Acid Suppression Treatment Research Articles

Oxidative damages are critical in pathogenesis of reflux esophagitis: implication of antioxidants in its treatment

Background: The facts that the severity of reflux esophagitis cannot be accurately predicted on the basis of acid exposure and acid suppression treatment is not enough for the complete healing, suggested that other damaging factors might be involved in pathogenesis of reflux esophagitis. Aims: The present study was designed to evaluate the oxidative stress as the major pathogenic factor of reflux esophagitis and the importance of antioxidant in treatment of reflux esophagitis. Materials and Methods: Reflux esophagitis was induced by the insertion of small caliber ring (3 mm in diameter) into the duodenum 1 cm distal to the ligament of Treitz in rats. Results: DA-9601, a novel antioxidant substance, attenuated the gross esophagitis significantly compared to that treated with ranitidine, histamine-2 receptor antagonist (H2-RA), in a dose-dependent manner. Severe, hemorrhagic, and longitudinal ulcerations were developed in H2-RA pretreated group, whereas mildly scattered erosions were observed in antioxidant-pretreated group. Significantly increased amounts of malondialdehyde (MDA), increased NF-κB activation, and the mucosal depletion of reduced glutathione (GSH) were observed in the esophagus of reflux esophagitis. H2-RA treatment didn’t affect the levels of GSH and MDA, whereas DA-9601 attenuated the decrement of the GSH levels and significantly decreased lipid peroxides in the esophagus. Antioxidants treatment showed significant reductions in the activation of NF-κB, inflammation-associated transcription factor, especially p50 component in accordance with significant higher levels of NF-κB repressor, IκBα expression. Conclusion: Oxygen-derived free radicals seem to be one of the important mediators in generation of reflux esophagitis, which suggests that the combination of antioxidant and anti-secretory medications will be ideal and more beneficial in the prevention and treatment of reflux esophagitis than currently prescribed antisecretory treatment alone.

Management of Barrett's oesophagus, dysplasia and early adenocarcinoma

There has been a dramatic increase in recent years in the incidence of Barrett's oesophagus and the oesophageal adenocarcinoma associated with it. Adequate monitoring strategies and improved diagnostic procedures are therefore essential. Alongside conventional video-endoscopy with four-quadrant biopsies, many additional diagnostic procedures are now available to improve monitoring. These allow the early diagnosis of dysplastic areas and early carcinomas. Both thermal procedures (argon plasma coagulation, multipolar electrocoagulation and KTP laser and Nd:YAG laser treatment) and non-thermal ablation procedures (photodynamic therapy) are used for the endoscopic ablation of Barrett's mucosa without dysplasia, being employed in addition to acid suppression treatment. On the basis of the data currently available, it is, however, not yet possible to offer a general recommendation in favour of endoscopic ablation. Alongside surgical treatment for high-grade dysplasia and early carcinoma, endoscopic treatment procedures, which have a much lower complication and mortality rate, will probably play an important role in the future. Endoscopic mucosal resection and photodynamic therapy are particularly promising. Long-term results with these procedures are, however, still awaited.

Short course acid suppressive treatment for patients with functional dyspepsia: results depend onHelicobacter pyloristatus

BACKGROUND AND AIMSTreatment of functional dyspepsia with acid inhibitors is controversial and it is not known if the presence ofHelicobacter pylori infection influences the response.METHODSAfter a complete diagnostic workup, 792...

DOES THE ERADICATION OF HELICOBACTER PYLORI CURE DUODENAL ULCER DISEASE IN COMMUNITIES WITH A HIGH PREVALENCE RATE? COMPARISON WITH LONG‐TERM ACID SUPPRESSION

SUMMARYThe long‐term effect of Helicobacter pylori eradication on the natural history of duodenal ulcer has been investigated and compared with long‐term acid suppression treatment in an endemic community for infection. Seventy‐three patients with endoscopically verified H. pylori positive active duodenal ulcer disease were included in this prospective study. Patients were divided into two groups. Group A patients (n=39) were given an omeprazole‐based triple eradication regimen, while group B patients (n=34) were given omeprazole alone followed by long‐term famotidine 20 mg daily as maintenance treatment. A control endoscopy was performed at the third month of treatment. The bacterium was eradicated in 32 (82%) of group A patients. All patients were followed up for two years and an endoscopy performed at the end of each year. H. pylori recurred in 13 patients and the reinfection rate was 44.8% over two years. Duodenal ulcer recurred in seven of these patients at two years (24.1%). There was a close association between H. pylori reinfection and ulcer relapse. Group B patients remained H. pylori positive during the study and the ulcer recurred in five of these patients (16.6%) despite continuous famotidine treatment. There was no statistically significant difference in ulcer relapse rate between the groups. These results suggested that H. pylori eradication is not an absolute solution for duodenal ulcer disease in high endemic regions and continuous maintenance treatment with H2‐receptor antagonists is still an alternative approach in some chronic recurrent cases.

Risks of endoscopy in hospitalized pediatric patients with collagen vascular diseases

Background: The gastrointestinal manifestations of the collagen vascular diseases have been well described in the pediatric population. These patients frequently have symptoms that constitute indications for endoscopy. However, the risks and benefits of endoscopy in this population have not been examined. Methods: A retrospective review of all patients with collagen vascular diseases hospitalized during a 7-year period was undertaken, and those patients who underwent endoscopy were identified. Results: Nine patients (5%) underwent endoscopic procedures (eight upper and three lower endoscopy). Complications and outcomes were analyzed. Indications for endoscopy included abdominal pain, gastrointestinal (GI) bleeding, and/or vomiting and diarrhea. Two patients had complications that required surgery within 1 day of the endoscopic procedure. One of these patients subsequently died with GI bleeding. Five of the nine patients had changes in their management after endoscopy. Helicobacter pylori infection was identified and treated in two patients. Three patients had esophagitis or gastritis and acid suppression treatment was started or optimized. Vasculopathy was present in the patients who had complications. Conclusions: This series suggests that endoscopy can provide useful information for the management of the pediatric patient with GI symptoms and collagen vascular diseases. However, because serious and potentially life-threatening complications can occur, great care is needed in evaluating the risk/benefit ratio of endoscopy in these patients. (Gastrointest Endosc 1999;49:622-5.)

Management of nonsteroidal anti-inflammatory drug-induced gastroduodenal disease by acid suppression.

One major cause of peptic ulceration is the use of nonsteroidal anti-inflammatory drugs (NSAIDs). The precise mechanisms through which NSAIDs cause peptic ulceration are unknown, but the discovery that they reduce the production of 'cytoprotective' prostaglandins led to the hypothesis that coadministration of exogenous prostaglandins heals and prevents NSAID-induced gastroduodenal ulcers and other mucosal lesions. Studies using high doses of misoprostol have shown that it does have a protective effect; however, gastrointestinal intolerance of this prostaglandin E2 analogue is common. Early indications that acid suppression was effective in the management of NSAID-related peptic ulcers came from studies showing that gastric ulcers could be healed by omeprazole in patients who continued to take NSAIDs. Other studies suggested that acid suppression reduces the incidence of mucosal lesions but that standard dose ranitidine protects only against duodenal lesions. Subsequent studies reported that higher dose H2 receptor antagonist therapy can protect against both gastric and duodenal ulcers during continued NSAID therapy. An ideal therapeutic strategy would heal NSAID-related ulcers and prevent the development of new NSAID-related lesions and complications in patients who are unable to discontinue NSAID therapy. A number of recent studies indicate that effective acid-suppressive treatment with the proton pump inhibitor omeprazole can achieve these aims. Overall, data from recent studies show that acid suppression with the proton pump inhibitor omeprazole at a dose of 20 mg daily is the most effective means of healing NSAID-associated gastroduodenal lesions and that it is the most effective prophylactic therapy. In the long run, the role of omeprazole will have to be evaluated with respect to its cost effectiveness compared with other strategies and with respect to the development of less damaging NSAIDs.

Considerations for long-term use of proton-pump inhibitors.

The safety of proton-pump inhibitors (PPIs) for long-term use is reviewed. PPIs are being used with increasing frequency to inhibit secretion of gastric acid in order to treat acid-related disorders such as gastroesophageal reflux disease and peptic ulcer disease. Some patients may require long-term acid suppressive treatment to control the symptoms of their disease, which raises questions about the long-term safety of PPIs. A thorough literature search was conducted, and the clinical consequences of sustained hypergastrinemia induced by all antisecretory therapy, the consequences of atrophic gastritis in patients infected with Helicobacter pylori, the effects of hypochlorhydria on bacterial overgrowth and nutrient absorption, and possible interactions of PPIs with other drugs were identified as areas of concern with long-term use of PPIs. Short- and long-term studies showed that PPIs have a wide safety margin and a favorable adverse-event profile with few drug interactions. Available data support the short- and long-term safety of PPIs.

BENEFITS AND RISKS OF ENDOSCOPY IN PEDIATRIC PATIENTS WITH CHRONIC VASCULITIDES. 757

The gastrointestinal manifestations of collagen vascular diseases, such as systemic lupus erythematosus and polymyositis, have been well described in the pediatric population. These patients frequently have symptoms which are indications for endoscopic studies. However, the risks and benefits of gastrointestinal endoscopy in this population have not been examined. A complete review for all rheumatologic patients admitted to Texas Children's Hospital during the past five years was performed and those patients undergoing endoscopy were identified. Ten patients (5%) underwent endoscopic procedures (nine upper and three lower endoscopies) which were analyzed with emphasis on resultant complications and therapeutic benefit. Indications for endoscopy included pain in six of ten patients, bleeding in three of ten patients and vomiting and diarrhea in one patient. Three patients had severe complications, two of which required surgery within one day of the endoscopic procedure. One of these patients subsequently died with GI bleeding. Five of the ten patients had changes in management following their endoscopy. Two patients had Helicobacter pylori and treatment was initiated. Three patients had esophagitis or gastritis and acid suppression treatment was started or optimized. Vasculopathy was present in the patients who had complications and may have contributed to their development. This study provides evidence that endoscopy can provide useful information for the management of the pediatric patient with GI symptoms and rheumatologic disease. However, since serious and potentially life-threatening complications occur, great care is needed in evaluating risk/benefit for endoscopic procedures in these high risk patients.

Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life.

Although oesophagitis is the most common diagnosis made at upper gastrointestinal endoscopy, data on the longterm outcome of affected patients are sparse. This study assessed the level of reflux symptoms, quality of life, drug consumption, and complications in patients at least 10 years after diagnosis of oesophagitis at one centre. One hundred and fifty two patients with typical reflux symptoms and a first time diagnosis by endoscopy of grade I-III oesophagitis between 1981 and 1984, were followed up using a postal questionnaire and telephone interview. Eighteen of 152 patients had died, 33 failed to respond, and 101 replied (mean follow up 11 years, range 121-160 months). Over 70% of patients still had heartburn at least daily (32%) or weekly (19%) or required daily acid suppression treatment (20%). Two patients (2%) had developed oesophageal strictures and one had Barrett's oesophagus. Two of eight quality of life scores (physical function and social function) measured by the Short Form-36 were significantly lower than Northern Ireland population scores. Nearly three quarters of patients previously diagnosed as having oesophagitis still had significant morbidity related to gastro-oesophageal reflux disease more than 10 years after diagnosis. Some quality of life scores were significantly lower than those of the general population.

Nonoperative management of esophageal strictures following esophagomyotomy for achalasia.

The optimal management of reflux-induced esophageal strictures that occur after esophagomytomy for achalasia is uncertain. This paper presents our experience with the nonsurgical treatment of postesophagomyotomy strictures in achalasia patients using endoscopic dilation and gastric acid suppression. Six patients with achalasia who had undergone prior esophagomyotomy subsequently developed recurrent dysphagia and were found to have an esophageal stricture. Esophagrams typically showed a markedly dilated esophagus with a narrowed, sharply angulated gastroesophageal junction. Esophageal manometry confirmed esophageal aperistalsis and, when measured, the LES pressure was < 5 mm Hg. Endoscopy showed esophageal inflammation and a fixed stricture at the gastroesophageal junction. Strictures were dilated under direct visualization using through-the-scope balloon dilators. Patients began gastric acid suppressive treatment at the same time. Five patients who remained symptomatic underwent repeat endoscopy, which demonstrated improvement in esophagitis. Dilation was then repeated with a larger balloon dilator. Over a mean follow-up period of 3.8 years, the average number of repeat dilations per patient was 3.6 (range: 0-12). All patients had symptomatic improvement and weight gain. No patient required surgery. We conclude that esophageal strictures after esophagomyotomy for achalasia can be safely treated using endoscopic dilation and gastric acid suppression, thus avoiding the need for reoperation.