Clarithromycin-resistant genotypes and eradication of Helicobacter pylori.

BACKGROUND: Three point mutations (A2143G, A2142G, and A2142C) have been involved in Helicobacter pylori clarithromycin resistance. OBJECTIVE: To compare the eradication rates among the different point mutations and the efficacy of triple therapy and a sequential regimen according to genotypic resistance. DESIGN: Post hoc subgroup study from a multicenter, randomized trial. SETTING: Two hospitals in central and southern Italy between January and December 2001. PATIENTS: 156 patients with H. pylori infection. MEASUREMENTS: Real-time polymerase chain reaction for assessing clarithromycin resistance; histology, rapid urease test, and 13C-urea breath test at entry and after 4 to 6 weeks. INTERVENTION: 7-day triple therapy (20 mg of rabeprazole, 500 mg of clarithromycin, and 1 g of amoxicillin) in 75 patients or a 10-day sequential regimen (20 mg of rabeprazole plus 1 g of amoxicillin for 5 days and 20 mg of rabeprazole, 500 mg of clarithromycin, and 500 mg of tinidazole for the remaining 5 days) in 81 patients. All drugs were given twice daily. RESULTS: Helicobacter pylori infection was eradicated in 11 of 23 patients (48%) with the A2143G mutation and in 14 of 15 patients (93%) with either A2142G or A2142C strains (difference, 45 percentage points [95% CI, 15 to 65 percentage points]; P = 0.004). The sequential regimen achieved a higher cure rate than triple therapy in A2143G mutate strains (difference, 49 percentage points [CI, 8 to 72 percentage points]; P = 0.024). LIMITATIONS: The post hoc substudy design may require further confirmation. Other limitations are the accessibility to the tool and the cost of investigations (70 euros per patient). CONCLUSIONS: The A2143G mutation seemed to be associated with a very low eradication rate. The sequential regimen achieved a higher cure rate than standard therapy even in patients with these strains.

[Prosthetic treatment in inoperable cancers of the oesophagus and cardia: a report of 7 cases]. / Il trattamento protesico nelle neoplasie inoperabili dell'esofago e del cardias: contributo di 7 casi.

The Authors report their personal experience with 9 patients affected by cardial cancer and 4 with medio-distal oesophageal cancer, treated at the Department of Surgical Sciences of the University of Foggia. Of the 9 patients with cardial cancers, 4 were submitted to total gastrectomy; while the other 5, who had clearly inoperable forms, were fitted with a self-expanding metal prosthesis (Ultraflex). Of the 4 cases with medio-distal oesophageal cancers, which were considered beyond any kind of surgical treatment, 2 (with stenosing forms) were fitted with the self-expanding prosthesis (Ultraflex), while the other 2 (with friable, bleeding tissue) were treated by laser therapy with all the drawbacks such treatment entails. After application of stents, dysphagia decreases and on the whole we obtain real functional success and a better quality of life. Furthermore, the percentage of acute complications such as profuse bleeding, perforation of the pharynx or migration of the prosthesis and late complications such as obstruction by food, neoplastic obstruction, or haemorrhage is marginal. Finally, the ease of application and the economic saving achieved (due to reduction in hospitalisation time and charges) confer undeniable additional advantages on the procedure.

Argon plasma coagulation of hemorrhagic solitary rectal ulcer syndrome.

Solitary ulcer syndrome (SUS) is a rare disorder that may provoke hematochezia. Argon plasma coagulation (APC) is used in a wide range of gastrointestinal bleeding. We experienced APC in a patient with a bleeding gigantic SUS: a 64-year-old woman who developed a SUS at 60. After 3 years, recurrent hematochezia, secondary anemia, and rectal pain occurred. Endoscopy revealed a large rectal bleeding ulcer. Moreover, the pain led the patient to assume analgesics. These conditions stimulated us to treat this ulcer with APC within 4 sessions; each session spaced out at 30-day intervals. The patient experienced and maintained the following benefits: (1) resolution of bleeding and secondary anemia after the first session, (2) reduction of ulcer depth, disappearance of pain and analgesic withdrawal at the end of the cycle, (3) almost complete endoscopic healing of the ulcer after 9 months of follow-up. This experience suggests that APC may represent a therapeutic approach for bleeding SUS even if controlled studies are necessary before recommending it as acceptable treatment.