Efficacy of triple therapy with a proton pump inhibitor, levofloxacin, and amoxicillin as first-line treatment to eradicate Helicobacter pylori.

BACKGROUND: Triple therapy including a proton pump inhibitor, clarithromycin, and amoxicillin (PPI-CA) is the first-choice treatment used for H. pylori eradication. The efficacy of this treatment is declining of late, and alternative therapies are currently under evaluation. OBJECTIVES: To evaluate the efficacy, safety and compliance of a triple therapy with a PPI, amoxicillin and levofloxacin (PPI-LA)--replacing clarithromycin--for the eradication of H. pylori. METHODS: The study included 135 patients (65% women), mean age 53 years, with dyspeptic symptoms and H. pylori infection proven by a positive urease rapid test, histological analysis, or C13-urea breath test. DIAGNOSIS: non-investigated dyspepsia 48.9%, functional dyspepsia 36.3%, and ulcerative dyspepsia 14.8%. Treatment was indicated with a proton pump inhibitor at usual doses, amoxicillin 1 g, and levofloxacin 500 mg, administered jointly during breakfast and dinner for 10 days. We studied the performance of this triple therapy and its effects using a questionnaire, and effectiveness by the negativity of the C13-urea breath test after 6-8 weeks after treatment discontinuation. Per protocol, we compared the effectiveness of PPI-LA with a control group of 270 patients treated with PPI-CA for 10 days. RESULTS: 130 patients (96.2%) could complete the treatment and follow-up protocol. Effectiveness (intention to treat) was 71.8% (97/135) and 74.6% (per protocol) (97/130). Sixteen patients (11.8%) had well-tolerated adverse effects, except for 5 subjects (3.7%) who dropped out. PPI-CA was effective (per protocol) in 204 patients out of 270 (75.5%) in the control group. CONCLUSIONS: Triple therapy with a PPI, amoxicillin and levofloxacin for 10 days is a well-tolerated treatment that is easy to comply with; however it has low efficiency - less than 80% - and is not recommended as a first-choice treatment for H. pylori eradication. Similar results were obtained with the classic triple therapy using a PPI, clarithromycin and amoxicillin.

Eficacia de una triple terapia con un inhibidor de la bomba de protones, levofloxacino y amoxicilina, como primer tratamiento, en la erradicación de Helicobacter pylori / Efficacy of triple therapy with a proton pump inhibitor, levofloxacin, and amoxicillin as first-line treatment to eradicate Helicobacter pylori

Introducción: la triple terapia con un inhibidor de la bomba de protones, claritromicina y amoxicilina (IBP-CA) es el tratamiento de primera elección más utilizado en la erradicación de H. pylori. La eficacia de este tratamiento está disminuyendo en los últimos años y se están valorando otras alternativas terapéuticas. Objetivos:valorar la eficacia, cumplimiento y seguridad de una triple terapia con un IBP, amoxicilina y levofloxacino, sustituyendo a la claritromicina, en la erradicación de H. pylori. Métodos: periodo de estudio: 2007-2008. Se incluyen 135 pacientes (65% mujeres), edad media de 53 años, con síntomas dispépticos e infección por H. pylori, constatada por positividad del test rápido de la ureasa, histología o prueba del aliento con urea-C13. Diagnósticos: dispepsia no investigada: 48,9%, dispepsia funcional: 36,3% y dispepsia ulcerosa: 14,8%. Se indica tratamiento con un inhibidor de la bomba de protones, a dosis habitual, amoxicilina 1 g y levofloxacino 500 mg (IBP-LA), administrados de forma conjunta en desayuno y cena, durante 10 días. Se valora el cumplimiento de la triple terapia y sus efectos adversos mediante interrogatorio y su eficacia mediante la negatividad de la prueba del aliento con urea-C13 practicada a las 6-8 semanas del término del tratamiento. Se compara la eficacia, por protocolo, del tratamiento con IBP-LA con la observada en un grupo control de 270 pacientes tratados con IBP-CA durante 10 días en los años 2006-2007. Resultados: 130/135 pacientes (96,2) del grupo de estudio completaron el tratamiento y el protocolo del seguimiento. La eficacia por intención de tratar fue del 71,8% (97/135) y por protocolo del 74,6% (97/130). Dieciséis pacientes (11,8%) presentaron efectos adversos bien tolerados, excepto en 5 pacientes (3.7%) que motivan el abandono del tratamiento. El tratamiento con IBP-CA resultó eficaz, por protocolo, en 204/270 (75,5%) pacientes del grupo control...(AU)

Background: triple therapy including a proton pump inhibitor, clarithromycin, and amoxicillin (PPI-CA) is the first-choice treatment used for H. pylori eradication. The efficacy of this treatment is declining of late, and alternative therapies are currently under evaluation. Objectives: to evaluate the efficacy, safety and compliance of a triple therapy with a PPI, amoxicillin and levofloxacin (PPI-LA) - replacing clarithromycin - for the eradication of H. pylori. Methods: the study included 135 patients (65% women), mean age 53 years, with dyspeptic symptoms and H. pylori infection proven by a positive urease rapid test, histological analysis, or C13-urea breath test. Diagnosis: non-investigated dyspepsia 48.9%, functional dyspepsia 36.3%, and ulcerative dyspepsia 14.8%. Treatment was indicated with a proton pump inhibitor at usual doses, amoxicillin 1 g, and levofloxacin 500 mg, administered jointly during breakfast and dinner for 10 days. We studied the performance of this triple therapy and its effects using a questionnaire, and effectiveness by the negativity of the C13-urea breath test after 6-8 weeks after treatment discontinuation. Per protocol, we compared the effectiveness of PPI-LA with a control group of 270 patients treated with PPI-CA for 10 days. Results: 130 patients (96.2%) could complete the treatment and follow-up protocol. Effectiveness (intention to treat) was 71.8% (97/135) and 74.6% (per protocol) (97/130). Sixteen patients (11.8%) had well-tolerated adverse effects, except for 5 subjects (3.7%) who dropped out. PPI-CA was effective (per protocol) in 204 patients out of 270 (75.5%) in the control group...(AU)

Colitis ulcerosa grave, con megacolon tóxico, resuelta con infliximab / Severe ulcerative colitis and toxic megacolon resolved with infliximab therapy

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Efficacy of low-dose lansoprazole in the treatment of non-erosive gastrooesophageal reflux disease. Influence of infection by Helicobacter pylori.

INTRODUCTION: Proton pump inhibitors (PPIs) are the most effective drugs to cure peptic esophagitis and control the symptoms of gastroesophageal reflux disease (GERD). In most patients with GERD esophagitis is not detected by endoscopy, which represents GERD with a negative endoscopy or non-erosive reflux disease (NERD). The influence of infection by H. pylori in the evolution of GERD is controversial since a protective action is identified by some studies, but not all. We conducted a clinical trial to assess the efficacy of lansoprazole 15 mg/day in the initial control of NERD symptoms, and as a secondary endpoint the impact of H. pylori infection on response to treatment. PATIENTS AND METHODS: A pilot, single-center clinical trial was conducted--single-blind regarding the experimental medication (unknown to patients), and double-blind regarding the information concerning H. pylori infection. Sixty (60) patients with NERD were initially included, who had suffered from daytime or nocturnal heartburn for 1-2 days in each of the last two weeks. Nine patients were excluded for failing to comply with the study protocol. The 51 remaining patients, 35 women and 16 men, with a mean age of 49 years, comprised the per protocol analysis population. Patients received treatment for two weeks with a capsule of the study medication (15 mg/day of lansoprazole), with daily controls on the presence and severity of daytime and nocturnal heartburn. Treatment was considered effective when, upon completion, patients referred a maximum of one episode of mild heartburn as defined in the protocol, or answered the following question in the affirmative: "Does the medication you are receiving satisfactorily control the symptoms of your disease?". During diagnostic endoscopy we obtained biopsies of the gastric body and antrum to investigate infection by H. pylori by means of a urease test. Treatment efficacy was assessed with no patients or doctors responsible for the study being aware of urease test results. RESULTS: 41 patients (80.3%) reported that treatment had satisfactorily controlled their symptoms, and 34 patients (66.6%) had a maximum of one episode of mild heartburn in the last week. Forty-two (42) patients (82.3%) had infection by H. pylori. No significant differences were observed in the response to treatment between patients with or without H. pylori infection. CONCLUSIONS: With the limitations of a pilot study, these results suggest that lansoprazole 15 mg/day is an effective treatment in the control of NERD symptoms, that it may be a good initial therapeutic strategy, and that, according to data available, H. pylori infection has no significant effect on the response to treatment.

Eficacia de lansoprazol a dosis bajas en el tratamiento de la enfermedad por reflujo gastroesofágico no erosiva. Influencia de la infección por Helicobacter pylori / Efficacy of low-dose lansoprazole in the treatment of non-erosive gastrooesophageal reflux disease. Influence of infection by Helicobacter pylori

Introducción: los inhibidores de la bomba de protones (IBP) son los fármacos más eficaces en la curación de la esofagítis péptica y en el control de los síntomas de la enfermedad por reflujo gastroesofágico (ERGE). En la mayoría de los pacientes con ERGE no se detecta esofagitis al practicarse endoscopia presentando una ERGE con endoscopia negativa o no erosiva (ERNE). La influencia de la infección H. pylori en la evolución de la ERGE es controvertida, ya que mientras que unos estudios le asignan una acción protectora, otros se la niegan. Hemos realizado un ensayo clínico para valorar la eficacia de lansoprazol 15 mg/día en el control inicial de los síntomas de la ERNE y, como objetivo secundario, la influencia de la infección H. pylori en la respuesta al tratamiento. Pacientes y métodos: se realiza un ensayo clínico piloto, unicéntrico, simple ciego en cuanto a la medicación experimental, no conocida por los pacientes, y doble ciego en cuanto a la información de la infección por H. pylori. Se incluyeron inicialmente 60 pacientes con ERNE que presentaban al menos dos días con pirosis diurna o nocturna en cada una de las dos últimas semanas. Se excluyeron 9 pacientes por incumplimiento del protocolo del estudio. Los 51 pacientes restantes, 35 mujeres y 16 hombres, con edad media de 49 años, constituyeron la población de análisis por protocolo. Los pacientes recibieron tratamiento durante dos semanas con una cápsula de la medicación de estudio (15 mg/día de lansoprazol), realizándose en este tiempo un seguimiento diario de la presencia e intensidad de la pirosis diurna y nocturna. Se consideró que el tratamiento era eficaz cuando a su finalización los pacientes referían haber presentado como máximo un episodio de pirosis de intensidad leve, según definición del protocolo, o bien respondían afirmativamente a la siguiente pregunta: “¿la medicación que recibe le controla de forma satisfactoria los síntomas de su enfermedad?”. Durante la endoscopia diagnóstica se obtuvieron biopsias de cuerpo y antro gástrico para investigar, mediante test de la ureasa, la infección por H. pylori. Se valoró la eficacia del tratamiento sin conocerse por los pacientes y médicos responsables del estudio los resultados de los test de ureasa. Resultados: cuarenta y un pacientes (80,3%) referían que el tratamiento les controlaba de forma satisfactoria la sintomatología y 34 pacientes (66,6%) habían presentado como máximo un episodio de pirosis de intensidad leve en la última semana. Cuarenta y dos pacientes (82,3%) presentaban infección por H. pylori. No se observaron diferencias significativas en la respuesta al tratamiento en los pacientes con o sin infección por H. pylori. Conclusiones: con las limitaciones propias de un estudio piloto, estos resultados, orientan a que lansoprazol 15 mg/día es un tratamiento eficaz en el control de la sintomatología de la ERNE, pudiendo ser una buena estrategia terapéutica inicial y que, con los datos disponibles, la infección por H. pylori no influye de forma significativa en la respuesta al tratamiento

Introduction: proton pump inhibitors (PPIs) are the most effective drugs to cure peptic esophagitis and control the symptoms of gastroesophageal reflux disease (GERD). In most patients with GERD esophagitis is not detected by endoscopy, which represents GERD with a negative endoscopy or non-erosive reflux disease (NERD). The influence of infection by H. pylori in the evolution of GERD is controversial since a protective action is identified by some studies, but not all. We conducted a clinical trial to assess the efficacy of lansoprazole 15 mg/day in the initial control of NERD symptoms, and as a secondary endpoint the impact of H. pylori infection on response to treatment. Patients and methods: a pilot, single-center clinical trial was conducted –single-blind regarding the experimental medication (unknown to patients), and double-blind regarding the information concerning H. pylori infection. Sixty (60) patients with NERD were initially included, who had suffered from daytime or nocturnal heartburn for 1-2 days in each of the last two weeks. Nine patients were excluded for failing to comply with the study protocol. The 51 remaining patients, 35 women and 16 men, with a mean age of 49 years, comprised the per protocol analysis population. Patients received treatment for two weeks with a capsule of the study medication (15 mg/day of lansoprazole), with daily controls on the presence and severity of daytime and nocturnal heartburn. Treatment was considered effective when, upon completion, patients referred a maximum of one episode of mild heartburn as defined in the protocol, or answered the following question in the affirmative: “Does the medication you are receiving satisfactorily control the symptoms of your disease?”. During diagnostic endoscopy we obtained biopsies of the gastric body and antrum to investigate infection by H. pylori by means of a urease test. Treatment efficacy was assessed with no patients or doctors responsible for the study being aware of urease test results. Results: 41 patients (80.3%) reported that treatment had satisfactorily controlled their symptoms, and 34 patients (66.6%) had a maximum of one episode of mild heartburn in the last week. Forty-two (42) patients (82.3%) had infection by H. pylori. No significant differences were observed in the response to treatment between patients with or without H. pylori infection. Conclusions: with the limitations of a pilot study, these results suggest that lansoprazole 15 mg/day is an effective treatment in the control of NERD symptoms, that it may be a good initial therapeutic strategy, and that, according to data available, H. pylori infection has no significant effect on the response to treatment

[Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis]. / Influencia de los antiinflamatorios no esteroideos en la hemorragia digestiva por úlceras o erosiones gastroduodenales en pacientes con cirrosis hepática.

INTRODUCTION: Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis. PATIENTS AND METHODS: We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission. RESULTS: NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C. CONCLUSIONS: NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension.

Influencia de los antiinflamatorios no esteroideos en la hemorragia digestiva por úlceras o erosiones gastroduodenales en pacientes con cirrosis hepática / Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis

Introducción: La enfermedad péptica gastroduodenal, con o sin complicaciones, es más frecuente en los pacientes con cirrosis hepática que en la población general y en su patogenia influirían factores dependientes de la hipertensión portal. La prevalencia de la infección por Helicobacter pylori en la población con cirrosis hepática es similar a la existente en la población general. Se objetiva conocer la influencia de los antiinflamatorios no esteroideos (AINE) en la etiología de la patología péptica gastroduodenal con hemorragia digestiva de los pacientes con cirrosis hepática. Pacientes y métodos: Se incluyó a 35 pacientes con cirrosis hepática con hemorragia digestiva por úlceras o erosiones gastroduodenales (grupo A), 125 pacientes no cirróticos, con hemorragia digestiva por úlceras o erosiones gastroduodenales (grupo B) y 70 pacientes con cirrosis hepática que ingresan sin hemorragia digestiva (grupo C). En todos los pacientes, mediante encuesta dirigida, se investiga el consumo de AINE, incluido ácido acetilsalicílico (AAS), en la semana previa al ingreso hospitalario. Resultados: Referían consumo de AINE 15 pacientes (42,8%) del grupo A, 102 pacientes (58,2%) del grupo B y 6 pacientes (8,5%) del grupo C. Se obtuvieron diferencias significativas al comparar los resultados del grupo A con el grupo C. Conclusiones: El consumo de AINE en los pacientes con cirrosis hepática sin hemorragia digestiva es bajo (8,5%), muy inferior al observado en los pacientes con cirrosis que ingresan con hemorragia por úlceras o erosiones gastroduodenales (42,8%). Se puede considerar que los AINE, como sucede en la población general, desempeñarían un importante papel en la patogenia de la hemorragia digestiva por patología péptica en la población con cirrosis hepática e hipertensión portal

Introduction: Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis. Patients and methods: We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission. Results: NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C. Conclusions: NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension

Influencia de los antiinflamatorios no esteroideos en la hemorragia digestiva por úlceras o erosiones gastroduodenales en pacientes con cirrosis hepática / Influence of nonsteroidal antiinflammatory drugs in gastrointestinal bleeding due to gastroduodenal ulcers or erosions in patients with liver cirrhosis

Introducción: La enfermedad péptica gastroduodenal, con o sin complicaciones, es más frecuente en los pacientes con cirrosis hepática que en la población general y en su patogenia influirían factores dependientes de la hipertensión portal. La prevalencia de la infección por Helicobacter pylori en la población con cirrosis hepática es similar a la existente en la población general. Se objetiva conocer la influencia de los antiinflamatorios no esteroideos (AINE) en la etiología de la patología péptica gastroduodenal con hemorragia digestiva de los pacientes con cirrosis hepática. Pacientes y métodos: Se incluyó a 35 pacientes con cirrosis hepática con hemorragia digestiva por úlceras o erosiones gastroduodenales (grupo A), 125 pacientes no cirróticos, con hemorragia digestiva por úlceras o erosiones gastroduodenales (grupo B) y 70 pacientes con cirrosis hepática que ingresan sin hemorragia digestiva (grupo C). En todos los pacientes, mediante encuesta dirigida, se investiga el consumo de AINE, incluido ácido acetilsalicílico (AAS), en la semana previa al ingreso hospitalario. Resultados: Referían consumo de AINE 15 pacientes (42,8%) del grupo A, 102 pacientes (58,2%) del grupo B y 6 pacientes (8,5%) del grupo C. Se obtuvieron diferencias significativas al comparar los resultados del grupo A con el grupo C. Conclusiones: El consumo de AINE en los pacientes con cirrosis hepática sin hemorragia digestiva es bajo (8,5%), muy inferior al observado en los pacientes con cirrosis que ingresan con hemorragia por úlceras o erosiones gastroduodenales (42,8%). Se puede considerar que los AINE, como sucede en la población general, desempeñarían un importante papel en la patogenia de la hemorragia digestiva por patología péptica en la población con cirrosis hepática e hipertensión portal

Introduction: Peptic ulcer disease, with or without complications, is more common in patients with liver cirrhosis than in the general population. Factors associated with portal hypertension are involved in its pathogenesis. The prevalence of Helicobacter pylori infection in patients with liver cirrhosis and the general population is similar. The aim of the present study was to determine the influence of nonsteroidal antiinflammatory drugs (NSAIDs) in the etiology of bleeding peptic ulcer disease in patients with liver cirrhosis. Patients and methods: We studied 35 patients with liver cirrhosis and gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group A), 125 noncirrhotic patients with gastrointestinal bleeding due to gastroduodenal ulcers or erosions (group B), and 70 patients with liver cirrhosis who were admitted to hospital without gastrointestinal bleeding (group C). All patients were questioned about NSAID consumption, including aspirin, during the week prior to hospital admission. Results: NSAID consumption was reported by 15 patients (42.8%) in group A, 102 patients (58.2%) in group B, and 6 patients (8.5%) in group C. Statistically significant differences were obtained when the results for group A were compared with those for group C. Conclusions: NSAID consumption in patients with liver cirrhosis without gastrointestinal bleeding was low (8.5%) and was much lower than that observed in patients with cirrhosis admitted to hospital for bleeding due to gastroduodenal ulcers or erosions (42.8%). As occurs in the general population, NSAIDs play a significant role in the pathogenesis of bleeding due to peptic ulcer disease in patients with liver cirrhosis and portal hypertension

Sarcoidosis, sclerosing cholangitis, and chronic atrophic autoimmune gastritis: a case of infiltrative sclerosing cholangitis.

We report a patient in whom sarcoidosis coexisted with sclerosing cholangitis and chronic atrophic autoimmune gastritis. There are some autoimmune diseases associated with primary sclerosing cholangitis; the difference between sarcoidosis and all other autoimmune diseases associated with primary sclerosing cholangitis is the ability of the former to damage the biliary tree. Moreover, when sarcoidosis behaves like cholestasis it can damage the biliary tree, mimicking primary sclerosing cholangitis, with high immunoglobulin M but without inflammatory bowel disease and p-ANCAs negative. We believe that it should be regarded as a single disease "infiltrative sclerosing cholangitis" because this is not a primary disease and sarcoidosis would be responsible for a beaded biliary tree.

[Prospective study on the influence of gastroduodenal ulcer hemorrhage on the diagnostic methods in Helicobacter pylori infection]. / Estudio prospectivo sobre la influencia de la hemorragia por ulcus gastroduodenal en los métodos diagnósticos de infección por Helicobacter pylori.

BACKGROUND: To know the influence of upper gastrointestinal bleeding in diagnostic methods of H. pylori infection. METHODS: We prospectively studied patients with peptic ulcers: 55 with upper gastrointestinal bleeding and 62 without upper gastrointestinal bleeding. We analysed the results of culture, urease test, Gram, histology and serological test IgG and IgA in both groups. H. pylori infection was determined by a positive culture or positive urease test and histology. RESULTS: Patients with upper gastrointestinal bleeding were older, but there were not statistical differences in sex, H. pylori prevalence infection or duodenal or gastric ulcers between patients with and without upper gastrointestinal bleeding. 78% having H. pylori infection. The urease test had a false negative rate in patients with upper gastrointestinal bleeding of 22% but only 3% in patients without upper gastrointestinal bleeding (p < 0.05). The culture, histology and Gram had higher false negative rate in upper gastrointestinal bleeding group than in non upper gastrointestinal bleeding group but without statistical significance. All patients with false negative urease test had antral culture positive. CONCLUSIONS: Urease test has a high false negative rate when is studied in patients with peptic ulcers and upper gastrointestinal bleeding. Caution should be made if urease test was used alone for diagnosis in patients with upper gastrointestinal bleeding. Urease test and culture together could be a good diagnostic method.

Hereditary angioedema: an infrequent cause of abdominal pain with ascites.

Patients with hereditary angioedema have episodes of local swelling, usually affecting the face, extremities, upper airway, and gastrointestinal tract. Only infrequently does it cause recurrent abdominal pain (with or without ascites); however, because it has potentially life-threatening complications, an early diagnosis is important. We describe a case of type I hereditary angioedema (a quantitative deficit of C1 inhibitor), the sole initial symptom of which was severe recurrent and self-limited abdominal pain, accompanied by ascites during these episodes. During a 4-yr period of treatment with danazol, the patient was virtually asymptomatic, despite levels of C4 and C1 inhibitor that remained below normal limits, and there have been no major side effects that could be attributed to treatment with androgens.

Laparoscopic findings in seven patients with nodular regenerative hyperplasia of the liver.

We describe the laparoscopic findings in seven patients with nodular regenerative hyperplasia of the liver. This unusual condition is characterized by nodules of hyperplastic hepatocytes diffusely distributed throughout the liver parenchyma, without fibrous septa between the nodules. In all patients, the diagnosis was made by liver biopsy under laparoscopic control. Laparoscopy revealed the presence of portal hypertension, nonnodular undulated liver surface, recognizable lobular pattern, and a hepatic consistency softer than normal to palpation. All of these findings indicated a diagnosis of nodular regenerative hyperplasia. Definitive diagnosis was established from biopsy specimens.