Oral Proton Pump Research Articles

Similar Effect of Vonoprazan and Oral Proton Pump Inhibitors for Preventing Rebleeding in Cases of Upper Gastrointestinal Bleeding.

Objective The use of a proton pump inhibitor (PPI) reduces rebleeding and mortality in patients with upper gastrointestinal bleeding (UGIB). Vonoprazan is a novel oral agent with strong and sustained acid-inhibitory activity. We clarified the effect of vonoprazan compared with oral PPIs in such patients. Methods We analyzed the Diagnosis Procedure Combination database. The primary outcome was rebleeding, and secondary outcomes were in-hospital mortality and in-hospital mortality after rebleeding. Propensity score matching was performed to balance the comparison groups, and logistic regression analyses were used to compare the outcomes between vonoprazan and oral PPIs. Patients Patients on vonoprazan or oral PPIs who underwent endoscopic hemostasis for UGIB between 2014 and 2019 were included. Results We enrolled 78,964 patients, of whom 27,101 and 51,863 were prescribed vonoprazan and a PPI, respectively. After propensity score matching, the rebleeding rate of vonoprazan did not significantly differ from that of oral PPIs [6.4% vs. 6.1%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.98-1.13]; similarly, the in-hospital mortality rate (1.4% vs. 1.5%; OR, 0.91; 95% CI, 0.79-1.05) and in-hospital mortality after rebleeding (0.3% vs. 0.2%; OR, 1.09; 95% CI, 0.78-1.54) also did not significantly differ between the groups. The acquired findings were robust across dose-restricted analyses and several sensitivity analyses. Conclusion Rebleeding and in-hospital mortality risks in patients on vonoprazan were similar to those in patients on oral PPIs. Considering the higher cost of vonoprazan, oral PPIs might be an optimal oral agent as an acid-suppressive therapy in such patients.

A Forgotten Cause of Dyspepsia

AbstractA 63-year-old female patient presented with complaints of epigastric pain for 2 months associated with postprandial fullness and early satiety. She gave history of open cholecystectomy 2 years back at a peripheral hospital. Her general physical and systemic examinations were within normal limits. Her routine investigations including hemogram, liver and renal biochemistries, and ultrasound abdomen were normal. She had received multiple courses of oral proton pump inhibitors, prokinetics, antacids, and antispasmodics but had no relief. In view of her persistent complaint and age more than 60 years, her esophagogastroduodenoscopy (EGD) was planned. Her EGD revealed deeply embedded large gauze piece in the posterior wall of the first part of duodenum. Her contrast-enhanced computed tomography revealed mottled appearance in first part of duodenum, which is nonmobile in subsequent images suggestive of gossypiboma. A final diagnosis of gossypiboma with partial migration of gauge into duodenal lumen was made. Endoscopic removal was not attempted in view of possible risk of perforation and patient shifted to the department of surgery for further management.

Laparoscopic sleeve gastrectomy makes acid reflux symptoms worse or better?: a prospective short-term observational study in patients with morbid obesity.

Gastroesophageal reflux symptom (GERS) occur frequently in obese patients. Although some surgeons avoid laparoscopic sleeve gastrectomy (LSG) in these patients for fear of postoperative exacerbation of GERS, this notion is not supported by sufficient medical evidence. This prospective study aimed to evaluate the impact of LSG on GERS. Shanghai East Hospital, Shanghai, China. Seventy-five LSG candidates were enrolled between April 2020 and October 2021. Only patients with completed preoperative and 6-month postoperative evaluation of GERS with the Reflux Symptom Score (RSS) and the Gastrointestinal Quality of Life index were included. Each patient's characteristics, including sex, age, drinking and smoking history, body mass index (BMI) at the time of surgery, recent BMI, comorbidities, glucose and lipid metabolism-related laboratory results, and uric acid and sex hormone levels were obtained. Sixty-five patients (33.8 ± 9.1 years) were finally included in our study. The mean preoperative BMI was 36.4 ± 6.8 kg/m2. Preoperative GERS were reported in 32 (49.2%) patients (RSS > 13), and 26 of them (81.3%) had dramatic remission at 6 months postoperatively. Four patients (12.1%) developed de novo GERS postoperatively, which were well-controlled with oral proton pump inhibitors. Furthermore, GERS were significantly correlated with preoperative BMI; the risk of developing new or worsening GERS postoperatively was positively associated with preoperative insulin resistance. A low incidence of de novo GERS and significant alleviation in preoperative GERS occurred in most obese patients after LSG. A patient with preoperative insulin resistance may not be suitable for LSG surgery owing to the increased risk of new or worsening of GERS postoperatively.

Eosinophilic gastroenteritis and colitis related to cow’s milk allergy: A case report

Objective: To provide evidence on clinical, laboratory, histopathological features, diagnostic and treatment of primary eosinophilic gastroenteritis in children. Case presentation: A 7-year-old boy admitted to the 108 Military Central Hospital with symptoms of abdominal pain, nausea and vomiting, recurrent diarrhea related to cow's milk intakes. The child was diagnosed with eosinophilic gastroenteritis, combined with increased serum IgE. The disease was stabilized with corticosteroids, oral proton pump inhibitors (PPIs) combined with the elimination of cow's milk from the daily diet. Conclusion: Primary eosinophilic gastroenteritis in children was definitively diagnosed based on exclusion of other causes of eosinophilia and 3 features: Gastrointestinal symptoms, endoscopy showed gastrointestinal eosinophilic infiltration, peripheral eosinophilia. Corticosteroids are the most effective and useful symptom control drugs in most cases in combination with a diet, eliminating the allergic component.

Drug-Associated Gastropathy: Diagnostic Criteria.

Drugs are widely used to treat different diseases in modern medicine, but they are often associated with adverse events. Those located in the gastrointestinal tract are common and often mild, but they can be serious or life-threatening and determine the continuation of treatment. The stomach is often affected not only by drugs taken orally but also by those administered parenterally. Here, we review the mechanisms of damage, risk factors and specific endoscopic, histopathological and clinical features of those drugs more often involved in gastric damage, namely NSAIDs, aspirin, anticoagulants, glucocorticosteroids, anticancer drugs, oral iron preparations and proton pump inhibitors. NSAID- and aspirin-associated forms of gastric damage are widely studied and have specific features, although they are often hidden by the coexistence of Helicobacter pylori infection. However, the damaging effect of anticoagulants and corticosteroids or oral iron therapy on the gastric mucosa is controversial. At the same time, the increased use of new antineoplastic drugs, such as checkpoint inhibitors, has opened up a new area of gastrointestinal damage that will be seen more frequently in the near future. We conclude that there is a need to expand and understand drug-induced gastrointestinal damage to prevent and recognize drug-associated gastropathy in a timely manner.

Association between occurrence of multiple white and flat elevated gastric lesions and oral proton pump inhibitor intake.

Multiple white and flat elevated lesions (MWFL) that develop from the gastric corpus to the fornix may be strongly associated with oral antacid intake. Therefore, this study aimed to determine the association between the occurrence of MWFL and oral proton pump inhibitor (PPI) intake and clarify the endoscopic and clinicopathological characteristics of MWFL. The study included 163 patients. The history of oral drug intake was collected, and serum gastrin levels and anti-Helicobacter pylori immunoglobulin G antibody titers were measured. Upper gastrointestinal endoscopy was performed. The primary study endpoint was the association between MWFL and oral PPI intake. In the univariate analyses, MWFL were observed in 35 (49.3%) of 71 patients who received oral PPIs and 10 (10.9%) of 92 patients who did not receive oral PPIs. The occurrence of MWFL was significantly higher among patients who received PPIs than in those who did not (p<0.001). Moreover, the occurrence of MWFL was significantly higher in patients with hypergastrinemia (p=0.005). In the multivariate analyses, oral PPI intake was the only significant independent factor associated with the presence of MWFL (p=0.001; odds ratio, 5.78; 95% confidence interval, 2.06-16.2). Our findings suggest that oral PPI intake is associated with the presence of MWFL (UMINCTR 000030144).

The inadvertent consequences of drug recalls: A case study of a recall of pantoprazole generics from the markets

IntroductionDrug recalls may impact treatment plans or access to suitable therapies. Thus, they inadvertently affect treatment outcomes. ObjectiveWe aimed to examine the impact of recalls on patients’ safety using pantoprazole-containing products recall as a case study in terms of the occurrence of potential drug-drug interactions (pDDIs). MethodsThis retrospective study used de-identified electronic health records of adult patients who had a prescription for oral proton pump inhibitors (PPIs) including pantoprazole, esomeprazole, lansoprazole, or omeprazole from April 2020 through September 2021 from a large tertiary care hospital. The study outcome definition was the prevalence of pDDIs in PPIs users before and after the recall date (March 2021). Changes in the prevalence of pDDIs were modeled using interrupted time-series. The rate ratio of pDDIs in the 12 months before and 6 months after the recall was modeled using negative binomial regression. ResultsA total of 1,826 pDDIs were identified, and the median monthly prevalence of pDDI before the recall was 102.5 which increased to 115.5 after the recall. A change in the level of pDDIs occurred immediately after the recall date, followed by a gradual decrease over time. The rate of pDDIs was 69% higher after the recall compared to the baseline (rate ratio 1.69; 95% confidence interval, 0.75–1.91). DiscussionRecall of pantoprazole-containing products was associated with a higher rate of pDDIs. However, the prevalence of pDDIs gradually decreased over time. We highlight the importance of planning of recall process and coordinating all potential stakeholders to avoid potential harms.Word count: 1450.

Pharmacoeconomic analysis of oral and injectable proton pump inhibitors available in India

Introduction: Proton pump inhibitors (PPIs) effectively suppress acid secretion and play an important role a lot of gastrointestinal disorders. PPIs are generally used long term by the patients. This can cause an increase in patient cost and subsequent decrease in adherence to the prescription. Hence, this study was done to assess the cost variation of PPIs. Methods: The cost of different brands of commonly used PPIs (10 capsules/tablets for oral drugs and one ampoule/vial for injectable drugs) was tabulated by referring to the “Monthly Index of Medical Specialties” October – December 2021, and 1mg online pharmacy. The cost ratio and percentage cost variation for various brands of a particular strength and dosage form was calculated and compared. Cost ratio &gt;2 and cost variation &gt;100% was considered significant. Results: The results showed a huge variation in costs of different brands with the highest being Rabeprazole 20mg (Cost ratio-16.4, Percentage cost variation-1540%) in oral formulation and Rabeprazole 20mg (11.9, 1090%) in the injectable formulation. Among oral drugs, Omeprazole 40mg has the lowest cost ratio and percentage cost variation (1.60, 60.34%) and Pantoprazole 40mg (1.51, 51.16%) in case of injectable formulations. Conclusion: There is a wide variation in the prices of PPIs available in the market. Huge demand for the commonly orally prescribed drugs like Omeprazole 20mg and Pantoprazole 40mg could be the reason for the high cost. Among injectable preparations, Pantoprazole 40mg is the most commonly prescribed but it has an acceptable cost ratio which is a positive sign.

Prognosis of patients with laryngeal contact granuloma: Development and validation of RCGSG score.

This study aimed to develop an objective and simple score for predicting the prognosis of patients with laryngeal contact granuloma (LCG) treated with local glucocorticoid injection combined with oral proton pump inhibitor (GI + PPI). Cox regression analysis was used to analyze the effect of baseline variables on the prognosis of 507 patients with LCG treated with GI + PPI. An easy-to-apply RCGSG (Reflus, Cough, Gender, and Surgery in GI + PPI therapy) score was developed based on the independent risk factors selected by univariate and multivariate Cox regression analyses. The score was internally validated by receiver-operating characteristic curve, calibration curve, and decision curve analysis. After univariate and multivariate analyses, male gender (hazard ratio [HR] 0.546, p < .001), laryngopharyngeal reflux (HR 0.702, p=.001), chronic cough (HR 0.709, p=.001), and history of surgical resection (HR 0.433, p < .001) were found to be the independent risk factors affecting the prognosis of LCG. According to the score, the median cure time was 3 months (95% confidence interval [CI] 2.81-3.19) in the low-risk group, 4 months (95% CI 3.74-4.26) in the moderate-risk group, and 5 months (95% CI 4.76-5.24) in the high-risk group. The bootstrap method was used to plot calibration curves for internal validation. The RCGSG score, developed based on laryngopharyngeal reflux, chronic cough, gender, and surgical resection history, has been internally verified to be a good predictor of the prognosis of patients with LCG receiving GI + PPI treatment. Level 4.

An extended 36-week oral esomeprazole improved long-term recurrent peptic ulcer bleeding in patients at high risk of rebleeding

BackgroundPatients with Rockall scores ≥6 have an increased risk of long-term peptic ulcer rebleeding. This study was aimed toward investigating whether an extended course of oral esomeprazole up to 1 year decreased ulcer rebleeding in such patients.MethodsWe prospectively enrolled 120 patients with peptic ulcer bleeding and Rockall scores ≥6. After an initial 16-week oral proton pump inhibitor (PPI) treatment, patients were randomized to receive a 36-week course of oral twice-daily esomeprazole 20 mg (Group D, n = 60) or once-daily (Group S, n = 60). Thereafter, they were divided into the PPI-on-demand (n = 32) and PPI-discontinued (n = 77) subgroups. Our previous cohort with Rockall scores ≥6 served as the controls (Group C, n = 135); they received only an initial 8- to 16-week oral PPI. The primary and secondary outcomes were peptic ulcer rebleeding during the first year and the second year-and-thereafter, respectively.ResultsFor the primary outcome, groups D and S comprised a higher proportion of rebleeding-free than Group C (P = 0.008 and 0.03, log-rank test). The competing-risks regression analysis confirmed that extended PPI use and American Society of Anesthesiologists classification were independent factors contributing to the primary outcome. For the secondary outcome, PPI-on-demand had a borderline higher proportion of rebleeding-free than Group C (P = 0.07, log-rank test); however, only the Rockall score was the independent factor.ConclusionsAn extended 36-week course of oral esomeprazole 20 mg, twice- or once-daily for patients with Rockall scores ≥6 reduced ulcer rebleeding during the first year, but the effect needed to be further validated when PPIs were shifted to on-demand or discontinued thereafter (NCT02456012, 28/05/2015).

A Case Study of Achalasia Presenting with Chest Pain

&lt;p&gt;胸痛為臨床常見主述，在排除心因性問題後，常因病人合併胃灼熱感，診斷為胃食道逆流。然而本案例為一位36歲女性，因反覆進食後胸痛、胃灼熱及逆流等症狀，依醫囑斷續服用氫離子幫浦抑制劑（Proton Pump Inhibitor, PPI）治療胃食道逆流約一年仍未改善，直至夜間逆流咳嗽加劇，轉至本院消化內科求治，問診後發現合併有吞嚥困難及體重減輕情形，安排上消化道內視鏡排除食道腫瘤後，經食道攝影檢查確診為食道弛緩不能症（achalasia）。個案接受經口內視鏡肌層切開術治療、營養重建及心理諮商後，胸痛、逆流及吞嚥困難等症狀大幅改善，體重也從44 kg回復至50 kg，焦慮程度亦漸緩解。針對反覆出現與胃食道逆流相似症狀，或經藥物治療無效者，應進一步評估有無吞嚥困難，與胃食道逆流作鑑別診斷，避免病人因進食困難，造成營養不良併發症，以及長期睡眠困擾導致負向情緒感受，嚴重影響生活品質。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Chest pain as a relatively common clinical symptom especially when excluding ischemic heart dis&amp;shy;ease, patients are often diagnosed with gastroesophageal reflux disease due to acid regurgitation and a sensation of heartburn. A 36-year-old woman had had been intermittently treated with an oral proton pump inhibitor (PPI) under the impression of gastroesophageal reflux disease for approximately one year due to recurrent chest pain, heartburn, and a sensation of regurgitation. However, the symptoms deteriorated with exacerbation at night, which was an indication of poor response to the oral medi&amp;shy;cation. Thus, she was transferred to the Department of Gastroenterology for further examination and treatment. After detailed inquiry, the patient also suffered from progressive dysphagia with body weight loss, chest pain and regurgitation sensation. Therefore, an upper gastrointestinal panendoscopy was performed to exclude the presence of esophageal tumors. A diagnosis of esophageal achalasia was confirmed after an upper gastrointestinal examination series was conducted. After informing the patient, per-oral-endoscopic myotomy was performed. Nutritional supplementation and psychological consultation were also provided. The patient&amp;rsquo;s symptoms (e.g., chest pain, regurgitation, and dyspha&amp;shy;gia) improved significantly. Body weight increased from 44 kg to 50 kg, and her anxiety level was gradually reduced. For those who diagnosed with recurrent gastroesophageal reflux disease along with a poor response to oral medications, a detailed inquiry and a specific examination should be conduct&amp;shy;ed for other differential diagnoses, (e.g., achalasia) that may have long-term negative impact on the patient&amp;rsquo;s nutritional status, sleep disturbance, negative emotions, and quality of life&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Prior oral proton-pump inhibitor use is associated with reduced severity of aspirin-related upper gastrointestinal bleeding in older people.

Low-dose aspirin is commonly used for primary or secondary prophylaxis against cardiovascular disease in older people. However, the potential risk of upper gastrointestinal (UGI) ulceration and bleeding associated with low-dose aspirin use is often not appreciated by prescribers and older consumers. Among 133 serial patients with UGI bleeding, aspirin-users aged ≥70 years had a ninefold increased likelihood of overt UGI bleeding compared with non-users, reducing by 90% in regular proton-pump inhibitor users (adjusted odds ratio 0.10). We recommend risk-versus-benefit discussions when recommending aspirin to older people.

The impact of deprescribing interventions on oral proton pump inhibitor utilisation in a Singapore tertiary hospital: A quality improvement initiative

Proton pump inhibitors (PPIs) are effective treatments for upper gastrointestinal pathologies and short-term courses are well-tolerated. However, indiscriminate use of PPIs is undesirable due to its potential harms. We implemented a series of deprescribing interventions between 2016 and 2017 to curb PPI overutilisation in our institution. The aim of this study was to evaluate the effectiveness and safety of these interventions. An institutional PPI deprescribing guide was disseminated by email and educational roadshows were conducted to prescribers. Interrupted time series analysis was used to evaluate the effectiveness of the deprescribing interventions over a 7-year period from 2013 to 2019. To ascertain the safety of PPI deprescribing, we analysed the peptic ulcer disease incidence from 2015 to 2018 and conducted a retrospective chart review of 262 inpatients who were deprescribed PPIs. Following the first intervention, there was a significant decrease in mean oral PPI utilisation by 2,324.46 defined daily doses (DDD) per 1,000 prescriptions (95% confidence interval [CI] -3,542.66, -1,106.26) per month, followed by a month-to-month decrease of 302.61 DDD per 1,000 prescriptions per month thereafter (95% CI -473.95, -131.27). A second targeted educational intervention was only effective in sustaining the decline in the outpatient, but not in the inpatient setting. There were no significant changes in incidence of peptic ulcer disease. In the retrospective chart review, a majority (62.6%) of patients remained deprescribed at 6 months. We observed a sustained decrease in PPI utilisation in our institution for more than 12 months following our educational interventions. Cautious deprescribing of PPIs in eligible candidates was found to be safe with low recurrence rates of upper gastrointestinal events.

Endoscopic and histopathologic features of Anti-PD-1-related collagenous colitis.

ObjectivesCancer patients treated with immune checkpoint inhibitors occasionally show persistent diarrhea accompanied by endoscopic features of ulcerative colitis. The endoscopic mucosal inflammation may appear mild in some patients compared to the clinical severity, which can make choosing a treatment challenging. In this study, we evaluated the factors that support the continuation of chemotherapy by assessing the endoscopic and histopathological characteristics of patients who experienced diarrhea after immune checkpoint inhibitor administration.MethodsThis study included eight patients who were diagnosed with collagenous colitis based on pathological assessments. We retrospectively investigated these patients’ backgrounds, laboratory data, and computed tomography images that were extracted from their medical records. We also summarized their endoscopic and pathologic findings.ResultsAll eight patients were being treated with anti‐programmed cell death‐1/programmed cell death‐ligand 1 therapeutic agents and had a recent history of oral proton pump inhibitor therapy. The anti‐programmed cell death‐1‐related collagenous colitis in these cases was characterized by endoscopically mild mucosal inflammation, high fecal calprotectin levels, and a lower frequency of intestinal wall thickening on computed tomography. Histological assessments showed CD8+ lymphocytes predominantly infiltrating the lamina propria and crypts of the colonic mucosa. Suspending the proton pump inhibitor therapy relieved the patients’ symptoms and allowed the continuation of the anti‐programmed cell death‐1/programmed cell death‐ligand 1 therapy.ConclusionsAnti‐programmed cell death‐1‐related collagenous colitis is reversible; appropriate diagnosis of adverse events is crucial for the continuation of immune checkpoint inhibitor therapy.

S3562 A Rare Case of Esophageal Dissecans Superficialis Occurring With Barrett's Esophagus

Introduction: Esophageal dissecans superficialis (EDS) is a rare desquamative disorder of the esophagus characterized by sloughing of the superficial mucosa. Less than 200 cases of EDS are reported worldwide. The pathogenesis is poorly understood. We present a case of EDS in the setting of Barrett’s esophagus (BE). The association of EDS with BE has not been previously reported. Case Description/Methods: The patient is a 66-year-old male with a history of hypertension, chronic obstructive pulmonary disease, and atrial fibrillation who was referred to an outpatient gastroenterology clinic for surveillance esophagogastroduodenoscopy (EGD) for BE. On medication review, he was taking amlodipine, carvedilol, albuterol, and aspirin. He smoked half a pack per day but denied significant alcohol or substance use. He was asymptomatic. On EGD, linear, peeling fragments of the superficial mucosa were found in the distal esophagus consistent with the classic features of EDS (Figure 1). A plaque of salmon-colored mucosa was also identified in the distal esophagus. Biopsies demonstrated BE and active inflammation. Outpatient treatment with a twice-daily oral proton pump inhibitor (PPI) was initiated. Three months later, repeat EGD revealed a short segment of BE and complete resolution of EDS. Discussion: EDS is a rare endoscopic finding. Clinical manifestations vary from an incidental finding to dysphagia, odynophagia, vomiting, heartburn, and abdominal pain. Although its pathogenesis is unclear, it is thought that EDS stems from conditions that cause esophageal damage, including heavy smoking, psychoactive medications, bisphosphonates, non-steroidal anti-inflammatory drugs, and cutaneous bullous disorders. We describe the first encounter of EDS in a patient with BE. In our case, it is speculated that chronic inflammation from gastroesophageal reflux disease and tobacco use caused mucosal injury, leading to the development of not only metaplastic changes but also sloughing esophagitis. This case highlights the importance of clinical recognition of EDS as its prognosis is generally favorable if treated promptly. Mucosal healing can be achieved with discontinuation of the culprit agent and PPI therapy, reducing unnecessary investigation and treatment.Figure 1.: Endoscopy showing multiple white sheets of peeling superficial mucosa with normal basal mucosa in the distal one-third of the esophagus, consistent with EDS.

675 FUNDOPLICATION VERSUS ORAL PROTON PUMP INHIBITORS FOR GASTROESOPHAGEAL REFLUX DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

Abstract Gastroesophageal reflux disease (GERD) is a widely studied and highly prevalent condition. However, few is reported about the exact efficacy and safety of fundoplication (FPT) compared to oral intake proton-pump inhibitors (PPI). This systematic review and meta-analysis of randomized clinical trials (RCT) aims to compare PPI and FPT in relation to the efficacy, as well as the adverse events associated with these therapies. Methods This systematic review was guided by PRISMA statement. Search carried out in June 2020 was conducted on Medline, Cochrane, EMBASE and LILACS. The inclusion criteria were (I) patients with GERD; (II) Randomized clinical trials, comparing oral intake PPI with FPT; (III) relevant outcomes for this review. The exclusion criteria were (I) reviews, case reports, editorials and letters (II) transoral or endoscopic FPT (III) studies with no full text. No restrictions were set for language or period. Certainty of evidence and risk of bias were assessed with GRADE Pro and with Review Manager Version 5.4 bias assessment tool. Results Ten RCT were included. Meta-analysis showed that heartburn (RD = −0.19; 95% CI = −0.29, −0.09) was less frequently reported by patients that underwent FPT. Furthermore, patients undergoing surgery had greater pressure on the lower esophageal sphincter than those who used PPI (MD = 7.81; 95% CI 4.79, 10.83). There was no significant difference between groups in the percentage of time with pH less than 4 in 24 hours, sustained remission and Gastrointestinal Symptom Rating Scale. Finally, FPT did not increase significantly the risk for adverse events such as postoperative dysphagia and impaired belching. Conclusion FPT is a more effective therapy than PPI treatment for GERD, without significantly increasing the risk for adverse events. However, before indicating a possible surgical approach, it is extremely important to correctly assess and select the patients who would benefit from FPT, such as those with severe erosive esophagitis, severe respiratory symptoms, low adherence to continuous drug treatment and patients with non-acid reflux, to ensure better results.

A PROTON PUMP INHIBITOR ALTERS THE pH OF THE HUMAN UTERINE CAVITY

To present two cases of increased pH of the uterine cavity after taking lansoprazole, an oral proton pump inhibitor (PPI). Case study. We examined infertile women to see whether chronic endometritis (CE) existed, through assessment of endometrial plasma cells (CD138 immunostained cells) and uterine microbiota by sequencing the 16S ribosomal RNA gene (Varinos Inc., Japan). CE was diagnosed applying the criteria (>5.15/10xmm2) reported by Liu et al. (1). We also examined the intrauterine pH directly on the endometrial surface using a Portal pH Meter (Japan Asch Inc., Japan) that has been utilized for the esophageal mucosa of esophagitis (2). We have reported in ESHRE annual meeting 2020 that intrauterine pH is weakly acidic (5.58±0.59) and it increases in the case of CE (6.67±0.39). Patient 1: A 44-year-old infertile woman noticed changes of her vaginal discharge after taking orally lansoprazole 30 mg for reflux esophagitis. Her initial intrauterine condition had been normal with pH: 6.3, Lactobacillus: 97%, and CD138-positive cells: 1.7/10xmm2. After PPI intake for a month, her intrauterine pH rose to 7.0, which suggested existence of CE. Therefore, we collected the endometrial tissue again and performed microbiota and pathological tests: Lactobacillus was 99% and CD138-positive cells were 1.6/10xmm2, which did not indicate CE histologically and bacterially. After discontinuing PPI, her intrauterine pH dropped to 6.7 with Lactobacillus: 97% and CD138-positive cells: 2.0/10xmm2. Patient 2: A 47-year-old woman, whose initial uterine pH had been 6.4, noticed a change of odor of vaginal discharge after taking PPI (lansoprazole 30 mg daily) for gastric ulcer. Her intrauterine pH rose to 7.1 with Lactobacillus :9.1% and CD138-positive cells: 0.7/10xmm2. After discontinuation of PPI, her intrauterine pH dropped to 6.2 with no CD138-positive cells, but Lactobacillus was 2.60%. We experienced two cases in which the pH of uterine cavity increased while taking oral PPI. We have reported that the uterine luminal pH in human is weakly acidic (around 6.0) and that the pH increases in the presence of CE or abnormal endometrial microbiota. In animals, such as mice (3) and mares (4), the uterine luminal pH is acidic at the time of implantation, and the acidic environment in the uterus is considered to be important for embryo implantation, and the vacuolar H + -ATPase pump, which is a type of proton pump, is expressed in the endometrium at the time of implantation in bovine (5) and mice (2), but there have been no reports in humans. These 2 cases which we presented here suggest that some proton pumps are also expressed in the endometrium and acidify the uterine cavity in humans, which could control the intrauterine environment independently of inflammation or microbiota.

Risk of upper gastrointestinal bleeding in patients on oral anticoagulant and proton pump inhibitor co-therapy.

BackgroundProton pump inhibitors (PPIs) are known to reduce the risk of upper gastrointestinal bleeding in patients on oral anticoagulants, and patients are increasingly on oral anticoagulants and PPI co-therapy. However, evidence is lacking on the safety and effectiveness of oral anticoagulants when co-administered with PPIs.MethodsAmong patients initiating oral anticoagulants (warfarin and non-vitamin K antagonist oral anticoagulants [NOACs], i.e. rivaroxaban, dabigatran, apixaban, and edoxaban) during 2013–2017, those concomitantly prescribed PPIs were identified (n = 19,851). The primary endpoint was hospitalization for major upper gastrointestinal bleeding, and secondary endpoints were death and ischemic stroke.ResultsDuring a mean 1.4 years of follow-up, the primary endpoint occurred in 512 (2.58%) patients. Overall, NOACs were associated with lower upper gastrointestinal bleeding risk after adjustment for age, sex, comorbidities and concomitant medications (adjusted hazard ratio 0.78, 95% confidence interval 0.65–0.94), compared to warfarin. There was no significant difference in upper gastrointestinal bleeding risk among the individual NOACs. This trend of reduced risk for upper gastrointestinal bleeding in NOACs compared to warfarin was consistent for both regular and reduced doses, throughout bleeding risk groups, and other subgroup analyses. NOACs were also associated with lower risk of death compared to warfarin. The risk for ischemic stroke was not significantly different among the oral anticoagulants in patients with atrial fibrillation.ConclusionIn patients on oral anticoagulant and PPI co-therapy, NOACs were associated with lower risk of upper gastrointestinal bleeding and mortality compared to warfarin, while there was no difference among the oral anticoagulants for stroke prevention. In patients on PPI therapy, NOACs may preferred over warfarin for decreasing risk of upper gastrointestinal bleeding and mortality.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.