Helicobacter pylori status and endoscopy follow-up of patients having a history of perforated duodenal ulcer.

BACKGROUND: The aim of this study was to determine whether the recurrence of symptoms or ulcer disease in patients with a history of perforated duodenal ulcer is related to Helicobacter pylori infection. METHODS: One hundred sixty-three consecutive patients with history of perforated duodenal ulcer unrelated to nonsteroidal anti-inflammatory drugs underwent upper endoscopy. Any recurrent symptoms or complications were documented. Regardless of the endoscopic findings, three antral biopsy specimens were taken for histologic examination and a rapid urease test. RESULTS: There was a preponderance of men (male/female = 5.3:1). The mean age was 55.9 years. Sixty-seven (41.1%) patients gave a history of recurrent epigastric pain, seven of whom also had a history of bleeding ulcer. Upper endoscopy was performed at a mean of 74.5 +/- 7.1 months after operation. Positive endoscopic findings were noted in 68 (41.7%) patients; H. pylori was found in the biopsy specimens from 77 (47.2%) patients. Recurrent duodenal ulcer was found in 29 (17.8%) patients and was significantly related to male gender, recurrent epigastric pain, bleeding ulcer, longer interval from previous operation, and positive H. pylori status. Positive H. pylori status and male gender were independent factors associated with recurrent duodenal ulcer. CONCLUSIONS: Recurrent ulcer disease in patients with a history of perforated duodenal ulcer is related to H. pylori infection.

A prospective randomized trial comparing the use of omeprazole-based dual and triple therapy for eradication of Helicobacter pylori.

BACKGROUND: Controversy surrounds the optimal composition, dosage, and duration of therapies for eradication of Helicobacter pylori. We prospectively compared omeprazole-based dual and triple therapies in the eradication of H. pylori in a randomized manner. METHODS: Between June 1995 and March 1997, 1000 consecutive patients with acid-peptic disease associated with H. pylori infection (duodenal ulcer, 388 patients, gastric ulcer, 179 patients; duodenitis, 173 patients; gastritis, 260 patients) were prospectively recruited. They were randomized to either a 2-wk (OA) course of omeprazole 20 mg and amoxicillin 1 g, both given twice daily, or treatment for 1 wk (OCM) with omeprazole 20 mg once daily, clarithromycin 500 mg twice daily, and metronidazole 400 mg twice daily. RESULTS: The age of these 1000 patients ranged from 16 to 90 yr, with a mean of 54.9 yr. Side effects occurred in 29.6% (95% confidence interval [CI] 25.6-33.8%) and 10.6% (95% CI 8.0-13.6%) of patients taking OCM and OA, respectively (p < 0.0001). Apart from taste disturbance, however, there were no significant differences in the incidences of side effects between the two groups. One patient in the OA group and four patients of the OCM group could not tolerate the medications, and therefore did not complete treatment (p = 0.37). Seven and 13 patients in the OA and OCM groups, respectively, refused a second endoscopy (p = 0.25). The remaining 975 patients underwent a second endoscopy. Positive endoscopic findings were significantly more common in the OA group (51/492; 10.4%; 95% CI 7.8-13.4%) than in the OCM group (25/483; 5.2%; 95% CI 3.4-7.5%) in the per-protocol (PP) analysis (p = 0.004). On intent-to-treat (ITT) analysis, the overall eradication rates in the OA and OCM groups were 73.6% (95% CI 69.5-77.4%) and 92% (95% CI 89.3-94.2%), respectively (p < 0.0001). On PP analysis, the corresponding rates were 74.8% (95% CI 70.7-78.6%) and 95.2% (95% CI 92.9-97.0%), respectively (p < 0.0001). CONCLUSIONS: A course of omeprazole, clarithromycin, and metronidazole for 1 wk is a safe, well-tolerated, efficacious, and cost-effective treatment for H. pylori infection.

A prospective randomized trial comparing the use of the flexible gastroscope versus the bronchoscope in the management of foreign body ingestion.

BACKGROUND: Foreign body ingestion is a common clinical problem in Hong Kong. Some recent reports have proposed the use of flexible nasoendoscopy for foreign body retrieval. The present study is a prospective randomized trial on the use of the flexible gastroscope and bronchoscope in the management of foreign body ingestion. METHODS: Two hundred sixteen patients older than 11 years were prospectively randomized to flexible endoscopic examination using either the gastroscope (108 patients) or the bronchoscope (108 patients). The duration of the procedure was noted. Patients were asked to assess their overall tolerance to the procedure on a scale of 1 (well tolerated) to 10 (unacceptable). RESULTS: A foreign body was retrieved in 68 patients (31.5%). There was no difference between the two groups in the foreign body retrieval rate, type of foreign body retrieved, duration of procedure, and tolerance level. In the group managed with the bronchoscope, however, three patients required the additional use of the gastroscope for foreign body retrieval at (for one patient) or below (for two patients) the cricopharyngeus. The patient's tolerance level was related only to the duration of procedure (rho = 0.386; p < 0.001). CONCLUSION: The use of the flexible gastroscope is recommended because of its efficacy, safety, and tolerability.

A prospective comparison of locally made rapid urease test and histology for the diagnosis of Helicobacter pylori infection.

BACKGROUND: A number of noncommercial preparations of urease test have been described. The present prospective study evaluated the accuracy of one such preparation for the diagnosis of Helicobacter pylori infection. METHODS: From February 1996 to November 1996, all patients undergoing elective upper endoscopy in a single endoscopy facility were included. Three antral biopsy specimens were taken. Two specimens were subjected to histologic examination, and one specimen was placed into a "locally made rapid urease test" (LRUT). Results of histologic examinations were taken as standards for comparison. The final result of LRUT was obtained on scrutiny of color changes at 4 hours after the start of the test. RESULTS: Two thousand three hundred sixteen patients (male/female = 1.5:1) with a mean age of 56.7 +/- 0.4 years were included. Five hundred sixty-two patients (24.3%) had a history of eradication treatment for H. pylori. Nine hundred fifty-three patients (41.1%) were found to be positive for H. pylori on histologic examination. In patients in whom a history of eradication therapy was absent, the sensitivity, specificity, and positive and negative predictive values of the LRUT were 92.8%, 97.6%, 97.5%, and 93.0%, respectively. In patients with a history of eradication treatment, the corresponding figures were 76.1%, 99.6%, 96.2%, and 96.9%. CONCLUSIONS: The locally made rapid urease test provides a simple, safe, rapid, inexpensive, and accurate test for the diagnosis of H. pylori infection.

Prospective double-blind placebo-controlled randomized trial on the use of ranitidine in preventing postoperative gastroduodenal complications in high-risk neurosurgical patients.

To determine the efficacy of ranitidine in preventing clinically acute overt gastroduodenal (GD) complications (bleeding and/or perforation) after neurosurgery, 101 patients with nontraumatic cerebral disease considered at high risk of developing postoperative GD complications were randomized in a standard double-blind manner to receive either ranitidine (50 mg every 6 hours) or placebo medication preoperatively. Postoperative serial GD endoscopy was used to document the occurrence of complications: an overt symptomatic complication was defined as bleeding requiring blood transfusion and/or surgery. Fifty-two patients received ranitidine and 49 received a placebo preoperatively; 30 developed overt GD bleeding; nine of these received ranitidine and 21 received a placebo. Ranitidine significantly reduced the incidence of bleeding (p < 0.05). Multivariate logistic regression analysis revealed three factors of independent significance in predicting overt GD bleeding: use of a placebo drug, a gastric pH of less than 4, and a high daily volume of gastric output. The authors conclude that ranitidine is useful in preventing postoperative GD complications in high-risk neurosurgical patients.

Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: risk models for rebleeding and mortality.

Clinical and endoscopic data were collected prospectively in 1050 patients with bleeding peptic ulcer admitted between September 1985 and July 1989 to the care of one surgical team. Seventy-nine patients underwent therapeutic endoscopy soon after admission and in 129 patients either immediate or early elective surgery was performed. Eight hundred and forty-two patients, in whom therapeutic endoscopy was not performed at any stage, underwent initial conservative management and data from this latter group are now presented. Shock on admission was defined as systolic blood pressure (BP) less than or equal to 100 mmHg on presentation. There were 10 deaths of 147 shocked patients (6.8%) compared with only 25 deaths of 695 patients (3.6%) not in shock (P less than 0.08). Bleeding recurred in 30 patients (20.4%) shocked on presentation but in only 96 (13.8%) with a BP greater than 100 mmHg (P less than 0.05). Twenty-one of 358 patients (5.9%) with endoscopic stigmata of recent haemorrhage (ESRH) died, but only 14 of 484 patients (2.9%) without such stigmata (P less than 0.05) died. In shocked patients rebleeding was evident in 21 of 73 (28.8%) cases with ESRH but in only 9 of 74 (12.2%) patients in whom ESRH were absent (P less than 0.02). In the absence of fresh blood at endoscopy rebleeding occurred in 22 of 124 (17.8%) shocked patients and only 74 of 629 (11.8%) of those not shocked on presentation (P less than 0.07). When ulcer size was documented rebleeding rates for ulcers less than or equal to 1 cm, less than or equal to 2 cm and greater than 2 cm in size were 54 of 485 (11.1%), 30 of 142 (21.2%) and 12 of 44 (27.3%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency surgical treatment for nonvariceal bleeding of the upper part of the gastrointestinal tract.

Endoscopic and biochemical data were collected prospectively from 1,530 patients admitted with nonvariceal bleeding of the upper part of the gastrointestinal tract between September 1985 and June 1989. Therapeutic endoscopy was done for 93 patients who underwent emergency surgical treatment for bleeding, subsequently required in 29 patients with seven postoperative fatalities. In contrast, 31 (15.7 per cent) of 198 patients (mortality rate of 9.6 per cent at 30 days) died in the hospital who had undergone emergency operation in whom therapeutic endoscopy had not been performed; data for this latter group is now presented. At admission, a greater likelihood of emergency operation was associated with a systolic blood pressure of 100 millimeters of mercury and endoscopic stigmatas of recent hemorrhage (ESRH) (p less than 0.001). Rebleeding rates for the presence of fresh blood, active spurting and oozing hemorrhage or visible vessel in an ulcer base were 26.5, 28.9 and 35.9 per cent, respectively. Endoscopic stigmatas were thus associated with an increased risk of bleeding (p less than 0.0001) and rebleeding led to a sixfold increase in the mortality rate. Congestive cardiac failure, chronic obstructive airway disease, chronic renal failure and a history of previous malignant disease were each associated with postoperative mortality rates of more than 50 per cent. An increased risk of mortality after emergency operation was related to age (p less than 0.0001), preoperative (p less than 0.002) and total (p less than 0.0001) blood transfusion requirement. Immediate operation after resuscitation and endoscopy was required in 87 patients; 11 deaths (hospital mortality rate of 12.7 per cent and 9.2 per cent at 30 days) occurred in this group compared with 20 fatalities (18.0 per cent) documented in 111 patients (9.9 per cent at 30 days) who underwent surgical treatment for rebleeding. We conclude that age, concomitant medical illness and preoperative and total transfusion requirements are each related to outcome after emergency operations. Such urgent intervention is best avoided if at all possible in patients with severe concomitant medical illness.

Bleeding peptic ulcer: a prospective evaluation of risk factors for rebleeding and mortality.

Clinical, endoscopic, and laboratory data were collected prospectively in 701 patients with bleeding peptic ulcer. The overall rebleeding rate was 16.1% and increased the risk of a fatal outcome by 17 fold (1.2% versus 20.6%, p less than 0.001). Rebleeding was documented in more than 75% of the group who did not survive following initial conservative management. Rebleeding was more likely (24.1% versus 14.2%, p less than 0.02) when shock was present on admission and the risk of a rebleed was doubled in patients over 60 years of age (22.1% versus 10.9%, p less than 0.001). Ulcers greater than 1 cm in size carried twice the risk of rebleeding (23.9% versus 12.4%, p less than 0.002). Concomitant medical illness had a significant adverse effect on outcome (p less than 0.05). Shock on admission was associated with a doubling of mortality figures (9.5% versus 3.7%, p less than 0.01). The identification of endoscopic stigmata of recent hemorrhage (ESRH) tripled the risk of mortality (7.5% versus 2.4%, p less than 0.002), ESRH were more frequently encountered when ulcer size was larger than 1 cm (61.4% versus 39.8%, p less than 0.001). Respective mortality rates for ulcers less than or equal to 1 cm and greater than 1 cm in size were 1.6% and 12.5% (p less than 0.001), corresponding mortality figures for patients over 60 years of age being 4.4% and 16.4% (p less than 0.002). The risk of a rebleed tripled (6.7% versus 2.6%, p less than 0.02) when ESRH were evident. There was a 6-fold increase in mortality following emergency surgery when compared with conservative management of patients in whom no surgical intervention was necessary (2.6% versus 14.9%, p less than 0.001). In summary, age over 60 years, previous medical illness, shock on admission, large ulcer size, and ESRH were each associated with an increased risk of rebleeding and mortality.

Factors influencing the development of gastrointestinal complications after neurosurgery: results of multivariate analysis.

A retrospective review of 526 patients who underwent neurosurgery for nontraumatic conditions over a 5-year period revealed 36 (6.8%) patients with endoscopically and or surgically documented postoperative gastrointestinal (GI) complications. Two patients had GI bleeding and perforation, and the remaining patients had bleeding only. Multivariate analysis indicated 5 factors that were of independent significance in predicting the development of postoperative GI complications. These factors included 1) inappropriate secretion of antidiuretic hormone, 2) preoperative coma (Glasgow Coma Score less than 9), 3) the presence of postoperative complications, 4) age greater than or equal to 60 years, and 5) pyogenic infection of the central nervous system. Further analysis of the 36 patients with GI complications revealed that they could be divided into three groups with different clinical courses. In Group I (n = 10), all patients died as a result of their neurological conditions; GI complications were just preterminal events and did not require treatment. In Groups II (n = 11) and III (n = 15), GI complications were symptomatic and life-threatening events, respectively. Eleven patients from Group III died as a direct result of the GI complications. Separate multivariate analyses based on the patients in Groups II and III revealed that preoperative coma was the only significant factor that predicted the occurrence of life-threatening complications. Patients who are at high risk of developing postoperative GI complications can thus be identified, and intensive prophylaxis may be instituted.

Cysticercosis of the breast.

A painless lump in the breast in a 43-year-old Chinese woman was found on surgical excision to be a cysticercus presumed to be that of Taenia solium. Routine investigations failed to reveal infection at any other site.