Gastropathy and diarrhea in diabetic patients: the presence of helicobacteriosis and PAS-positive vascular deposits in gastric and duodenal mucosa.

AIM: To determine the presence of vascular periodic acid-Schiff's reagent (PAS) positive deposits in the gastric and duodenal mucosa of diabetic patients and controls. METHODS: Forty-six poorly controlled diabetic patients with digestive symptoms, aged 23 to 63 years (32 type I patients on insulin therapy with a mean diabetes duration of 14.2 +/- 3.1 years (mean +/- SE) and 13 type II patients with a mean diabetes duration of 7.2 +/- 2.3 years) were included. Of these, 17 had mainly gastropathic symptoms while 13 had diarrhea, and the remaining 16 patients had nonspecific symptoms. Forty control individuals of similar age and gender were included. Biopsy specimens were taken from areas of grossly normal gastric and duodenal mucosa. RESULTS: Gastric mucosa samples were pathological in 38 of 46 diabetic patients (18 cases of chronic active H. pylori antral gastritis, 13 cases of chronic active H. pylori pangastritis and 7 cases of nonspecific chronic gastritis). Duodenal mucosa samples were pathological in 32/46 diabetic patients. In the control group, 21 of 40 gastric samples (5 cases of chronic active H. pylori antral gastritis, 3 cases of chronic active H. pylori pangastritis and 13 cases of H. pylori-negative chronic gastritis) and 12/40 duodenal samples were pathological. Both helicobacteriosis and gastric and duodenal mucosa pathologies were significantly (p < 0.01) more common in diabetic patients than in controls. No significant associations were found between histological findings of gastric mucosa and of duodenal mucosa in diabetics and the control group. PAS-positive material in the vascular wall of gastric (16/46 vs. 2/40 in controls) and duodenal mucosa specimens (25/46 vs. 5/40 in controls) was significantly more common among diabetics (p = 0.001 for gastric and p < 0.001 for duodenal mucosa). No significant association was found between the presence of gastropathy or diarrhea compared to the presence of neuropathy, retinopathy, nephropathy or the type of diabetes. CONCLUSION: Endoscopic specimens from the gastroduodenum of diabetic patients revealed a large quantity of PAS positive vascular deposits, probably reflecting the condition of the mucosal vessels in our patients.

Amoxycillin, clarithromycin and either sucralfate or pantoprazole for eradication of Helicobacter pylori in duodenal ulcer (a randomized controlled trial).

BACKGROUND: Sucralfate enhances the anti-Helicobacter pylori activity of antimicrobials and has an inhibitory effect on H. pylori. AIM: To evaluate the efficacy and safety of one-week sucralfate-based eradication therapy for H. pylori infection in patients with duodenal ulcers, compared with treatment based on pantoprazole, in a randomized controlled multicenter study. METHODS: One hundred and twenty patients with active duodenal ulcers and H. pylori infection were treated with amoxycillin 1 g b.d. plus clarithromycin 500 mg b.d. for the first 7 days. Patients were randomly assigned to receive either sucralfate 1 g t.d.s. for 4 weeks (SAC group; n = 60) or pantoprazole (PAC group; n = 60) 40 mg b.d. for the first 7 days and 40 mg o.d. for the next 3 weeks. The patient's H. pylori status was determined by a urease test and histological investigation before the treatment, and again 4 weeks after cessation of all medication. RESULTS: One hundred and eleven patients completed the study. H. pylori infection was eradicated in 76.4% (42/55) of patients in the SAC group (ITT analysis: 70%, 95% CI: 58-80%) vs. 85.7% (48/56) of patients in the PAC group (ITT analysis: 80%, 95% CI: 70-89) (N.S.). All ulcers had healed. There were no significant differences between the two regimens regarding the occurrence of adverse effects. CONCLUSION: Our study shows that one-week triple therapy with amoxycillin, clarithromycin and either pantoprazole or sucralfate are effective regimens to cure H. pylori infection in patients with duodenal ulcer.

The influence of Helicobacter pylori infection on gastrin and somatostatin values present in serum.

BACKGROUND/AIMS: Recent studies on the role of Helicobacter pylori in pathogenesis of duodenal ulcers have focused on the mechanism by which H. pylori infections causes exaggerated gastrin release. METHODOLOGY: We compared the gastrin and somatostatin serum values between two groups of patients; 37 H. pylori-positive ones and 29 H. pylori-negative ones. We applied radioimmunoassay technique to determine the gastrin and somatostatin values in serum. H. pylori was confirmed by urease test and by histopathological color according to Giemsa. RESULTS: The level of gastrin in the serum of Helicobacter pylori-positive patients with chronic gastritis were significantly higher in relation to H. pylori-negative patients. The somatostatin concentration in the sera of H. pylori-positive patients with duodenal ulcer (16.27 +/- 9.49 pg/mL) were less in comparison with those without duodenal ulcer (23.25 +/- 13.59 pg/mL). CONCLUSIONS: The results suggest that H. pylori infection suppresses the somatostatin secretion.

Cancer incidences in the digestive tube: is cobalamin a small intestine cytoprotector?

Malignancies are common in the digestive tube, although with unequal distribution among segments. The aim of this paper was to compare available interpretations of the low cancer incidence in the small bowel and high in the large bowel. Supposed mechanisms include relatively small bacterial population, large secretion of liquid and rapid transit in the small bowel. Small bowel mucosa is the main absorptive part of the digestive tube with absorption rates for various nutrients so high that they can even be considered as clearances from the intestinal content. Consequently, these nutrients are not present in the large bowel. An alternative explanation is that an absorbable protective substance from the intraluminal content, might protect the mucosa from malignant transformations. It can be speculated that if there are any cytoprotective substances in the digested food their effect would be expressed mostly in the absorptive small intestine, leaving the large bowel mucosa unprotected. Vitamin B12 might be a possible candidate for this role. Cobalamin molecules are initially bound to haptocorrin (Hc) in the stomach, but in the small intestine B12 is transferred to intrinsic factor (IF) after the action of pancreatic trypsin on Hc. Cobalamin-IF complexes are absorbed in the terminal ileum leaving only a small fraction of B12 to enter the large bowel. We have tried to summarize available data regarding cancer incidences in digestive tube, segmental length and transit times of tube content. Cancer density is calculated as incidence per length and transit speed as length per transit time. Cancer incidences for seven intestinal segments were considered low if they were below one case per 100 000 inhabitants annually, while the low cancer density meant less than six cases per 100 000 inhabitants per metre. For instance, transverse colon was considered as a high cancer incidence place (2.15 cases), with low cancer density (4.3 cases/m). Transit speed more than 0.3 metre/hour was associated with low cancer incidences (accuracy 0.85) and low cancer density segments (accuracy 1.00). Cobalamin availability showed similar distribution, available in low incidence segments and unavailable in high incidence segments. Experimental studies are needed to quantify B12 availability in the large bowel and to determine whether small amounts of B12-IF or, perhaps, B12-haptocorrin complexes are absorbed by the small bowel mucosa. Without that, no cytoprotective effects of B12 in the digestive tube can be expected.

Histochemical changes in the rectal mucosa of diabetic patients with and without diarrhea or constipation.

Sixty-four diabetic patients, 35 with diarrhea, 15 with constipation and 14 without stool problems, and forty healthy subjects, were subjected to rectosigmoidoscopy. During rectosigmoidoscopy, rectal biopsy specimens for histological and histochemical analysis were obtained. Histological findings of nonspecific colitis in 25 out of 64 diabetic patients were uniformly distributed among the three groups (p = 0.959). However, the finding was slightly more common in diabetic patients than in controls (eight out of 40 control subjects, p = 0.043). A positive PAS reaction was observed in 30 out of 64 diabetic patients and was also uniformly distributed among the three groups (p = 0.508), but was significantly more common among diabetic patients than controls (three out of 40, p < 0.001). A positive reaction to cholesterol was found in 46 out of 64 diabetic patients, also uniformly distributed among the three groups (p = 0.773). It was significantly more common in diabetic patients than in controls (nine out of 40, p < 0.001). Reactions of the rectal mucosa histological specimens to glycogen and triglycerides were negative, both in diabetic patients and in controls. In conclusion, it appears that stool problems among our diabetic patients were not related to the positivity of PAS or to the positive cholesterol reaction in the rectal mucosa histological specimens. Since positive findings of both reactions were more common in specimens taken from diabetic patients than in controls, positive reactions might be related to metabolic disturbances in diabetic patients.

Pantoprazole, amoxycillin and either azithromycin or clarithromycin for eradication of Helicobacter pylori in duodenal ulcer.

BACKGROUND: Studies have shown that 1-week triple therapy consisting of a proton pump inhibitor, amoxycillin and clarithromycin may cure Helicobacter pylori infection in the majority of patients. AIM: To establish whether pantoprazole plus amoxycillin in association with either azithromycin or clarithromycin is useful in curing H. pylori infection in patients with a duodenal ulcer. METHODS: One hundred and ten patients with active duodenal ulcers and H. pylori infection were treated with pantoprazole (days 1-7, 40 mg b.d.; days 8-28 40 mg o.d.) plus amoxycillin 1 g b.d. for the first 7 days. Patients were randomly assigned to receive either azithromycin 500 mg o.d. for the first 6 days (PAAz group; n=55) or clarithromycin 500 mg b.d. for the first 7 days of treatment (PAC group; n=55). H. pylori status was determined by urease test and histology before the treatment, and again 4 weeks after cessation of any medication. RESULTS: One hundred and three patients completed the study. H. pylori infection was eradicated in 78% (39/50) of patients in the PAAz group (ITT analysis: 71%, 95% CI: 61-83%) vs. 81% (43/53) of patients in the PAC group (ITT analysis: 78%, 95% CI: 69-90%) (N.S.). All ulcers had healed. CONCLUSION: Our study shows that 1-week triple therapy with pantoprazole, amoxycillin and either azithromycin or clarithromycin is not satisfactory (<80% ITT H. pylori eradication rate).

[Cholinesterase in the differential diagnosis of parenchymal and obstructive icterus and in the differentiation between malignant and benign obstruction]. / Cholinesterase in der Differentialdiagnostik des parenchymatischen und obstruktiven Ikterus und bei der Differenzierung maligner und benigner Obstruktion.

Determination of CHE has already been proven as a useful test in the diagnosis of liver diseases. Our investigation included 2 groups of patients: a group suffering from parenchym hepatitis caused by virus infection A and B, and a second group of patients suffering from etiologically different obstructive hepatitis (malign and benign obstruction). Our tests show that there is lower CHE activity in patients with hepatitis B. There is a remarkable difference of CHE activity in benign and malign obstructive hepatitis.

[Isoenzymes of gammaglutamyltransferase in patients with obstructive and hepatocellular icterus]. / Die Isoenzyme der Gammaglutamyltransferase bei Patienten mit obstruktivem und hepatozellulärem Ikterus.

We have been determining the GGT IE isoenzyme in patients with hepatitis A and B with decomposed liver cirrhosis, with obstructive hepatitis caused by the gall stones. In patients with hepatitis A and B the IE is located between albumin and betaglobulin, as well as in patients with obstructive hepatitis caused by the gall stones; in the latter partly between Alpha 1 and Alpha 2 globulin. In patients with decompensated liver cirrhosis (37.7% of the patients) there was IE activity 100% in Alpha 2 globulin area; in 6.25% of patients the activity was in the prealbumin area. In patients with secondary liver tumors we got a rather high increase of the GGT IE activity in Alpha 1 globulin area, in 77.7% of the patients even 80 to 100%. In some patients with disease progression we noticed the GGT IE activity in Beta globulin area. The results in primary liver malignomas were different. In 68.5% of the patients the GGT IE activity dominated in Alpha 1 globulin area.

Symptom structure and psychiatric comorbidity of combat-related post-traumatic stress disorder.

The placement of the diagnostic category of post-traumatic stress disorder (PTSD) among anxiety disorders reflects the recognition that anxiety is a predominant reaction to trauma. Indeed, the symptoms of PTSD overlap considerably with those of other anxiety disorders. The nosological criteria render PTSD as quite a heterogeneous diagnosis. Two individuals with no common symptoms can be diagnosed as having PTSD. In this report we provide information on the phenomenology and psychiatric comorbidity in a sample of 33 patients with combat-related PTSD. The finding of clinical heterogeneity in subjects with combat-related PTSD and the therapy implications are discussed.

High dose omeprazole plus amoxicillin and azithromycin in eradication of Helicobacter pylori in duodenal ulcers.

BACKGROUND: The aim of our study was to establish whether one-week triple therapy regimen (omeprazole, amoxicillin, azithromycin) with low dose (2 x 20 mg/day) or high dose omeprazole (2 x 40 mg/day) is more effective in curing H. pylori infection in patients with active duodenal ulcer disease. METHODS: One hundred and twenty patients with duodenal ulcer and H. pylori infection were treated with amoxicillin 2 x 1000 mg/day for the first 7 days plus azithromycin 500 mg/day for the first 6 days. Patients were randomly assigned to receive either omeprazole 2 x 20 mg/day for the first 7 days (group A; n = 60) or omeprazole 2 x 40 mg/day for the first 7 days (group B; n = 60). After 7 days all patients in both groups continued treatment with omeprazole (40 mg/day (days 8-14) and 20 mg/day (days 15-28)). H. pylori status was determined by urease test and histology before the treatment and 4 weeks after cessation of any medication. RESULTS: One hundred and thirteen patients completed the study. H. pylori infection was eradicated in 73.2% [41/56] of patients in group A (intention-to-treat [ITT] analysis: 68.3%; 95% CI: 58.6-80.4%) vs. 82.5% [47/57] of patients in group B (ITT analysis: 78.3%; 95% CI: 67.8-87.9%; NS). All ulcers had healed after 4 weeks of omeprazole treatment. Side effects, usually minor, were recorded in 12.5% (group A) and in 14% (group B) of patients (NS), but therapy was discontinued for only one patient in group B (NS). CONCLUSION: There was no statistically significant difference between one-week triple therapy regimen (omeprazole, amoxicillin, azithromycin) with high dose omeprazole (2 x 40 mg/day) and regimen with low dose omeprazole (2 x 20 mg/day) in curing H. pylori infection in patients with active duodenal ulcer disease.

Changes in sex hormones during an oral glucose tolerance test in healthy premenopausal women.

OBJECTIVE: To assess the effect of an acute elevation in circulating insulin on serum androgen levels in healthy obese women with different body-fat distributions. DESIGN: Controlled clinical study. SETTING: The Endocrinology Unit of an academic medical center. PATIENT(S): Seventy healthy premenopausal women participated: 27 women with upper-body obesity, 22 women with lower-body obesity, and 21 normal-weight women as controls. INTERVENTION(S): A 75-g oral glucose tolerance test (OGTT) was performed for all participants. MAIN OUTCOME MEASURE(S): Anthropometry and serum concentrations of glucose, insulin, free T, DHEAS, androstenedione, E2, and sex hormone-binding globulin (SHBG) at fasting, 60 minutes, and 120 minutes after oral glucose loading. RESULT(S): Although androgens and E2 levels in all three groups declined modestly, there were no statistically significant differences in response of the sex hormones to an OGTT in the two obese groups and normal-weight women. No correlation was found between changes in sex-hormone levels during an OGTT and insulin rise. Increased body mass index and more pronounced abdominal fat localization resulted in basal hyperinsulinemia, markedly exaggerated glucose-induced insulin levels, and hyperandrogenism, as was evident by significantly elevated free T and low SHBG serum levels. CONCLUSION(S): There were no statistically significant differences in androgen response to acute hyperinsulinemia during an OGTT between obese women with different regional fat distributions and lean controls.

Pantoprazole versus omeprazole in the treatment of reflux esophagitis.

Pantoprazole is a new proton pump inhibitor with a potent antisecretory activity, well defined pharmacokinetics and safety profile. The aim of this single blind, randomized clinical trial was to compare the efficacy of pantoprazole (PAN) 40 mg/day and omeprazole (OME) 20 mg/day in patients with grade I and II GERD (Savary-Miller classification). A total of 120 patients were included (PAN = 60 and OME = 60). In the per protocol/analysis, healing rates at 4 weeks were 76.3% PAN and 71.2% OME (ns), and at 8 weeks 94.7% PAN and 92.9% OME (ns). In the intention to treat analysis, healing rates at 4 weeks were 75% PAN and 70% OME (ns), and at 8 weeks 90% PAN and 86.6% OME (ns). Both pantoprazole and omeprazole were well tolerated with no serious drug related adverse events. Pantoprazole 40 mg/day was found to be safe and effective therapy comparable to omeprazole 20 mg/day in the short-term treatment for reflux esophagitis (grade I and II).

Infection with Helicobacter pylori and long-term use of non-steroidal antiinflammatory drugs.

The use of nonsteroidal anti inflammatory drugs (NSAID) is associated with an increased risk of peptic ulcer and of ulcer complications. However, the relation between Helicobacter pylori infection and gastroduodenal damage associated with NSAID use is unclear. This study investigated the prevalence of Helicobacter pylori infection in patients with arthritis (n = 85) taking NSAID, trying to find out whether the patients taking NSAID and infected with H. pylori were more likely to have dyspepsia, mucosal damage or chronic active gastritis than those without H. pylori infection. H. pylori was identified by biopsy, rapid urease test and histologic test. Dispeptic symptoms were assessed according to a standardized questionnaire. Gastroduodenal mucosal damage was graded endoscopically (using a modified Lanza scale) and the diagnosis of chronic gastritis was based on the histologic criteria of the Sydney system. The frequency of H. pylori infection was found to increase with age. No statistically significant difference was observed in the presence of damage to gastroduodenal mucosa between the patients with and without H. pylori infection. H. pylori infection was found to be associated with an increased frequency and severity of dyspeptic symptoms in patients with arthritis taking long-term NSAID. Chronic active gastritis was only present in patients with H. pylori infection. H. pylori infection was shown to be associated with an increased frequency and severity of dyspeptic symptoms in patients with arthritis on long-term NSAID therapy, without causing an increased damage to gastroduodenal mucosa.

Hyperinsulinemia and sex hormones in healthy premenopausal women: relative contribution of obesity, obesity type, and duration of obesity.

Insulin secretion in response to an oral glucose tolerance test (OGTT) and sex hormone levels (free testosterone, androstenedione, dehydroepiandrosterone sulfate [DHEAS], estradiol, and sex hormone-binding globulin [SHBG]) were evaluated in 49 healthy obese premenopausal women (body mass index [BMI], 30 to 50.6 kg/m2) and 21 control subjects (BMI, 17.8 to 24.0 kg/m2) with normal glucose tolerance and without signs of hyperandrogenism. Obese women were divided into two groups according to waist to hip ratio (WHR): 27 subjects with upper-body obesity (WHR > 0.85) and 22 subjects with lower-body obesity (WHR < 0.8). Both fasting and glucose-induced insulin levels were higher in women with upper-body obesity than in controls (P < .001) and those with lower-body obesity (P < .001). Hyperandrogenism was observed in women with upper-body obesity, as evident by significantly elevated free testosterone (P < .05 v controls and subjects with lower-body obesity) and decreased SHBG (P < .001 v controls). The most important independent determinants of fasting insulin levels were BMI (P < .01) and the ratio of DHEAS to free testosterone (P < .01). The most important determinants of cumulative insulin response were WHR (P < .0005), duration of obesity (P < .01), and androstenedione levels (P < .01). In conclusion, in healthy obese premenopausal women without clinical signs of hyperandrogenism, a high BMI and more pronounced upper-body fat localization resulted in hyperinsulinemia and hyperandrogenism. The duration of obesity exaggerated the glucose-induced insulin level and cumulative insulin response independently of the degree of obesity and obesity type. The ratio of DHEAS to free testosterone was an independent determinant of fasting insulin concentration. Furthermore, the ratio of DHEAS to free testosterone rather than either of these androgens alone may be important in the regulation of insulin action in women.

Omeprazole, azithromycin and amoxicillin or amoxicillin plus clavulanic acid in eradication of Helicobacter pylori in duodenal ulcer disease.

Treatment with omeprazole (OME), azithromycin (AZI) and amoxicillin (AMO) resulted in encouraging Helicobacter pylori cure rates in pilot and control studies. The aim of this study was to establish whether OME + AZI in combination with either AMO or ACA (amoxicillin plus clavulanic acid) are effective in curing H. pylori infection. A hundred patients with active duodenal ulcer and H. pylori infection were treated with OME (day 1-10: 2 x 40 mg/day, day 11-24: 40 mg/day, day 25-42: 20 mg/day) plus AZI 500 mg/day for the first 6 days. Patients were randomly assigned to either AMO 2 x 1000 mg/day (group A, n = 50) or ACA 2 x 1250 mg/day (group B, n = 50) during the first 10 days of treatment. H. pylori status was determined by urease test and histology before and 6 weeks after completion of therapy. Ninety-five patients completed the study. H. pylori infection was eradicated in 85.4% (41/48) patients from group A (intention-to-treat (ITT) analysis: 82%) versus 91.5% (43/47) patients from group B (ITT) analysis: 86%) (NS). All ulcer had healed after 42 days of omeprazole treatment. Side effects, usually minor, were recorded in 12.5% (group A) and 14.9% (group B) of patients (NS). Therapy had to be discontinued in two patients (one in group A and one group B) only. Ten-days treatment with OME and AZI (for the first 6 days) with AMO or ACA are simple and highly effective regimens to cure H. pylori infection in patients with duodenal ulcer disease.

[Omeprazole and azithromycin with and without metronidazole in the eradication of Helicobacter pylori in duodenal ulcer disease]. / Omeprazol i azitromicin s metronidazolom ili bez njega za eradikaciju Helicobactera pylori u duodenalnoj ulkusnoj bolesti.

This prospective, single blind, randomized study was designed to compare the efficacy and tolerance of two therapeutic schedules for eradication of H. pylori in patients with duodenal ulcer. Patients were randomized into two groups. Group 1 (n = 25) was treated with omeprazole 20 mg each morning for 28 days, azithromycin 500 mg/day for 5 days and metronidazole 3 x 500 mg/day for 5 days. Group 2 (n = 25) was treated with omeprazole 20 mg/day for 28 days and azithromycin 500 mg/day for 5 days. H. pylori status was determined by rapid urease test and histology before and 1, 6 and 12 months after the therapy. After 4 weeks of treatment ulcers healed in 96% (24/25) of patients in the first group and in 92% (23/25) of patients in the second group. One and 12 months after the treatment, eradication of Helicobacter pylori was achieved in 72% (18/25) of patients in the first group and in 64% (16/25) of patients in the second group. In 12 months after the treatment ulcer recurred in 43.7% (7/16) of patients in whom H. pylori was not eradicated and in 2.9% (1/34) of patients with eradicated H. pylori. The side effects were minor and/or transitory and did not require discontinuation of the treatment.

Another therapeutic schedule in eradication of Helicobacter pylori.

In this study, the efficacy and tolerability of two different therapeutic schedules in eradicating Helicobacter pylori and healing duodenal ulcer were evaluated. The study included 60 patients with duodenal ulcer and Helicobacter pylori infection. They were randomly allocated to either of two groups: group 1 (N = 30) received omeprazole 20 mg for 28 days, amoxicillin 3 x 500 mg for 7 days and metronidazole 3 x 500 mg for 5 days, and group 2 (N = 30) received omeprazole 20 mg for 28 days, ACA (amoxicillin 500 mg plus clavulanic acid 125 mg) 3 x 625 mg for 7 days and metronidazole 3 x 500 mg for 5 days. Endoscopic examination, bioptic urease test and histologic examination were performed before, and 30 and 90 days after the treatment. Endoscopic examination was also performed one month after the beginning of the treatment, when healing of duodenal ulcer was observed in 90% (27/30) of the group 1 patients and in 93.3% (28/30) of the group 2 patients. The Helicobacter pylori eradication achieved in group 1 and 2 was 76.7% (23/30) and 83.3% (25/30), respectively. Side effects were present in 20% (6/30) of the group 1 patients and in 23.3% (7/30) of the group 2 patients. Side effects were mild and did not require interruption of the treatment. A higher rate of eradication was achieved in group 2 than in group 1, but the difference was not statistically significant.

Lansoprazole versus omeprazole in the treatment of reflux esophagitis.

To evaluate the therapeutic potential of the newly developed proton pump inhibitor lansoprazole in patients with reflux esophagitis (grade I and II according to Savary Müller criteria), the authors performed a single blind, randomized clinical trial comparing 20 mg omeprazole and 30 mg lansoprazole, involving 60 patients at two clinical hospitals. The treatment period was or 8 weeks, and main efficacy variables were healing of endoscopic changes and relief of reflux symptoms. No significant difference in terms of healing and relief of reflux symptoms was found either after 4 or after 8 weeks of treatment. In conclusion, 30 mg lansoprazole daily was found to be safe and effective therapy comparable to omeprazole in the short-term treatment for reflux esophagitis (grade I and II).