Úlcera péptica Helicobacter pylori-negativa. ¿Cuál es su etiopatogenia y tratamiento? / Helicobacter pylori-negative peptic ulcer. What is its aetiopathogenesis and treatment?

Si bien se acepta que la gran mayoría de úlceras pépticas se relacionan con el germen Helicobacter pylori, en los últimos años se observa un incremento creciente de úlceras en las que no se demuestra la presencia de esta infección. Este hecho se ha relacionado en parte con el descenso en la prevalencia de Helicobacter pylori en la población, consecuencia de la mejoría en las condiciones higiénico-sanitarias y de vivienda.Las causas relacionadas con las úlceras Helicobacter pylorinegativas son: 1. Pruebas diagnósticas de infección falsamente negativas. Representan en la práctica asistencial un 25 por ciento de las úlceras consideradas Helicobacter pylori-negativas (prueba diagnóstica negativa falsa 5 por ciento, tratamiento previo o concomitante de antibióticos, bismuto o inhibidores de la bomba de protones 20 por ciento).2. Tratamiento con aspirina (AAS) o antiinflamatorios no esteroideos (AINE). Es sin duda la causa más frecuente y representa entre el 50-60 por ciento de todas las úlceras sin infección.3. Otras causas (síndrome de Zolinger-Ellison, Helicobacter Heilmannii, enfermedades generales del tubo digestivo como enfermedad de Crohn, amiloidosis, gastroenteritis eosinofílica, etc.) pueden ser las responsables de menos del 5 por ciento de todas las úlceras Helicobacter pylori-negativas.4. Úlceras pépticas "idiopáticas". Se consideran aquéllas en las que no es posible encontrar una posible causa y representan entre el 5-15 por ciento de todas las úlceras sin infección y que probablemente tienen como factor importante la hipersecreción ácida (AU)

Helicobacter pylori-negative peptic ulcer. What is its aetiopathogenesis and treatment?

Although the vast majority of peptic ulcers are widely considered as related to the germ Helicobacter pylori, ulcers exhibiting absence of this infection are increasingly seen in recent years. This fact has been partly related to a decreased prevalence of Helicobacter pylori among the population, a consequence of improved hygiene and housing conditions. Causes in relation to Helicobacter pylori-negative ulcers are: 1. Falsely negative infection diagnostic tests. They represent 25% of ulcers considered as Helicobacter pylori-negative in health-care practice (falsely negative diagnostic test 5%, previous or concomitant therapy with antibiotics, bismuth or proton pump inhibitors 20%). 2. Aspirin (ASA) or non-steroidal anti-inflammatory drug (NSAID) therapy. This is no doubt the most common cause, representing 50 to 60% of all infection-free ulcers. 3. Other causes (Zollinger-Ellison syndrome, Helicobacter heilmannii, generalised gut disease such as Crohn's disease, amyloidosis, eosinophilic gastroenteritis, etc.) may be responsible for less than 5% of all Helicobacter pylori-negative ulcers. 4. "Idiopathic" peptic ulcers. Thus are considered ulcers for which no potential cause may be found, representing 5-15% of all infection-free ulcers. Acid hyper-secretion is probably an important factor in them.

La calidad de vida. ¿Se puede medir realmente? / Quality of life. Can it really by measures?

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Aspectos éticos de la práctica médica en el SIDA / Ethical aspects of medical practice in AIDS

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[Survey on Helicobacter pylori and peptic ulcer in Spain]. / Encuesta sobre Helicobacter pylori y úlcera péptica en España.

OBJECTIVE: The goal of this study is to determine, through a national survey, the degree of acceptance among gastroenterologists of the relationship between Helicobacter pylori and peptic ulcer, and how they manage their patients according to this association. STUDY DESIGN: An observational study through a self-administered questionnaire. PARTICIPANTS: The questionnaire was distributed to 690 gastroenterologists from all over Spain. The questionnaire was answered by 687 specialists. RESULTS: Most (98.1%) Spanish specialists accept the relationship, 1.5% are reluctant, and 0.3% are irresolute. Eradication treatments are prescribed by 96.4% of the gastroenterologists, mainly omeprazole+amoxicillin, in 1994, though only 40.8% of gastroenterologists always prescribe it for H. pylori positive peptic ulcer. A control of the effectiveness of the treatment is undertaken by 84.3% of gastroenterologists. CONCLUSIONS: The relationship between H. pylori and ulcer is accepted by Spanish gastroenterologists, as well as eradication therapy.

[Functional dyspepsia, gastric emptying of solids, and Helicobacter pylori infection]. / Dispepsia funcional, vaciado gástrico de sólidos e infección por Helicobacter pylori.

UNLABELLED: The origin of functional dyspepsia (FD) is unknown, however, abnormal gastric emptying and infection by H. pylori have been suggested as possible causes. OBJECTIVE: The aim of this study was to test the hypothesis that infection by H. pylori could be related to alterations in gastric emptying of solids and play a role in the pathophysiology of dyspepsia. METHODS: Studies were performed on 12 controls: 6 males, 6 females, age 40 +/- 13, and on 45 FD patients: 15 males and 30 females, age 43.5 +/- 12. Clinical criteria for FD diagnosis were post-prandial epigastric pain, nausea, vomiting or epigastric bloating, with normal blood test, upper endoscopy and abdominal ultrasound. Diagnosis of H. pylori infection was either by growth positive on culture of antral biopsy or by all of the following: on Gram stain, urease test positive and visualization of microorganisms in the antral biopsy. Gastric emptying of solids was studied with a radio-nuclide technique. Patients were prospectively classified in 4 groups according to the main symptom: reflux-like, ulcer-like, dysmotility, and non-specific. RESULTS: H. pylori infection was observed in 21/32 (66%) FD patients. No significant differences in the gastric emptying of solids between the control group and patients with FD (tl/2 80 +/- 17 minutes vs 75 +/- 16 min). The presence of H. pylori infection did not influence gastric emptying rates (78 +/- 16 minutes in infected patients vs 73 +/- 15 min in non infected patients). Gastric emptying times were similar among the four subgroups of FD patients. CONCLUSIONS: No significant differences in gastric emptying of solids were found in H. pylori infected persons as compared with the controls. These findings suggest that H. pylori infection and/or changes in gastric emptying of solids do not play a role in the pathophysiology of FD.

[Chronic inflammatory intestinal disease in Catalonia (Barcelona and Gerona)]. / Enfermedad inflamatoria crónica intestinal en Cataluña (Barcelona y Gerona).

We show the results of a retrospective study carried out during ten years (1978-1987), in Catalonia in the provinces of Barcelona and Gerona. The aim of the study was to evaluate the incidence and prevalence of inflammatory chronic bowel disease in our country, its clinical aspects, management and long term survival. An epidemiological inquiry was sent to all the hospitals and gastroenterologists of Catalonia. Nine hundred and seventy six answers were received from 20 Hospitals and four specialists. All of them were revised by the Research Committee, and 761 were validated for their inclusion in the study. The prevalence of the disease was similar both in Barcelona (19 per 100,000) and Gerona (18 per 100,000). The incidence of ulcerative colitis increased during the study, from 0.4 in 1978 to 0.8 in 1987, with a peak of maximum incidence (1.0 per 100,000) in 1985. In the same way, an increase in the incidence of Crohn's disease from 0.2 to 0.7 per 100,000, was observed. The mean incidence per year was 0.6 and 0.4 respectively, similar to the incidence observed in other Spanish regions during the same period of time. Finally we show the most important clinical and therapeutic aspects as well as the survival data.

[Multilocular peritoneal inclusion cysts in puerperium]. / Quistes peritoneales multiloculares de inclusión en una puérpera.

We report the case of a 26 year old female with low abdominal pain occurring post-partum. Ultrasonography revealed the existence of pelvic cysts. Laparotomy allowed the resection of the cysts interpreted at that time as hydatic cysts. Four months later the patient was readmitted because of a recurrence of the cysts. Pathological examination made the final diagnosis of multilocular peritoneal inclusion cysts. The literature on this rare condition, previously denominated cystic benign mesothelioma, is reviewed. Recurrence may be prevented by the use of sclerosing agents during the surgical intervention.

[Morphology of chronic gastritis associated with Campylobacter pylori infection]. / Morfología de la gastritis crónica asociada a infección por Campylobacter pylori.

Recently, a close relation has been found between infection of the gastric mucosa by Campylobacter pylori and chronic gastritis. To establish the possible existence of characteristic morphologic changes in this disease, which can be differentiated from other unrelated forms of gastritis, we analyzed the antral biopsies obtained from 75 patients, 35 with duodenal peptic ulcer and 40 with nonulcerous dyspepsia. The diagnosis of C. pylori infection is based on positive biopsy culture or, if not, when following three requirements are met: positive urease test before 24 hours, identification of the germ by Gram stain and visualization in the tissue of microorganisms with morphology similar to that of C. pylori. We found that 85.5% of the 55 patients with C. pylori infection present active chronic gastritis with lymphoid nodes (GCA + NL), while this morphology is only found in 5 of the 20 uninfected patients. The association of GCA + NL with C. pylori infection is highly significant (p less than 0.0001). We think that it could be a local immunologic response to the stimulus of the bacterial antigen, and that it has sufficient morphologic entity to differentiate it from other inflammatory processes of the gastric mucosa of still unknown etiology.

Endoscopic cytology of cancer of the esophagus and cardia: a long-term evaluation.

Between January 1979 and December 1986, 858 endoscopic cytological examinations of the esophagus were performed, including 309 patients with confirmed malignancies. A positive cytological diagnosis of cancer was made in 289 (93.5%). Adequate biopsies were obtained in 269 instances (87.0%), being positive in 238 cases (overall positivity of biopsy, 77.02%). The combined use of biopsy and cytology provided a correct diagnosis in 98.0% of cases. The cytological examinations were positive in 30 of 40 patients (75.0%) with obstructing lesions in whom no satisfactory biopsies could be obtained. No false positive diagnosis was made among the 550 patients with benign conditions. In this series, cytology increased the yield of biopsy by 20.8%.

Laparoscopic cytology--an evaluation.

Cytological sampling by abrasion and/or aspiration was done in a consecutive series of 927 patients at the time of laparoscopy. Cytological examination confirmed the diagnosis of malignancy in 312 out of 335 cases of primary or secondary liver cancer (93.1%). Biopsy was positive in 262 out of 303 patients (86.4%). The combined use of cytology and biopsy provided a positive diagnostic accuracy of 97.6%). The cytological report was positive in 215 out of 239 (89.9%) proven extrahepatic malignancies (gallbladder, gynecological, peritoneal). Biopsy was positive in 180 out of 199 cases (90.4%). The combined use of cytology and biopsy provided an accuracy of 95.8%). There was only one false positive diagnosis of malignancy. The sensitivity of laparoscopic cytology was 93.1% and its specificity 100% in liver disease. Sensitivity was 90.3% and specificity 99.4% in other types of abdominal cancer. In these series, cytological examination added 15.6% positive results (liver) and 11.7% (other lesions) to those of biopsy, which was not performed in 89 patients in whom it was considered too risky or technically too difficult.