Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study.

BACKGROUND: Early computed tomography (CT) (within 4 full days after symptom onset) may be performed to distinguish acute pancreatitis (AP) from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed practice and yield of early CT in patients with an established clinical diagnosis of AP in a Dutch cohort (EARL study). METHODS: Multicenter observational study. Etiology, disease course, CT timing, Balthazar CT score, and clinical management were evaluated. RESULTS: First documented hospital admissions of 166 patients were analyzed. Etiology was biliary (42.8%), unknown (20.5%), alcoholic (18.1%), post-endoscopic retrograde cholangiopancreatography (11.4%), and miscellaneous (7.2%). In 89.2% (148/166), the disease course was mild. Out of 18 patients with severe AP, 11 eventually developed (peri)pancreatic necrosis. At least one CT (range 1-12) was performed in 47% (78/166) of all patients and in 62.8% (49/78) it was acquired within 4 full days after symptom onset. Practice, timing, and Balthazar CT score of early CTs were not significantly different between mild and severe AP. None of the early CTs showed necrosis and no alternative diagnoses were established. In 89.8% (44/49), clinical management was not altered after early CT. In 10.2% (5/49), prophylactic antibiotics were started, but in absence of necrosis. CONCLUSIONS: A CT scan was frequently acquired early in the course of AP, but its yield was low and had no implications with regard to clinical management. It seems prudent that clinicians should be more restrictive in the use of early CT, in particular in mild AP, to prevent unnecessary radiation exposure and to save costs.

Colonoscopy-controlled intra-individual comparisons to screen relevant neoplasia: faecal immunochemical test vs. guaiac-based faecal occult blood test.

BACKGROUND: Guaiac-based faecal occult blood tests (g-FOBTs) are most commonly used in colorectal cancer (CRC) screening programmes. Faecal immunochemical tests (FITs) are thought to be superior. AIM: To compare performance of a g-FOBT and a quantitative FIT for detection of CRCs and advanced adenomas in a colonoscopy-controlled population. METHODS: We assessed sensitivity and specificity of both FIT (OC-sensor) and g-FOBT (Hemoccult-II) prior to patients' scheduled colonoscopies. RESULTS: Of the 62 invasive cancers detected in 1821 individuals, g-FOBT was positive in 46 and FIT in 54 (74.2% vs. 87.1%, P = 0.02). Among 194 patients with advanced adenomas, g-FOBT was positive in 35 and FIT in 69 (18.0% vs. 35.6%, P < 0.001). Sensitivity for screen relevant tumours (197 advanced adenomas and 28 stage I or II cancers) was 23.0% for g-FOBT and 40.5% for FIT (P < 0.001). Specificity of g-FOBT compared to FIT for the detection of cancer was 95.7% vs. 91.0%, P < 0.001) and for advanced adenomas (97.4% vs. 94.2%, P < 0.001). CONCLUSIONS: Faecal immunochemical test is more sensitive for CRC and advanced adenomas. Sensitivity of FIT for screen relevant tumours, early-stage cancers and advanced adenomas, is significantly higher. Specificity of g-FOBT is higher compared with FIT.

Nutritional management of patients with acute pancreatitis: a Dutch observational multicentre study.

BACKGROUND: Following a nil per os (NPO) regimen, most patients with acute pancreatitis (AP) can resume normal oral intake within 1 week. If not tolerated, it is recommended to initiate artificial feeding, preferably by the enteral route. AIM: To evaluate the nutritional management of patients with AP in a Dutch cohort (EARL study). METHODS: Observational study in 18 hospitals. Total days of NPO, tube feeding (TF) with/without oral feeding, total parenteral nutrition (TPN) and total starvation time were analysed. RESULTS: In mild AP, a majority of cases (80.7%, 117/145) were managed with an NPO regimen only. Twenty-seven patients (18.6%) with mild AP additionally received TF; one received TPN. Of those with severe AP, more than half of the patients (56.2%, nine of 16) were treated with TF besides an NPO regimen; four received TPN. TF was delivered preferably via the jejunal route. The median period of total starvation was 2 days for both mild and severe AP. Only 5.5% (nine of 164) of patients had a prolonged starvation time of more than 5 days. CONCLUSIONS: The total time of starvation was limited in a majority of patients admitted for AP. According to international guidelines, additional nutritional interventions were quickly undertaken with enteral feeding via the jejunum as the preferred route.

[The effect of Helicobacter pylori eradication on chronic use of acid-suppressant medication by patients in general practice; a randomised, double-blind study]. / Het effect van Helicobacter pylori-eradicatie op chronisch gebruik van maagzuursecretieremmende medicatie door patiënten in de huisartsenpraktijk; een gerandomiseerd, dubbelblind onderzoek.

OBJECTIVE: To study the feasibility of tapering long-term acid-suppressant drugs (ASD) use in chronic dyspeptic patients in relation to Helicobacter pylori eradication. DESIGN: Prospective randomised double-blind study. METHOD: Patients from 54 general-practitioner practices in the Amsterdam area were studied in the period 1 April 1997 - 30 September 1999 after selection on the basis of their use of acid suppressants for a period of at least 8 weeks. After gastroscopy the patients with a peptic ulcer (PUD) and H. pylori were treated with eradication therapy and patients without an ulcer but with H. pylori were randomised for eradication or placebo treatment. After a gradual reduction of acid suppressants over a 3-week period following the intervention, the patients kept a diary for 24 weeks of the quantities of acid suppressants and antacids they used. RESULTS: Of the 1083 patients approached, 434 were prepared to undergo the gastroscopy. Data for the follow-up period were available for 186 of the 227 H. pylori-positive patients. Of them 61% stopped ASD use during follow-up. The mean daily ASD dosage per patient decreased by 85% from 1.85 to 0.27 units (p < 0.05), with minimal antacids use. Of the 75 patients with peptic-ulcer disease 86% stopped ASD use. In patients with functional dyspepsia no difference in ASD use was observed after successful H. pylori eradication or placebo. Patients with mild reflux disease (GERD) used more ASD after H. pylori eradication than after placebo (p < 0.05). CONCLUSION. After H. pylori eradication many patients with PUD stopped ADS use, while GERD patients used more ASD than after placebo. A gradual withdrawal of long-term ASD use, supported by antacids and on-demand use of low-dosage ASD, facilitated reduction of ASD use during 6 months.

Helicobacter pylori and gastro-oesophageal reflux disease: association and clinical implications. To treat or not to treat with anti-H. pylori therapy?

BACKGROUND: It has been reported that patients are at risk of developing reflux oesophagitis after successful anti-Helicobacter pylori therapy, and the presence of the bacterium might be protective against the development of reflux oesophagitis. METHODS: Review of the literature. RESULTS: H. pylori is relevant to the management of oesophagitis because it increases the pH-elevating effect of proton-pump inhibitors. which increase the tendency of H. pylori gastritis to progress to atrophic gastritis, and because eradication of H. pylori increases the likelihood of oesophagitis. H. pylori increases basal gastrin levels, basal acid output, meal-stimulated maximal acid output and 24-h intragastric acidity. The effects on gastric acid production depend on the distribution of gastritis in the stomach. CONCLUSION: H. pylori eradication may induce or exacerbate gastro-oesophageal reflux by its influence on gastric acidity and the antisecretory action of proton-pump inhibitors.

Helicobacter pylori and functional dyspepsia. What to do after the Maastricht II consensus meeting?

BACKGROUND: Despite many clinical studies, there is still much discussion on the relation between Helicobacter pylori and functional dyspepsia. METHODS: Critical review of recommendations for H. pylori eradication in dyspepsia. RESULTS: The debate can be separated into three major problems. First, how to identify the dyspeptic patient suffering from H. pylori infection. Second, is H. pylori infection causative for complaints in this patient? Third, what is the clinical course of functional dyspepsia after successful H. pylori eradication? In the recent Maastricht II consensus, it is strongly recommended that H. pylori-positive patients with functional dyspepsia should be treated with anti-H. pylori therapy. In this review, the pros and cons of H. pylori eradication in patients with functional dyspepsia are discussed. The reader can decide what is the best management of an individual patient. CONCLUSIONS: This review gives the relevant background information allowing clinicians to decide what the best management is in individual H. pylori-positive patients with dyspepsia.

How do primary care physicians use long-term acid suppressant drugs? A population-based analysis of Dutch general practices.

OBJECTIVES: A considerable proportion of the medication budget of Dutch general practitioners is spent on prescribed long-term acid suppressant drugs. We investigated the magnitude of long-term prescription of acid suppressant drugs in general practice and the frequency and means of confirming the primary working diagnosis. STUDY DESIGN: We used a retrospective descriptive study of 24 general practices in the Amsterdam region. POPULATION: We identified those receiving long-term acid suppressant therapy (12 or more weeks/year) from a total of 46,813 patients by extracting data from pharmacy databases. OUTCOMES MEASURED: We measured the amount and duration of prescriptions for each medication, indications for prescription, and investigations performed by general practitioners. RESULTS: Of the 46,813 patients, 922 (2%) received long-term acid suppressant therapy. The duration of prescription varied from 12 weeks in 8% of patients to > 52 weeks in 23% of patients (mean = 33 weeks). In 25% of patients, no investigations were performed; 75% of patients underwent endoscopy or ingested a barium meal. The predominant diagnoses in investigated patients were ulcer disease (39%), gastroesophageal reflux disease (49%), and functional dyspepsia (gastritis, normal aspect; 18%). Helicobacter pylori status was available in 29% of patients with ulcer disease. Eradication therapy was reported in 44% of these patients. CONCLUSIONS: Among patients of physicians in general practice in the Amsterdam region, 2% used long-term acid suppressants. Patients with ulcer disease may stop taking acid suppressants after apparent successful H pylori eradication. Tapering strategies must be developed for patients with mild reflux disease or functional dyspepsia.