Adherence to treatment in inflammatory bowel disease.

AIM: Adherence to therapy is important to ensure success. We wanted to explore this feature in patients with inflammatory bowel disease. PATIENTS AND METHODS: We explored adherence to treatment and its modifiers in 40 patients with inflammatory bowel disease using a battery of tests. RESULTS: A 67% of patients (95% CI: 51-81%) acknowledged a certain degree of involuntary nonadherence, and 35% (95% CI: 20-51%) of voluntary nonadherence. Overall, 72% (95% CI: 56-85%) of patients had some form of nonadherence. An objective correlation of these self-reported data was assessed by the determination of urine salicylate levels in the subset of patients treated with mesalazine or its derivatives (15 cases). Two of them (13%) had no detectable urinary drug levels, indicating complete nonadherence. Voluntary nonadherence was higher in patients with lower scores in the intestinal (p = 0.02) and social areas (p = 0.015) of IBDQ-32, as well as in those with less active Crohn s disease (p < 0.005), patients with high depression scores and high patient-physician discordance (p = 0.01), patients with long-standing disease (p = 0.057), patients who considered themselves not to be well informed about the treatment they were getting (p = 0.04) or who trusted their attending physicians less (p = 0.03). CONCLUSIONS: Intentional nonadherence to therapy is prevalent among patients with inflammatory bowel disease. A correction of factors associated to poor adherence could lead to higher therapeutic success.

Long-term persistence of molecular disease after histological remission in low-grade gastric MALT lymphoma treated with H. pylori eradication. Lack of association with translocation t(11;18): a 10-year updated follow-up of a prospective study.

BACKGROUND: Localized low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma can regress after Helicobacter pylori eradication, but IgV(H) gene monoclonality may persist. We studied the long-term histological and molecular follow-up of 24 patients and the possible association of t(11;18) with the persistent monoclonality. PATIENTS AND METHODS: From January 1994, 24 untreated patients with stage I low-grade gastric MALT lymphoma associated with H. pylori were prospectively studied. They all received eradication treatment and were sequentially followed-up with endoscopies for histological and molecular studies. Rearrangement of the IgV(H) gene was studied by PCR analysis. MALT1 locus alterations were studied by FISH. RESULTS: Twenty-two of the 24 patients (91%) achieved disappearance of the lymphoma. Eighteen (82%) of the 22 histologically cured patients and 16 of the 19 (84%) with long follow-up had monoclonality. Three patterns of development of IgV(H) gene rearrangements were observed: four patients (21%) had polyclonal rearrangements; eight (58%) had maintained/intermittent monoclonality and four (21%) had occasional monoclonality, mostly after H. pylori reinfection. Only one patient (6%) with persistent monoclonality relapsed. The remaining 18 patients maintained the remission, despite the persistent monoclonality in 15, for a median of 66 months (range 20-113). t(11;18) was not found in any of the patients with persistent monoclonality. Time and the number of endoscopies performed were not related with the occurrence of monoclonality. CONCLUSIONS: In stage I low-grade gastric MALT lymphoma eradication of H. pylori achieves prolonged histological remission in 90% of patients, but molecular remission is not accomplished in most cases. Molecular disease persists for years, but is not associated with t(11;18).

Adhesión al tratamiento en la enfermedad inflamatoria intestinal / Adherence to treatment in inflammatory bowel disease

Objetivo: la adhesión al tratamiento es importante para el éxito del mismo. Quisimos conocer este dato en pacientes con enfermedad inflamatoria intestinal. Pacientes y métodos: hemos explorado la adhesión al tratamiento y sus condicionantes en 40 pacientes con enfermedad inflamatoria intestinal, aplicando una batería de pruebas. Resultados: un 67% (IC 95%: 51-81%) de los pacientes presentaba algún grado de falta involuntaria de adhesión. A su vez, un 35% (20-51%) de los pacientes presentaba algún grado de falta voluntaria de adhesión. Globalmente, un 72% (56-85%) de los pacientes presentó uno u otro tipo de falta de adhesión. El correlato objetivo, se obtuvo mediante la determinación de salicilatos en orina en el subgrupo de pacientes bajo tratamiento con mesalazina o derivados (15 casos). Dos de ellos (13%), no tenían niveles detectables, traduciendo falta absoluta de adhesión al tratamiento. La adhesión intencionada era tanto más baja cuanto menores eran las puntuaciones en las áreas intestinal (p=0,02) y social (p=0,015) del IBDQ-32, así como en aquellos con enfermedad de Crohn menos activa (p < 0,005), pacientes con puntuaciones altas de depresión y alta discordancia con el médico (p = 0,01), pacientes con largo tiempo de evolución de su enfermedad (p = 0,057), los que no se consideraban bien informados acerca de sus medicaciones (p = 0,04) o con menos confianza en sus médicos (p = 0,03). Conclusiones: la falta de adhesión intencionada es prevalente en este grupo de pacientes. La corrección de los factores que la predicen puede mejorar los resultados terapéuticos

Aim: adherence to therapy is important to ensure success. We wanted to explore this feature in patients with inflammatory bowel disease. Patients and methods: we explored adherence to treatment and its modifiers in 40 patients with inflammatory bowel disease using a battery of tests. Results: a 67% of patients (95% CI: 51-81%) acknowledged a certain degree of involuntary nonadherence, and 35% (95% CI: 20-51%) of voluntary nonadherence. Overall, 72% (95% CI: 56-85%) of patients had some form of nonadherence. An objective correlation of these self-reported data was assessed by the determination of urine salicylate levels in the subset of patients treated with mesalazine or its derivatives (15 cases). Two of them (13%) had no detectable urinary drug levels, indicating complete nonadherence. Voluntary nonadherence was higher in patients with lower scores in the intestinal (p = 0.02) and social areas (p = 0.015) of IBDQ-32, as well as in those with less active Crohn's disease (p < 0.005), patients with high depression scores and high patient-physician discordance (p = 0.01), patients with long-standing disease (p = 0.057), patients who considered themselves not to be well informed about the treatment they were getting (p = 0.04) or who trusted their attending physicians less (p = 0.03). Conclusions: intentional nonadherence to therapy is prevalent among patients with inflammatory bowel disease. A correction of factors associated to poor adherence could lead to higher therapeutic success

Pyoderma gangrenosum associated with ulcerative colitis: response to infliximab.

Pyoderma gangrenosum is an extraintestinal manifestation of inflammatory bowel disease that can be therapeutically troublesome. We comment on the case of a patient with clinically inactive ulcerative colitis who progressively developed necrotic lesions on both tibial aspects of his legs, which corresponded both clinically and histologically to pyoderma gangrenosum. Treatment with steroids and azathioprine could not control this complication. A single dose of infliximab 5 mg/kg was given, achieving an impressive response of the skin lesions followed by complete healing 3 months later. Infliximab can be useful in the management of refractory extraintestinal manifestations of inflammatory bowel disease.

Seven-day proton pump inhibitor, amoxicillin and clarithromycin triple therapy. factors that influence Helicobacter pylori eradications success.

AIM: To evaluate which factors influence eradication success with standard triple therapy for Helicobacter pylori. PATIENTS AND METHODS: A prospective study was made of 891 patients infected by H. pylori and diagnosed with duodenal ulcer (n=422), gastric ulcer (n=221), or functional dyspepsia (n=248). Initially, an endoscopy with biopsies of antrum and body (haematoxylin-eosin stain), and a 13C-urea breath test were performed. All patients were treated for seven days with either omeprazole 20 mg twice daily in 442 patients (OCA) or pantoprazole 40 mg twice daily in 449 patients (PCA), associated to clarithromycin (500 mg twice a day) and amoxicillin (1 g twice a day). Two months after completing therapy urea breath test was repeated to confirm eradication. RESULTS: Mean age +/- SD was 51.6 +/- 15 years, 61% were male. Overall eradication rate was 73.7% (95% CI 69-77%) and 80.8% (77-84%) with OCA and PCA therapy, respectively, showing significant difference between treatment regimens (chi 2 =6.3; p= 0.01). As refers to underlying diseases, H. pylori eradication was achieved in 77.4% (74-80%) of peptic ulcers and 77% (71-82%) of functional dyspepsia (p=n.s.). With our two treatment regimens (OCA/PCA) eradication success was 74/81% in peptic ulcer (p=0.03), and 72/80% in functional dyspepsia (p=0.1). In the multivariate analysis, type of therapy was the only variable that correlated with eradication success (odds ratio 1.5; 95% CI: 1.1-2.1) (chi2 model: 6,4; p=0.01). CONCLUSIONS: Standard triple therapy containing a proton pump inhibitor, clarithromycin and amoxicillin for seven days achieves in our community a moderate eradication success; this result could improve by using pantoprazole instead of omeprazole. This therapy is equally effective in patients with peptic ulcer and functional dyspepsia.

Acute pancreatitis in childhood.

AIM: to evaluate etiological agents involved in acute pancreatitis in children, as well as clinical, laboratory and radiological findings and the illness clinical course. PATIENTS AND METHODS: we reviewed the cases of acute pancreatitis diagnosed over the last 15 years. The criteria used for cases to be included were acute abdominal pain, elevated serum amylase levels and/or ultrasound abnormalities in the pancreatic area in conscious patients, and the last two criteria in unconscious patients. RESULTS: thirty-one children were included (average age 7.9 years, range 2-15; 55% males). Infection and gallstones were the most common causes (19 and 16 %, respectively). In all, 9.7% of cases were drug-related (valproic acid, L-asparaginase, azathioprine combined with high doses of methylprednisolone); 6.5% were traumatic in origin and another 6.5% was due to systemic diseases. In 35.5 % no cause was found (idiopathic). The most frequent symptoms were abdominal pain (90%) and emesis (38%). Amylase serum levels were elevated in all patients. Abdominal ultrasound scans were abnormal in 64%, with an increase in the pancreatic area in 48% and hypoechogenicity in 51%. Seven cases required surgical treatment (22%). Seven children had acute pancreatitis, and three of them died as a result of shock unrelated to pancreatitis. Relapse of disease occurred in 19% of patients. CONCLUSIONS: acute pancreatitis should always be considered in children with abdominal pain. There are a wide variety of etiological factors and in a high percentage of patients no underlying cause is found. Prognosis is variable owing to the heterogeneity of the clinical course of this illness in children.

Pancreatitis aguda en la infancia / Acute pancreatitis in childhood

Objetivo: evaluar los agentes etiológicos implicados en los cuadros de pancreatitis aguda en los niños, así como los hallazgos clínicos, de laboratorio y radiológicos, y el curso evolutivo de esta enfermedad. Pacientes y métodos: se revisan los casos diagnosticados de pancreatitis aguda en un periodo de 15 años. Se consideraron criterios de inclusión, en los pacientes conscientes la presencia de dolor abdominal agudo junto con valores elevados de amilasa sérica y/o anormalidades ecográficas en la celda pancreática, y en los pacientes inconscientes la existencia de valores elevados de amilasa sérica junto con anormalidades ecográficas en el páncreas. Resultados: treinta y un niños cumplían estos criterios (edad media 7,9 años, rango 2-15; 55 per cent varones). Las infecciones y la litiasis biliar fueron las causas más frecuentes (19 y 16 per cent, respectivamente). El 9,7 per cent fueron secundarias a fármacos (ácido valproico, L-asparaginasa, azatioprina asociada a metilprednisolona a dosis altas). Un 6,5 per cent tenían un origen traumático y otro 6,5 per cent fueron debidas a enfermedades sistémicas. En el 35,5 per cent no se encontró ninguna causa (idiopáticas). Los síntomas más frecuentes fueron dolor abdominal (90 per cent) y vómitos (38 per cent). Se hallaron cifras elevadas de amilasa en todos los pacientes. La ecografía abdominal mostraba anormalidades en el 64 per cent de los enfermos y los hallazgos más comunes fueron el aumento del área pancreática (48 per cent) y la hipoecogenicidad (51 per cent). Se realizó tratamiento quirúrgico en 7 casos (22 per cent). Siete niños (22 per cent) presentaron una pancreatitis grave. Tres niños en situación de shock fallecieron por causas ajenas a la pancreatitis. En el 19 per cent de los pacientes la enfermedad recidivó. Conclusiones: la pancreatitis aguda es una enfermedad a tener en cuenta en los niños que consultan por dolor abdominal. Existe una amplia variedad de factores etiológicos y en un porcentaje significativo de enfermos no se encuentra causa alguna. El pronóstico es variable debido a la heterogeneidad en la evolución de esta entidad clínica en la infancia (AU)

Healing of Helicobacter pylori gastric ulcers: only eradication matters.

INTRODUCTION: some authors suggest that Helicobacter pylori eradication favors gastric ulcer healing. OBJECTIVE: to study which factors influence ulcer healing in patients suffering from gastric ulcer with H. pylori infection. SUBJECTS AND METHODS: a prospective study of 230 patients with gastric ulcer associated to H. pylori infection. Chronic ingestion of non-steroidal anti-inflammatory drugs was considered as an exclusion. In an initial endoscopy, malignancy was histologically excluded and two biopsies each of antrum and body were obtained. Also, ELISA IgG serology and a 13C-urea breath test were performed. Eradication therapy with omeprazole (20 mg twice a day), clarithromycin (500 mg twice a day) and amoxicillin (1 g twice a day) was administered for seven days, followed by omeprazole 20 mg once a day for five more weeks. Endoscopy was repeated after 6 weeks of treatment and breath test was repeated 2 month after completing therapy. RESULTS: overall gastric ulcer healing was achieved in 80.8% (95% CI: 75-85%) of cases by intention-to-treat, and in 82.6% (77-87%) per protocol. Ulcer healing was achieved in 94.3% (90-97%) of patients with eradication success, but only in 40.8% (28-54%) of patients with eradication failure (p<0.0001). In the multivariate analysis, H. pylori eradication was the only variable that correlated with ulcer healing (odds ratio 24; 95% CI: 10-56; p<0.0001) (x2 model: 64.4; p<0.0001). Additional variables (age, sex, sporadic ingestion of NSAIDs, smoking, previous ulcer disease, ulcer size and location) were not related to healing. CONCLUSION: H. pylori eradication favors ulcer healing in patients with gastric ulcer, which is an argument in favor of the etiological role of the microorganism in this disease. Other factors did not influence ulcer healing.

Efficacy of quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection.

AIM: To study the efficacy of a 7-day quadruple regimen combining pantoprazole, bismuth, tetracycline and metronidazole as rescue treatment for Helicobacter pylori infection after failure of standard triple therapy. METHODS: A prospective study was made of 140 patients infected with H. pylori and diagnosed with peptic ulcer or non-ulcer dyspepsia in whom triple therapy with proton pump inhibitor, clarithromycin and amoxicillin had failed. The patients were treated with quadruple therapy including pantoprazole, 40 mg twice daily, colloidal bismuth subcitrate, 120 mg four times daily, tetracycline, 500 mg four times daily, and metronidazole, 500 mg three times daily, for 7 days. Two months after completion of therapy, a 13C-urea breath test was performed to confirm eradication. RESULTS: With quadruple therapy, the H. pylori eradication rates were 82% (95% confidence interval (CI), 75-88%) by 'intention-to-treat' and 85% (95% CI, 79-91%) by 'per protocol'. No major side-effects were observed. No differences in eradication success were observed in relation to underlying disease (peptic ulcer: 85% (95% CI, 76-91%) vs. non-ulcer dyspepsia: 83% (95% CI, 68-93%)) or smoking habits (smokers: 86% (95% CI, 75-93%) vs. non-smokers: 83% (95% CI, 71-91%)). CONCLUSION: Quadruple therapy with pantoprazole, bismuth, tetracycline and metronidazole for 7 days is an effective H. pylori eradication treatment for patients in whom standard triple therapy has failed.

Role of Helicobacter pylori infection and its eradication in patients with subclinical hepatic encephalopathy.

AIMS: Helicobacter pylori infection in cirrhotic patients has been associated with episodes of hepatic encephalopathy (HE), although conclusive data are still lacking. This prospective study has evaluated the prevalence of H. pylori infection in 37 patients with advanced cirrhosis of the liver and subclinical hepatic encephalopathy (SHE), diagnosed by changes in psychometric tests and/or electrophysiological tests, as well as the repercussion of H. pylori eradication on ammonaemia and the evolution of this disorder. RESULTS: A positive result for H. pylori infection was obtained in 22/37 (59%) patients. Initial fasting blood levels of ammonia were high in both groups. Infected and non-infected patients showed similar levels (62.05 mmol/l v. 62.5 mmol/l), which were lowered by the standard diet, although statistical significance was only reached in the infected patient group (53.05 +/- 26 mmol/l; P < 0.05). Infection was eradicated in 19 patients, but no reduction of blood levels of ammonia was observed after H. pylori eradication among infected patients (52.37 +/- 29 mmol/l). No change has been found in either group after the administration of diet or antimicrobials with regard to psychometric and/or electrophysiological tests. CONCLUSIONS: H. pylori infection does not contribute significantly to high blood levels of ammonia in patients with advanced cirrhosis and SHE. Likewise, H. pylori eradication does not induce any improvement in the psychometric and/or electrophysiological tests used to define SHE.

Regression of gastric high grade mucosa associated lymphoid tissue (MALT) lymphoma after Helicobacter pylori eradication.

BACKGROUND: Most low grade gastric lymphomas arising from the mucosa associated lymphoid tissue (MALT) are related to Helicobacter pylori colonisation. Cases with disease limited to the stomach can be cured after H pylori eradication and remain in remission for years. In contrast, high grade lymphomas of the stomach, although also related to H pylori, do not usually respond to eradication treatment. CASE REPORT: A 36 year old patient was referred from another hospital with a diagnosis of a low grade gastric MALT lymphoma associated with H pylori. The patient was in stage I and while waiting for the biopsies to be reviewed H pylori eradication therapy was given as the first step of treatment. Review of the biopsies showed a high grade immunoblastic lymphoma with areas of low grade gastric MALT lymphoma (high grade gastric MALT lymphoma or diffuse large B cell lymphoma with areas of MALT type lymphoma of the WHO classification). The patient received no further treatment but has been closely followed up for 32 months with sequential endoscopies to obtain biopsies for histological studies, H pylori cultures, and polymerase chain reaction analysis of the IgH gene. RESULTS: After H pylori eradication the patient had a complete histological response that has been maintained for 32 months. Monoclonal IgH gene rearrangement persisted for 32 months. CONCLUSION: The response of this patient indicates the possibility that some cases of high grade gastric MALT lymphoma (possibly patients in stage I with a superficial or limited disease) may still be responsive to H pylori antigenic drive and may be cured with eradication therapy. Prospective studies should be performed to identify patients with high grade gastric MALT lymphomas that may respond to eradication therapy and be spared of other more aggressive treatments.

The effect of liver transplantation on circulating levels of estradiol and progesterone in male patients: parallelism with hepatopulmonary syndrome and systemic hyperdynamic circulation improvement.

The correction of hepatopulmonary syndrome (HPS) after liver transplantation (LT) remains controversial. The aims of our study were to: 1) analyze whether LT reverses HPS; 2) note any relationship between HPS and the systemic hemodynamic disturbance; and 3) note changes in circulating sex hormones and the possible association with pulmonary and systemic hemodynamic changes. Systemic hemodynamic parameters, cardiac output and systemic vascular resistance (SVR), sex hormones, and intrapulmonary vasodilatation assessed by contrast transesophageal echocardiography, and gas exchange abnormalities were investigated in 19 patients with advanced cirrhosis prior to and 6 months (176.8+/-30 days) after LT. LT was followed by a marked reduction in cardiac output (6.6+/-1.7 vs 3.5+/-0.5 l/min; p<0.001) and SVR (1039+/-460 vs 1978+/-294 dyn x sec x cm(-5); p<0.005). Before LT, circulating estradiol and progesterone levels were invariably elevated (66+/-22 pg/ml and 1.8+/-1.1 ng/ml, respectively, normal values <31 pg/ml and 0.35 ng/ml, respectively), and dropped after LT (28+/-12 pg/ml p<0.001 and 0.38+/-0.2 ng/ml; p<0.001, respectively). Seventeen of 19 patients had intrapulmonary vasodilatation and increased alveolar-arterial oxygen difference, thereby fulfilling diagnostic criteria for HPS. Patients with HPS presented higher cardiac output (p<0.05), lower SVR (p<0.01), and higher progesterone and estradiol levels than patients without HPS (p<0.05). LT produced normalization of intrapulmonary vasodilatation in all patients. LT normalized hyperdynamic circulation and is a useful therapeutic option in patients with HPS. Normalization of sex hormone levels after LT suggests that they could play a pathogenic role in the development of HPS.

Helicobacter pylori eradication versus one-year maintenance therapy: effect on relapse and gastritis outcome.

OBJECTIVE: The aim of this study was to determine ulcer healing and H. pylori eradication rates obtained with triple therapy (omeprazole, amoxicillin and clarithromycin). Ulcer relapsing rate one year after eradication was also assessed. Maintenance therapy with placebo was compared with ranitidine therapy and the effect of eradication on histological variables of the gastric mucosa was studied. METHODS: A prospective, double-blind parallel study was performed in 85 patients endoscopically diagnosed of duodenal ulcer H. pylori positive. Patients were randomized to a 7-days triple therapy (group A) or omeprazole plus antibiotic placebo (group B). All patients were treated only with omeprazole for the next three weeks. Patients with ulcer healing after treatment were entered in a one-year follow up phase with ranitidine placebo (group A) or ranitidine (group B). Endoscopy and biopsies were performed at baseline, after treatment (5 weeks) and after 12 months of follow-up or when relapsing symptoms appeared. RESULTS: Healing rate was 90.2% in group A and 85.7% in group B. Eradication rate was 78% in group A and 0% in group B. Out of 37 healed patients in group A, eradication was achieved in 29 and only one relapse was found (3.4%). Three out of eight patients with healing but without eradication relapsed at 12 months (35%) (p < 0.05). Histopathological results showed statistically significant differences (p < 0.05) between eradicated and non eradicated patients in terms of severity of inflammation and intestinal metaplasia, but not in terms of atrophy. CONCLUSIONS: H. pylori eradication is useful to prevent ulcer relapse and to improve gastric mucosa status.

Treatment of low grade gastric mucosa-associated lymphoid tissue lymphoma in stage I with Helicobacter pylori eradication. Long-term results after sequential histologic and molecular follow-up.

BACKGROUND AND OBJECTIVES: Most cases of gastric low-grade mucosa-associated lymphoid tissue (MALT) lymphoma are associated with H. pylori. In localized disease (stage I), eradication of H. pylori can result in histologic regression of the lymphoma in 50% to 100% of the patients. Moreover, in half of the apparently cured patients a monoclonal rearrangement of the IgH gene can be demonstrated. However, data on the long-term outcome of the patients are scarce. We report the evolution of a series of patients followed-up since 1994 in order to evaluate the long-term outcome of the apparently cured lymphoma. DESIGN AND METHODS: From January 1994 to July 2000, 19 consecutive patients with stage I gastric low grade MALT lymphoma were sequentially studied in our hospital. They had all been diagnosed by endoscopy and had had a complete staging (including CT-scan, contrast X-ray of the small bowel, bone marrow biopsies, immunophenotyping of bone marrow and peripheral blood and, in the later years, endoscopic ultrasonography). Diagnosis required established histologic criteria for low grade MALT lymphoma in the samples obtained by endoscopy. The investigation of H. pylori status included histologic search, serology and breath test urea-(13)C. Only patients in stage I disease associated with H. pylori were included in the study. Patients received standard triple therapy for eradication of H.pylori and after treatment were sequentially followed-up with endoscopies performed every 2-3 months in the first year, every 6 months in the second year and then yearly. Post-treatment biopsies were obtained by endoscopy for histologic studies, H. pylori cultures and molecular studies. The criteria of Wotherspoon et al. were used for the histological evaluation. Molecular studies were performed with a polymerase chain reaction analysis of the IgH gene using semi-nested procedures with consensus primers for the V(H) (Fr3A/Fr2A) and J(H) (LJH and VLJH) regions. RESULTS: After the eradication treatment, 18 of the 19 patients (94.7%) achieved histologic regression of the MALT lymphoma that occurred after a mean of 4.6 months (range 2-19). In 11 of the 18 histologically cured patients (61%) a monoclonal rearrangement of the IgH gene was demonstrated. In 2 patients the monoclonality disappeared completely, but 9 of the 11 patients (82%) had either persistent (3 patients) or intermittently persistent (5 patients) monoclonality for as long as 64 months. None of the patients who achieved a histologic remission (either with or without monoclonality) relapsed after a mean follow-up of 37 months (range 2-78). Two patients were lost to follow-up and another patient died of a gastric carcinoma; the remaining 15 patients are still in histologic remission after a mean period of 43 months (range 5-78). Ten patients studied between 1994 and the end of 1996 are in remission after a mean of 59 months (range 33-78). INTERPRETATIONS AND CONCLUSIONS: In most cases of gastric low-grade MALT lymphoma in stage I eradication of H. pylori can produce histologic regression of the lymphoma and this regression can be maintained for years. However, IgH gene monoclonality can be detected and persists in most cases. Although this persistent monoclonality seems to indicate the presence of a latent lymphoma population, over a period of 6 years it has not so far influenced the outcome. These findings indicate that in cases of localized gastric low-grade MALT lymphoma associated with H. pylori, the first step of treatment should be eradication of the H. pylori; however, a close and long follow-up is essential to determine the ultimate outcome of these patients and the possible significance of the persistent monoclonality.

Chronic urticaria and Helicobacter pylori.

BACKGROUND: Although the clinical manifestations of chronic urticaria (CU) are similar in most patients, a variety of factors should be taken into consideration. In general, the cause of CU cannot be determined in most patients, and it is considered idiopathic. In the past several years, relationships between some patients with CU and hepatitis C or autoimmune thyroid diseases have been established. Similarly, other factors may also be considered as possible causes to explain certain patients with CU. Previously, some patients with CU have had their disease attributed to Helicobacter pylori (HP), but the relationship was only clinical. OBJECTIVE: None of the patients previously described included an immunological study. Thus, we studied a patient with CU, who showed marked clinical improvement after eradication of HP, to demonstrate an IgE relationship with this skin disease. METHODS: First, blood analytical parameters, roentgenograms, fecal examination for parasites, and skin tests were performed to try to establish an etiology. In addition, endoscopy with gastric biopsy confirmed HP colonization, and eradication treatment was prescribed. To investigate an immunological relationship, other tests performed included the following: HP-specific IgG, histamine release induced by HP, HP-specific IgE, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis with immunoblotting. RESULTS: The blood analytical parameters, roentgenograms, fecal examination for parasites, and skin tests were all negative. In contrast, the tests for HP-specific IgG, histamine release induced by HP, and HP-specific IgE were all positive. In addition, the sulfate-polyacrylamide gel electrophoresis with immunoblotting showed specific IgE binding to an extract of HP. CONCLUSIONS: Our results may indicate an immunological IgE relationship between HP colonization and CU in this particular patient.

Erradicación de helicobacter pylori, versus tratamiento de mantenimiento / Helicobacter pylory eradication versus oneyear maintenance therapy: effect on relapse and gastritis outcome

Objetivo: el objetivo de este estudio fue evaluar las tasas de curación de úlcera y erradicación de H. pylori conseguidas con triple terapia (omeprazol, amoxicilina y claritromicina). También se evaluó la tasa de recidivas tras un año de la erradicación y tratamiento de mantenimiento con placebo comparado con terapia con ranitidina y se evaluó el efecto de la erradicación sobre variables histológicas de la mucosa gástrica. Métodos: se realizó un ensayo clínico, doble ciego y de grupos paralelos con 85 pacientes con úlcera duodenal comprobada endoscópicamente y H. pylori positivos. Los pacientes fueron randomizados a recibir triple terapia durante 7 días (grupo A) u omeprazol más placebo de antibióticos (grupo B). Todos los pacientes fueron tratados con omeprazol durante las tres semanas siguientes. Los pacientes en los que cicatrizó la úlcera entraron en la fase de seguimiento de 1 año de duración con placebo de ranitidina (grupo A) o ranitidina (grupo B). Se realizaron endoscopias y biopsias al inicio, tras el tratamiento erradicador (a las 5 semanas) y a los 12 meses de seguimiento o cuando aparecieran síntomas de recidiva. Resultados: la tasa de curación fue del 90,2 por ciento en el grupo y del 85,7 por ciento en el grupo B. La tasa de erradicación fue del 78 por ciento en el grupo A y del 0 por ciento en el grupo B. Entre los 37 pacientes del grupo A que cicatrizaron la úlcera, 29 habían sido erradicados y sólo uno recidivó (3,4 por ciento). Tres de los 8 pacientes que cicatrizaron pero no erradicaron mostraron recidiva a los 12 meses (35 por ciento) (p < 0,05). Los resultados histopatológicos mostraron diferencias estadísticamente significativas entre los pacientes erradicados y no erradicados por lo que se refiere a la intensidad de la inflamación y a la metaplasia intestinal (p < 0,05) pero no por lo que respecta a la atrofia. Conclusión: la erradicación de H. pylori es útil para prevenir la recaída ulcerosa y mejorar el estado de la mucosa gástrica, incluida la metaplasia intestinal (AU)

[Basal concentrations of gastrin and pepsinogen I and II in gastric ulcer: influence of Helicobacter pylori infection and usefulness in the control of the eradication]. / Concentraciones basales de gastrina y pepsinógeno I y II en la úlcera gástrica: influencia de la infección por Helicobacter pylori y utilidad en el control de la erradicación.

AIM: To study the influence of Helicobacter pylori eradication on basal gastrin and pepsinogen I and II levels in patients with gastric ulcer over a 1-year follow-up period, and to assess the usefulness of these values in confirming H. pylori eradication after treatment. METHODS: Fifty-six patients with gastric ulcer and H. pylori infection were prospectively studied. At the beginning of the study, endoscopy with biopsies for histologic examination and urease testing was carried out, as were 13C-urea breath test and blood samples for determination of gastrin and pepsinogen I and II values by radioimmunoassay and serology. Histologic study, 13C-urea breath test and laboratory determinations were repeated at months 1, 6 and 12 after completion of eradication treatment. RESULTS: H. pylori infection was eradicated in 82.1% of patients. In patients with successful H. pylori eradication, the initial mean gastrin value was 75.5 +/- 39.1 pg/ml, while at 1 month after treatment this value decreased to 49.2 +/- 21 pg/ml (p < 0.0001). No further reductions were noted. Initial pepsinogen I and II values were 104 +/- 58 and 15.8 +/- 10 ng/ml, respectively, whereas at month 1 after treatment these values were 77 +/- 42 and 7.3 +/- 4 ng/ml, respectively (p < 0.0001) and were 72 +/- 41 and 6.7 +/- 3 ng/ml respectively at month 6 (p < 0.01); no further variations were observed thereafter. The area under the ROC curve which reveals eradication through reductions in hormonal values was 0.70 for gastrin, 0.78 for pepsinogen I, 0.93 for pepsinogen II and 0.92 for the pepsinogen I/II ratio. At months 6 and 12 after treatment completion, differences in mean gastrin and pepsinogen I and II values between the patients with normal histologic findings and those with chronic gastritis were significant (p < 0.05). CONCLUSIONS: a) H. pylori eradication is associated with an early fall in basal gastrin values and a progressive decrease in basal pepsinogen I and II values. b) In patients with gastric ulcer, determination of the decrease in basal pepsinogen II levels is a useful and early non-invasive method for confirming eradication. c) Determination of gastrin and pepsinogen I and II values may be useful for assessing improvement in gastritis 6 months after treatment completion.

Actitud quirúrgica en pacientes con tumor estromal recurrente del tubo digestivo / Surgical treatment of gastrointestinal stromal tumor

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