bleeding.

AIM: To test the impact of intravenous omeprazole on Helicobacter pylori eradication for bleeding peptic ulcers. METHODS: A total of 175 H. pylori-infected patients with bleeding peptic ulcers were randomized into either an omeprazole group or a ranitidine group, receiving intravenous omeprazole or ranitidine for 3 days after endoscopy. Afterwards, 1-week triple therapy was used to eradicate H. pylori for both groups. Six weeks later, either a 13C-urea breath test or follow-up endoscopy was performed to assess the success of H. pylori eradication. RESULTS: The rebleeding rate was lower in the omeprazole group vs. the ranitidine group (6% vs. 17%, P < 0.05). The H. pylori eradication rate was higher in the omeprazole group (intention-to-treat analysis: 83% vs. 66%, P < 0.05; per protocol analysis: 93% vs. 80%, P < 0.05). For patients with duodenal ulcers, the per protocol H. pylori eradication rate of the omeprazole group was higher than that of the ranitidine group (93% vs. 73%, P < 0.05). CONCLUSIONS: Intravenous omeprazole can decrease the risk of rebleeding of peptic ulcers. For duodenal ulcers, in particular, intravenous omeprazole may even improve the H. pylori eradication rate of the subsequent triple therapy.