Antisecretory Drugs Research Articles

THE STRETTA PROCEDURE RESULTS IN SUSTAINED IMPROVEMENT OF ANTI-SECRETORY DRUG USE AND GERD SYMPTOMS AT 3 YEARS FOLLOW-UP, WHILE NORMALIZING GASTRIC EMPTYING FUNCTION IN THE MAJORITY OF IMPAIRED SUBJECTS

Purpose: To evaluate the long-term (up to 3 year) effect of the Stretta Procedure on anti-secretory drug utilization, GERD symptoms, and patient satisfaction. Further, gastric emptying studies were used to assess whether Stretta improves gastric emptying function in those subjects with baseline impairment. Methods: Between August 2000 and April 2004, 214 subjects with GERD and inadequate symptom control despite PPI bid underwent the Stretta procedure. All procedures were performed by a single physician, (MN), on an outpatient basis using conscious sedation. Baseline and follow-up (6, 12, 24 and 36 month) GERD-HRQL scores (0–50), heartburn (0–5), satisfaction (0–5) and medication-use were collected. Gastric emptying studies were performed on a subset of patients at baseline and 8 months. Results: The total treated pool includes 214 subjects (128 females, 59.8%). There were no significant acute adverse events. Complete follow-up was available for subjects at each follow-up interval as follows: 6 months (n = 174), 1 year (n= 146), 2 years (n = 90), and 3 years (n = 57). GERD-HRQL, heartburn, satisfaction, and medication use were significantly improved at all follow-up intervals (6, 12, 24, 36 months, all p <0.001)) and scores at each interval were superior to those achieved on baseline drug therapy. Further, there was no significant diminution of effect with increasing time of follow-up. Baseline and follow-up gastric emptying studies were available for 73 patients. The % emptied at 90 minutes improved from 60 ± 22% to 81 ± 23% (p <0.001). At baseline, 29 (40%) of subjects had delayed gastric emptying, while at follow-up only 12 (16%) had delayed gastric emptying. This represents normalization in 67% of those with abnormal baseline studies. Conclusions: The Stretta procedure has a significant positive and sustained effect on anti-secretory medication use and GERD symptoms, with durability of response demonstrated at 3 years. The observed improvement was superior to that achieved with escalated baseline anti-secretory therapy. Gastric emptying was improved overall, with normalization in 67% of those with baseline impairment.Table

Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease

The endoscopic delivery of temperature-controlled radiofrequency energy to the gastroesophageal junction (Stretta procedure) recently has been shown effective for patients with gastroesophageal reflux disease (GERD). However, its effectiveness has been assessed mainly over short periods (6-12 months). This study aimed to evaluate long-term results of the Stretta procedure. All patients undergoing the Stretta procedure since August 2000 were prospectively evaluated under an institutional review board-approved protocol. All patients with a follow-up period longer than 18 months were recruited for a 24-h pH study and mailed a follow-up survey, which included the following: Short Form 12 (SF-12) health status questionnaire, GERD-specific quality-of-life questionnaire (QOLRAD), and queries regarding long-term satisfaction and medication use. The Stretta procedure was performed on 82 patients, and 41 patients with a follow-up period longer than 18 months qualified for the study. Follow-up surveys were completed by 36 patients (88%) during a mean follow-up period of 27.1 +/- 3.7 months. Of these 36 patients, 30 (83%) were highly satisfied with the procedure and would have it performed again. More than half of the Fifty Stretta patients (56%) had completely discontinued their use of proton pump inhibitors (PPIs), and an additional 31% had reduced their dose significantly. The mean PPI equivalent doses were 37.8 +/- 22.2 mg/day before the Stretta procedure and 11.6 +/- 14.6 mg/day at 27-month follow-up assessment (p = 0.001). According to the patient outcomes for daily PPI use (yes/no), the patients were divided into two groups: responders (n = 20) and nonresponders (n = 16). The responder group scored higher in QOLRAD score (p = 0.0001), SF-12 physical score (p = 0.038), and SF-12 mental score (p = 0.003). In the 24-hour pH study, the responder group demonstrated a significant decrease in distal esophageal acid exposure time (6.4% +/- 1.5% to 3.1% +/- 1.4%; p = 0.0001). The Stretta procedure results in a statistical significant long-term decrease in GERD symptoms and PPI use. The treatment effect is durable beyond 2 years, and 56% of patients had discontinued their user of all antisecretory drugs.

P0879 PERIPHERAL EOSINOPHILS (PE) IN CHILDHOOD EOSINOPHILIC OESOPHAGITIS

Introduction: Eosinophilic Oesophagitis (EO) is characterized by a high density of intraepithelial eosinophils (>20 HPF) in oesophageal biopsies, usually in absence of gastro-oesophageal reflux. Frequently children present with dysphagia and have a history of asthma, increased number of peripheral eosinophils are reported in 80% of cases. Aim: to present data on Peripheral Eosinophil (PE) count in consecutive children we diagnosed with EO in the last 5 years. Methods: Case Description: EO was diagnosed in 7 children (5 males, age range 6 mos-14 yrs) for a heavy eosinophil infiltrate at histology in oesophageal mucosa (>20 Eosinophils per 400× High Power Field, median: 30 eos/HPF, range 20–50) and normal gastric and duodenal mucosa without eosinophils. All but one showed no gastro-esophageal reflux at 24-hour pH-monitoring, and 4 had been previously treated with an antisecretory drug without clinical or histologic response. Asthma was present in 3 and dysphagia in 2. They were all treated with Fluticasone inhaled without spacer (3 puffs t.i.d: 250 mg/puff) for 6 weeks and trained to swallow immediately after the puffs to allow a significant portion of the drug to deposit into the oesophagus. Endoscopy and esophageal biopsy were repeated after therapy. Good clinical and histologic response was seen in all but 2 children where compliance was poor (they responded to a second course). Two children relapsed 1 and 4 years later, and treatment was repeated with good response. Peripheral eosinophils (PE) were counted at each endoscopy. Results: Results: PE counts were increased at baseline (median 810/muL range 400–1162) and significantly decreased in 5 cured children (median 239/muL range 97–401, p=.01) but were unchanged in children with persistence of EO due to non compliance. In 2 relapsing children eosinophils increased again 700 and 956/muL respectively. A significant correlation was found between PE and mucosal eosinophil density (r = 0.74, p<.001) Conclusion: Conclusion: PE were always increased in children with EO and significantly decreased in cured children. Relapses were associated to a new increase in PE counts. More studies should focus on this findings, that may reveal clinically useful to monitor response to treatment and relapses.

Empirical use of antisecretory drug therapy delays diagnosis of upper gastrointestinal adenocarcinoma but does not effect outcome.

Upper gastrointestinal cancer carries a poor prognosis. Although the incidence of gastric adenocarcinoma is falling, oesophageal adenocarcinoma is increasing. This has been attributed to an increasing prevalence of gastro-oesophageal reflux disease, commonly treated empirically in primary care with antisecretory drugs. Treatment has been associated with delayed diagnosis but it is unclear if this influences prognosis. To ascertain the effect of antisecretory drugs on time to diagnosis, symptoms, tumour stage and outcome. A retrospective cohort study of primary care records for 747 patients diagnosed with upper gastrointestinal adenocarcinoma at South Tees NHS Trust between 1991 and 2001. Mean time from the onset of symptoms to diagnosis was 30 weeks. Mean and median times at the primary care stage were longer than at the hospital stage for both oesophageal and gastric cancer (P < 0.0001). Patients with benign symptoms prescribed antisecretory drugs were referred later than those not on antisecretory drugs (P < 0.0001), as were patients with alarm symptoms (P = 0.0008). Prior use of antisecretory drugs delayed diagnosis by 17.6 weeks (mean) but had no effect on tumour stage at diagnosis or survival. Prior antisecretory drug therapy was associated with delayed diagnosis of upper gastrointestinal adenocarcinoma irrespective of presenting symptoms. Concerns that delays might adversely affect tumour stage or long-term survival were not substantiated.

The Stretta Procedure Improves GERD Symptoms and Anti-secretory Drug Use at 2 Years, while Normalizing Gastric Emptying Function in the Majority of Impaired Subjects

Aims: To evaluate the long-term effect of the Stretta Procedure on GERD symptoms, patient satisfaction and anti-secretory drug utilization. Further, gastric emptying studies were used to assess whether Stretta can improve gastric emptying function in those subjects with baseline impairment. Methods: Between August 2000 and October 2003, 202 subjects with GERD and inadequate symptom control despite PPI bid underwent the Stretta procedure. All procedures were performed by a single physician (MN) on an outpatient basis using conscious sedation. Baseline and follow-up (6, 12 and 24 month) GERD-HRQL scores (0-50), heartburn (0-5), satisfaction (0-5) and medication use were collected. Gastric emptying studies were performed on a subset of patients at baseline and 8 months. Results: There were 202 subjects (122 females, 60.4%) treated. There were no significant acute adverse events. Two year follow-up was available for 72 patients. GERD-HRQL, heartburn, satisfaction, and medication use were significantly improved at all follow-up intervals (6, 12, 24 months) and were superior to that achieved on baseline drug therapy. Specifically, baseline GERD-HRQL improved from 29.0 ± 10.9 to 1.5 ± 4.4 (p<0.001) at 2 years, while heartburn improved from 4.0 ± 1.2 to 0.0 ± 0.7 (p<0.001). Satisfaction improved from 1.0 ± 0.9 to 5.0 ± 0.9 (p<0.001) at 2 years. GERD medication requirement was reduced from bid PPI to prn H2RA or PPI at 2 years (p<0.001). Baseline and follow-up gastric emptying studies were available for 74 patients. The % emptied at 90 minutes improved from 60 ± 22% to 81 ± 23% (p<0.001). At baseline, 29 (40%) of subjects had delayed gastric emptying, while at follow-up 12 (16%) had delayed gastric emptying. This represents normalization in 67% of those with abnormal baseline studies. Conclusions: The Stretta procedure has a significant and positive effect on GERD symptoms and medication use, with durability of response demonstrated at 2 years. The observed improvement was superior to that achieved with escalated baseline anti-secretory therapy. Gastric emptying was improved overall, with normalization in 67% of those with baseline impairment.

Épidémiologie des complications digestives liées à l’aspirine à faible dose

Low-dose aspirin (< 330 mg/d) is recommended for the prevention of myocardial infarction or ischemic stroke. Six to 12% of the general population is exposed to low-dose aspirin. The most frequently studied digestive complications are bleeding peptic ulcers, whose risk is increased twofold by low-dose aspirin treatment, and non-complicated peptic ulcers. History of bleeding or non-complicated peptic ulcer, alcohol intake, concomitant treatment with NSAID or calcic inhibitors are demonstrated risk factors of bleeding ulcer associated with low-dose aspirin. The role of enteric coating, of low-dose aspirin dose, of delay since low-dose aspirin treatment onset, and of Helicobacter pylori infection, remains controversial. Antisecretory drugs (H2 inhibitors, proton pump inhibitors), and nitroglycerin are associated with a decreased risk of bleeding ulcer. The protective effect of COX-2 inhibitors on the risk of bleeding ulcer is suppressed by concomitant treatment with low-dose aspirin. The risk of no- complicated peptic ulcer was increased by low-dose aspirin intake by a factor 2.9 in one study. Low-dose aspirin dose, infection by Helicobacter pylori, NSAID intake, and absence of enteric coating, are possible risk factors for non-complicated peptic ulcer. No association was retrieved with alcohol intake and peptic ulcer history.

Longevity of balloon-stabilized skin-level gastrostomy device.

The gastrostomy button is increasingly used in patients requiring long-term enteral feeding. No data are available addressing the longevity of balloon-type gastrostomy buttons. The aim of this study was to evaluate the longevity of balloon-type gastrostomy buttons in children and the cause of the button removal. During a period of 2.5 years, 165 gastrostomy (Mic-Key, Medical Innovations Corporation, Draper, Utah, U.S.A.) buttons were inserted in 84 children. In all patients, the button replaced a standard tube gastrostomy. The first button was usually inserted under general anesthesia at least 2 months after the insertion of a surgical gastrostomy tube. Additional replacement was performed without sedation. Mean longevity of balloon-type gastrostomy buttons was 5 months (range, 14 days-14 months). Causes of button removal were: inner balloon rupture (n = 101, 61%); leak around button or deflation of the balloon (n = 23, 14%); accidental removal (n = 20, 12%); device damage (n = 5), and obstruction (n = 3). When considering the subgroup with inner balloon rupture, the longevity of the button was 6 months (range, 1-13 months). No correlation was found between duration of gastrostomy button and underlying disease, age of the patient, or the use of antisecretory drugs. Although the Mic-Key button has the advantage of an easy insertion, its major limitation is the high frequency of inner balloon rupture, which was the primary main reason for removal.

Concomitant use of buffered and enteric-coated low-dose aspirin products and antisecretory drugs

Buffered and enteric-coated formulations of low-dose aspirin therapy are although expected to avoid gastrointestinal complications, there are reports that these modified products are associated with such complications. One available option for preventing aspirin-induced gastrointestinal complications is the simultaneous use of the agents that inhibit acid secretion such as H(2)-receptor antagonists and proton pump inhibitors. We compared the frequency of prescriptions for antisecretory drugs between users of either buffered or enteric-coated low-dose aspirin. Monthly prescriptions at the National Cardiovascular Center for aspirin products and antisecretory drugs were counted from January 1998 to December 2002. Counting was based on information from a prescription database file compiled from a computerized order entry system. Time-series analyses were performed to determine changes in the frequency of prescriptions for low-dose aspirin products and antisecretory drugs. In addition, the frequency of prescriptions for antisecretory drugs was compared in individuals using either buffered or enteric-coated low-dose aspirin. A significant reduction in the frequency of prescriptions for H(2)-receptor antagonists was observed during 2001 in users of enteric-coated low-dose aspirin compared with users of buffered low-dose aspirin users. In contrast, we observed a significant increase in the frequency of prescriptions for H(2)-receptor antagonists in users of enteric-coated low-dose aspirin during 2002. This change in prescribing H(2)-receptor antagonists in users of enteric-coated low-dose aspirin began in the latter half of 2001. Proton pump inhibitors accounted for 0.31% of prescriptions in users of buffered low-dose aspirin and 0.47% in users of enteric-coated low-dose aspirin, with this difference being statistically significant. The findings of the present study do not support the notion that enteric-coated low-dose aspirin reduces the risk of gastrointestinal complications and is safer than buffered low-dose aspirin products. However the usual caution about making inferences from observational retrospective data is appropriate.

Review article: approaches to the long-term management of adults with GERD-proton pump inhibitor therapy, laparoscopic fundoplication or endoscopic therapy?

The goals of gastro-oesophageal reflux disease (GERD) treatment are to control symptoms, heal the injured oesophageal mucosa, and prevent complications. Pharmacological therapy is effective in producing acute symptom relief and mucosal healing, as well as the long-term maintenance of remission. Proton pump inhibitors are the mainstay of GERD therapy. However, the need for daily administration, failure to provide complete symptom relief and costs of these agents may limit their use in some patients, prompting a consideration of alternative treatment strategies. Laparoscopic fundoplication may achieve symptom relief and healing of the oesophagitis in these individuals, but its invasiveness, cost and inherent surgical risks have created an interest in endoscopic therapies for GERD, with several emerging during the past few years. These interventions may either be viewed as an alternative therapy or as 'bridge' therapy, with patients still choosing to be treated with acid anti-secretory drugs or fundoplication if the endoscopic procedure fails to provide adequate symptom relief or if symptoms recur. Patient selection is critical for the success of fundoplication as well as endoscopic procedures, with ideal candidates being those with well-established endoscopically documented GERD, abnormal pH monitoring, normal oesophageal motility studies, and who have experienced at least partial symptom relief with proton pump inhibitor therapy. Hiatal hernia is not a contra-indication to fundoplication, while endoscopic intervention is best suited for those with a hiatal hernia of less than 3 cm in length. The long-term efficacy, cost-effectiveness, and impact of endoscopic procedures on extra-oesophageal manifestations of GERD and risk for GERD-related complications has not been determined.

Aging and upper gastrointestinal disorders

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of gastro-esophageal reflux disease (GERD) in old age. GERD symptoms are different in the elderly compared to young or adult patients; moreover, esophagitis is a more severe disease in the elderly than in young subjects, relapse occurring in a high percentage of cases in those elderly patients who are not in maintenance therapy with antisecretories. In old age, PPIs are more effective than H2-blockers in healing and reducing the relapse of esophagitis; PPI therapy is well tolerated and very effective even in elderly subjects with concomitant diseases and treatments. Discontinuing maintenance treatment with PPIs after 6 months is associated with a significant increase in the relapse rate. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide. Approximately 53-73% of elderly peptic ulcer patients are Helicobacter pylori positive; however, the percentage of H. pylori-positive elderly patients who are treated for their infection remains very low. We now have data that demonstrate the benefit of curing H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis. One-week PPI-based triple therapy regimens including clarithromycin, amoxycillin and/or nitroimidazoles are highly effective and well tolerated in elderly patients. Low doses of both PPIs and clarithromycin (in combination with standard doses of amoxycillin or nitroimidazoles) are sufficient. Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID and/or aspirin. Several strategies are available to prevent NSAID-related peptic ulcers, i.e. the use of low doses and/or less damaging NSAIDs, the use of coxibs, gastroprotection with antisecretory drugs, the eradication of H. pylori infection in infected patients as well as educational programs to reduce inappropriate prescriptions. Strategies for subgroups of patients that will take account of the GI and non-GI risks, i.e. disability, co-morbidity and friality of patients, according to a comprehensive geriatric assessment are recommended.

Natural history of gastro-oesophageal reflux disease without oesophagitis (NERD) – a reappraisal 10 years on

Background and aim. Ten years ago we published a study describing the 6-month outcome of 33 outpatients with typical gastro-oesophageal reflux disease symptoms and pH-metry proven excess gastro-oesophageal reflux but without endoscopical evidence of oesophagitis, currently referred to as patients with gastro-oesophageal reflux disease without oesophagitis. We now present an update of that report concerning morbidity, drug consumption and quality of life of the original patients 10 years after the initial diagnosis. Methods. The study consisted of the retrieval and revision of all clinical and instrumental records concerning the cohort of 33 above-mentioned patients. Data are available regarding annual intervals within the first 5 years from original diagnosis and, subsequently, with a follow-up ranging from 7 to 14 years (median 10 years). The records of these 33 patients were reviewed, including the results of clinical visits at the outpatients department, of oesophagogastroduodenoscopies and pH- metries. Finally, a telephonic interview was conducted by means of a structured questionnaire, aiming at evaluating present symptoms, actual therapy if any, health-related quality of life and other information regarding any gastro-oesophageal reflux disease symptoms. Results. Of the original 33 patients, 31 are still alive and 2 were lost to follow-up. Of the 29 remaining, only 1 is definitively not complaining of any gastro-oesophageal reflux disease-related symptoms. Within 5 years of the first diagnosis, oesophagitis was found in all but one of the 18 subjects who underwent repeated endoscopy. At the latest follow-up check, after a median of 10 years, out of the 28 still complaining of gastro-oesophageal reflux disease symptoms, 21 (75%) were presently taking antisecretory drugs (proton pump inhibitors and H-2 receptor antagonists) because of gastro-oesophageal reflux disease symptoms/lesions, 12 of whom intermittently or on demand and the remaining 9 continuously. Two patients (2/28) underwent antireflux surgery, but despite this were still taking antisecretory drugs (in one case H2-RA; in the other proton pump inhibitor). The health-related quality of life, self-evaluated by the patient by means of a VAS scoring from 0 (worst possible) to 10 (best possible) increased significantly from 3.2 to 6.5 from baseline (before therapy) to present time, possibly due to the positive effect of present therapy. Conclusions. Our study conducted on a cohort of endoscopy-negative patients with pH-metry-confirmed reflux disease has shown that after a median time of 10 years following the original diagnosis, the majority of patients have, in fact, developed reflux oesophagitis and are on prolonged antisecretory therapy because of recurrent gastro-oesophageal reflux disease symptoms/lesions. The study confirms that gastro-oesophageal reflux disease without oesophagitis, as well as gastro-oesophageal reflux disease at large, is a chronic disease characterised by increasing severity with time, which requires protracted medical therapy in a vast proportion of patients. Absence of endoscopic oesophagitis at presentation does not represent a positive prognostic factor.

Dyspepsia management in primary care.

Dyspepsia is common in western society. Prompt endoscopy is imperative in all patients with sinister symptoms or if symptoms first appear after the age of 50-55 years, but the optimal management of younger patients with uncomplicated dyspepsia is still open to debate. The literature on the management of uncomplicated dyspepsia is reviewed and a personal view is presented. Strategies based on non-invasive detection of Helicobacter pylori are probably the most cost-effective. Currently (H. pylori prevalence 30%-40%), a 'test and treat' approach using a non-invasive test to detect H. pylori is likely to be the most efficient first step. If the patient is H. pylori-negative or if symptoms persist after successful H. pylori eradication, empirical treatment with an anti-secretory drug is justified. Endoscopy is reserved for those patients in whom this approach fails. If the prevalence of H. pylori decreases, the positive predictive value of any non-invasive H. pylori test will become too low. A 'test and scope' approach in which a positive test can be confirmed by two or more biopsy-based tests is then more appropriate. At a very low prevalence of H. pylori in the dyspeptic population, non-invasive testing for H. pylori loses its significance and empirical treatment with an antisecretory drug becomes a rational first step. The optimal approach to management of uncomplicated dyspepsia is dependent on the prevalence of H. pylori among the dyspeptic population. At the current prevalence rate, 'test and treat', followed by acid suppressive treatment in the case of persisting symptoms, is the most appropriate strategy.

Do children with gastroesophageal reflux become adults with gastroesophageal reflux? What is the role of Acid suppression in children?

Do children with gastroesophageal reflux become adults with gastroesophageal reflux? What is the role of Acid suppression in children?

Eradication of Helicobacter pylori and use of antisecretory drugs: population based cohort study

Helicobacter pylori is an important risk factor for peptic ulcers. If infection with H pylori is cured, ulcers associated with H pylori do not recur. An H pylori “test and...

The medical management of intestinal failure: methods to reduce the severity.

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel enterocutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudoobstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90-120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and > 1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.

Review article: the treatment of refractory Helicobacter pylori infection.

The occurrence of refractory Helicobacter pylori infection is increasing. When the bacteria are not eradicated it means that the antibiotics have not reached the gastric mucosa at a sufficient concentration and over a sufficient time lapse to kill them. The main reasons for this are poor patient compliance, resistant bacteria, low gastric pH and a high bacterial load. Therefore, when administering a new treatment, it is important to choose antibiotics which do not face resistance problems and which increase the dosage of antisecretory drugs and the duration of treatment and, if possible, to add a topical agent such as bismuth salt. The recommended empirical strategy is to prescribe quadruple therapy or, alternatively, 2-week triple therapy including amoxicillin-metronidazole, tetracycline-metronidazole or amoxicillin-rifabutin. However, when H. pylori is susceptible, clarithromycin can still be used. In the case of a high level of metronidazole resistance, furazolidone can be employed. In each case, it is important to ensure good patient compliance, and counselling is helpful in this regard. However, the best approach remains the prevention of refractory H. pylori infection and, for this purpose, antimicrobial susceptibility testing before first-line therapy is important and should be encouraged.

Endoscopic antireflux therapy.

The management of gastroesophageal reflux disease has gained increasing attention during the past two decades due to a high prevalence in Western societies, new insights in pathophysiology, new potent antisecretory drug therapy, and the advent of minimal invasive surgery. There has always been some discussion between gastroenterologists and surgeons about conservative or surgical treatment options. Others view these different therapies as complementary concepts and both options are needed. There is evidence that the majority of patients with gastroesophageal reflux disease are best treated by proton pump inhibitors (PPIs). There is also evidence that the principle of mechanical augmentation of the gastroesophageal junction by a fundoplication is a good treatment option in patients with severe progressive reflux disease. Recently, several consensus projects developed evidence-based criteria for the indication for conservative and surgical therapy [9, 18, 21]. More than 10 years ago, the British gastroenterologist Paul Swain developed a sewing machine handled by flexible endoscopy to perform limited surgical maneuvers in the gastrointestinal lumen [30, 44, 45]. The idea of minimizing surgical trauma even more by performing operative procedures inside the gastrointestinal (GI) tract opens a new perspective in minimal invasive treatment. As a consequence, in the past few years a whole spectrum of new endoscopic techniques have been developed to treat gastroesophageal reflux disease by intraluminal therapeutic action. This article provides an overview of the available techniques.

Omeprazole Plus Azithromycin and Either Amoxicillin or Tinidazole for Eradication of Helicobacter pylori Infection

To establish whether omeprazole plus azithromycin in association with either amoxicillin or tinidazole is effective in curing Helicobacter pylori infection in dyspeptic patients. Many antibiotics in combination with antisecretory drugs have been used in an attempt to find the optimal regimen for eradication of H. pylori. Azithromycin is a macrolide that achieves high concentrations in gastric tissue after a single 500-mg oral dose. A total of 160 consecutive symptomatic patients with H. pylori received omeprazole 20 mg twice daily for 1 week, azithromycin 500 mg/d for 3 days, and were randomly assigned to either amoxicillin 1 g twice daily (OAzAm group, n = 80) for 1 week or tinidazole 500 mg twice daily for 3 days (OAzT group, n = 80). H. pylori status was assessed by rapid urease test and histology at entry and by histology and (13)C-urea breath test after the end of the therapy. H. pylori was eradicated in 62.5% of patients in the OAzAm group (intention to treat [ITT] 62.5%) and in 71.2% of patients in the OAzT group (ITT 71.2%). Although the compliance was excellent and the side effects negligible, the regimens used were partially effective for the eradication of H. pylori.

Discrepancies between population-based data and adverse reaction reports in assessing drugs as causes of acute pancreatitis.

Many drugs are believed, clinically, to cause acute pancreatitis. We used information held on the UK General Practitioner Research Database to compare risks for drugs for which reports of pancreatitis were common or uncommon. Drug prescriptions were examined in 3673 patients with acute pancreatitis and in matched controls. Odds ratios were calculated for recent (1-90 days before the episode), past (91-360 days before the episode) or continuing (prescription in both periods) use. Odds ratios were markedly increased for recent antisecretory use in non-ulcer patients only [all H2-antagonists, 12.4 (9.5-16.4); all proton pump antagonists, 9.3 (6.6-13.0)], with smaller increases for past [3.1 (2.5-3.7) and 3.5 (2.6-4.6), respectively] and continuing [2.6 (2.2-3.1) and 3.7 (2.9-4.7), respectively] use in patients without ulcer. Recent users of mesalazine showed a markedly increased risk [9.0 (1.8-44.6)], with smaller increases in past and continuing users [4.5 (1.3-16.0) and 2.5 (1.2-5.0), respectively]. Odds ratios for other drugs, suspect or not, were modestly increased, irrespective of whether the use was recent, past or continuing. The presence of gall-stones was not associated with a modified risk. Mesalazine, azathioprine and antisecretory drugs in non-ulcer subjects may increase the risk of pancreatitis, but warnings of drug-induced pancreatitis are generally not accompanied by increased population risks.

Electrokinetic study of omeprazole drug in aqueous suspensions

Omeprazole is a antisecretory drug used against gastric ulcers. In this work, we investigate the electric surface characteristics of omeprazole by means of determinations of its electrophoretic mobility, μ e . The effects of pH and the concentration of different electrolytes on the mobility of the drug particles will be analysed. pH seems to be the main variable governing the surface charge and stability of the drug. Specific adsorption of ions is also important.