Treatment of Helicobacter pylori infection 14-day concomitant quadruple therapy versus triple therapy: A parallel double-blind randomized controlled trial.

Background and Aims: Successful Helicobacter pylori (Hp) eradication with the traditional 7-day course of proton pump inhibitor triple therapy is declining. Prolonging therapy to 14 days is associated with better eradication rates. Most learned societies recommend concomitant quadruple therapy (QC) as a first-line alternative therapy for this bacterial infection. The aim of this study is to compare the efficacy and safety of triple therapy (TT) and QC for the eradication of Hp infection. Methods: A parallel double-blind randomized controlled trial was conducted. The diagnosis of Hp infection was made by pathological examination of gastric biopsies. Patients were randomly assigned to two treatment groups: either QC (esomeprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily) or triple therapy (esomeprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses) for 14 days. The efficacy of the treatment is defined by Hp eradication attested by a negative breath test performed 6 weeks after the completion of treatment. Treatment outcomes were compared using the chi-square test, while binary logistic regression identified predictors of treatment failure. Results: Ninety-two patients were included. Forty-two patients belonged to the QC group and 50 to the TT group. No significant difference was noted between the two groups concerning the rate of Hp eradication either by intention to treat (81% vs. 72% respectively, p = 0.31) or per protocol (81.6% vs. 76.1% respectively, p = 0.54). Likewise, there was no difference between the two groups in terms of tolerance to treatment (59.5% for QC vs. 58% for TT, p = 0.88). No factor has been associated with treatment failure. Conclusion: There was no significant difference in the rate of HP eradication between the QC and the 14-day triple therapy. Neither regimen should be used topically because of their low eradication rates.

The role of quantitative HBsAg in the natural history of e antigen-negative chronic hepatitis B: A Tunisian prospective study.

BACKGROUND/AIMS: During the natural course of Chronic Hepatitis B (CHB) infection, differentiation between inactive carrier (IC) and HBeAg negative CHB is a subject of ongoing debate. We studied the role of hepatitis B surface antigen (HBsAg) level as a means of differentiating between CHB and IC in a group of untreated chronic HBeAg-negative HBV-infected patients. STUDY: A total of 115 HBeAg negative carriers were enrolled and followed up for>12 months; 78 as inactive carriers (IC), and 37 as active carriers (AC). Among ACs, patients were categorized according to the highest rate of viral load: AC1 (n=23), active carriers with persistent HBV-DNA<20,000 IU/mL; AC2 (n=14), active carriers with HBV-DNA>20,000 IU/mL. RESULTS: HBsAg levels were higher in AC compared to IC patients (1607 IU/ml vs. 225 IU/ml respectively, P=0.001). Among the AC group, the 23 AC1 cases had HBsAg levels significantly lower than the 14 AC2 patients (1756 IU/mL vs. 3327 IU/mL respectively; P<10-3). HBsAg showed weak correlation with HBV-DNA in the whole cohort (r=0.44, P<0.01). The suggested cutoff value of HBsAg titer to differentiate between the two groups was 938 IU/mL. Combined single-point quantification of HBsAg (938 IU/mL) and HBV DNA (2000 IU/mL) identified IC with 87.2% specificity and 91.7% positive predictive value. CONCLUSION: This study confirms the predictability of a one-time combined HBsAg and HBV DNA measurement for true inactive carriers requiring neither strict follow-up nor antiviral treatment.

Diverticular disease of the small bowel: a rare cause of the duodenojejunal flexure obstruction (a case report).

The small bowel is the least common site for diverticula in the entire gastrointestinal tract. Chronic upper intestinal obstruction due to diverticula is very rare. We report a case of multiple small bowel diverticula causing mechanical obstruction of the duodenojejunal flexure.

Transudative chylothorax in liver cirrhosis; an underappreciated entity.

Chylothorax is a rare pathology with potentially severe consequences. Transudative chylothorax remain an extremely rare entity. Cirrhosis is often an underappreciated cause. We report a case of transudative chylothorax in 62-year-old woman with cirrhosis due to hepatitis C.

Black esophagus: a case report.

INTRODUCTION: Acute esophageal necrosis, also known as black esophagus, is a rare digestive complication, frequently manifested by an upper gastrointestinal hemorrhage and occurs in patients with comorbidities. AIM: To report the case of a patient with a black esophagus revealed by an upper gastrointestinal hemorrhage. OBSERVATION: A 72-year-old patient with a history of diabetes mellitus, hypertension and ischemic heart disease was hospitalized in surgical intensive care unit for hemorrhagic shock induced by cholecystectomy. On the 7th postoperative day, the patient developed acute hematemesis. Gastroscopy showed circumferential necrosis, localized in the middle and lower third of the esophagus and stopped abruptly at the gastroesophageal junction. Gastric mucosa was strictly normal. The bulb and the first part of duodenum showed multiple superficial ulcers without signs of recent hemorrhage. The patient was placed on absolute diet and total parenteral nutrition associated with high-dose intravenous proton pump inhibitor. Second-look gastroscopy, performed six days later, showed a significant improvement in esophageal lesions. The evolution was marked by the occurrence of pneumonia complicated by septic shock which caused patient's death. CONCLUSION: Black esophagus is a rare pathology of multifactorial etiology. Treatment is based on proton pump inhibitors in combination with resuscitation measures to control comorbidities. Mortality remains high due to the seriousness of comorbid disease states often associated with this condition.

Primary biliary cholangitis : therapeutic and evolving aspects about 46 cases.

BACKGROUND: Primary biliary cholangitis (PBC) is a rare autoimmune chronic liver disease whose prevalence is increasing. Medical treatment is based on ursodeoxycholic acid. It association with autoimmune hepatitis defined the overlap syndrome (OS). AIM: It was to determine therapeutic and evolving characteristics of PBC and to compare them to those in subjects having an overlap syndrome. METHODS: This was a retrospective study of all the patients' files with PBC from hepato-gastroenterology department at Monastir hospital from April 1999 to November 2013. RESULTS: Forty six patients were included in our study: 43 women and 3 men with an average age of 55 years. OS was retained in 13 patients. Cirrhosis was retained in 21 patients. Thirty-eight patients were treated with ursodeoxycholic acid (UDCA) associated with corticosteroids and immunosuppressors in the case of OS. After an average follow-up of 50 months [13-169 months] the overall response rate to UDCA was 55%. This rate was comparable between the 2 groups isolated PBC and OS. It was lower in the cirrhosis group compared with non-cirrhotic patients (40% vs 65%, p=0,06). One patient underwent a liver transplantation. Three patients were died as a result of decompensated cirrhosis. CONCLUSION: Our study highlights the frequency of cirrhosis at the time of PBC diagnosis, which may explain the low rate of response to UDCA. There is no difference in the therapeutic and evolving aspects between patients with isolated PBC and those with SC.

Squamous cell carcinoma of the rectum cured after chemoradiation.

The primary squamous cell carcinoma of the rectum is a rare tumor that presents epidemiological, etiopathogenic and evolutionary characteristics different from those of adenocarcinoma . We report the case of a primary squamous cell  carcinoma well  differentiated  from medium-high   rectal junction in a 59 year old patient treated with a chemoradiation first ,followed by surgical resection. However, the anatomical examination of the  surgical specimen did not show tumoral tissue.

Clarithromycin versus metronidazole in first-line Helicobacter pylori eradication. Prospective randomized study of 85 Tunisian adults.

BACKGROUND: Although primary resistance to metronidazole remains high (56,8%), it is more widely used than clarithromycin as a firstline Helicobacter pylori (H. pylori) treatment in the common Tunisian practice. AIM: To compare the eradication rate in two protocols including clarithromycin versus metronidazole in Tunisian adults. METHODS: From July 2005 to December 2007, 85 patients aged 18 to 75 years presenting with gastro-duodenal lesions with H. pylori infection and requiring its eradication were included in the study. They were randomized to receive alternatively a seven-day triple therapy including: Omeprazole + Amoxicillin + Clarithromycin (OAC group) or Metronidazole (OAM group) twice a day. A second endoscopy with new biopsies was carried out 6 weeks after treatment to control eradication. RESULTS: Eighty five patients finished the protocol. The OAC and OAM groups included 46 and 39 patients respectively. They were comparable with respect to age, gender, clinical presentation and initial lesions. The total eradication rate was 60%. It was significantly higher in the clarithromycin group (69.6%) than in the metronidazole group (48.7%): p < 0.05. CONCLUSION: Clarithromycin is more effective than metronidazole in H. pylori eradication. It should be made available in our hospital's nomenclature. This would prevent iterative eradication courses and probably reduce treatment cost.