Bismuth-based quadruple therapy versus standard triple therapy for the eradication of Helicobacter pylori in Belgium: a multicentre, non-blinded randomized, prospective study.

Background: Helicobacter pylori (Hp) infection predisposes to malignant and non-malignant diseases warranting eradication. In Belgium, resistance rates for clarithromycin demonstrate regional variations making the use of standard triple therapy (STT) borderline acceptable. According to a recent Belgian survey, STT and bismuth-based quadruple therapy (BQT), are equally frequent prescribed as first line treatment for treatment naïve Hp positive patients. This study aims to evaluate the eradication rates (ER) of BQT versus STT. Methods: Multicentre, non-blinded randomized, prospective study comparing ER in treatment-naïve Hp positive patients. ER were compared by intention to treat (ITT) and per protocol (PP) analysis. Results: Overall 250 patients were included (STT 126, BQT 124). Seventeen patients were lost to follow-up (6,8%). No significant difference in ER between BQT and STT was observed in ITT (73% vs 68%, p= 0,54) neither in PP analysis (81% vs 75%, p= 0,33). Side effects and endoscopic findings were comparable between groups. Post-hoc analysis showed no differences according to gender or site allocation. Conclusion: The numerical advantage of BQT did not translate in a significant improvement of ER when compared with STT. These results question the cost-effectiveness of BQT, while confirming the suboptimal eradication rates on STT. A nationwide monitoring of resistance patterns, maximal investments in treatment adherence as well as a detailed follow-up of the changing treatment landscape are mandatory to continuously optimise Hp ER in Belgium.

Cheilitis granulomatosa and Crohn's disease : a case report.

In this case report we describe the evolution of Cheilitis granulomatosa (GC) in a young patient with Crohn's disease during treatment with anti-TNF-alfa therapy.

Transluminal removal of a giant fibrovascular polyp of the esophagus.

Giant fibrovascular polyps of the esophagus are rare benign tumors that originate at the hypopharynx or the upper third of the esophagus. Because of the indolent and benign nature they are mostly discovered when very large with symptoms like dysphagia or regurgitation of the polyp into the mouth which can cause asphyxia and dead. The removal of these polyps is obligatory. Although more than 100 cases of giant fibrovascular esophageal polyps have been described in literature so far, the approach for removal is not yet standard and needs a customized use of medical technology from different disciplines. We present the case of a 42 year old man in whom a giant polyp was removed transorally by a combination of instruments and materials from different disciplines (gastroenterological, surgical and laryngological).

Terminal ileitis after kidney transplantation : Crohn's disease or other? Case reports and literature review.

The finding of a terminal ileitis after kidney transplantation can cause a diagnostic challenge. Because the development of Crohn's disease under immunosuppressive therapy is unlikely, this diagnosis should only be considered after exclusion of infectious disease and drug-related intestinal toxicity. Defining the underlying cause of terminal ileitis is often hampered by a shortage of specific diagnostic tests or their lack of sensitivity. We present three patients with terminal ileitis after kidney transplantation resulting from different etiologies. Subsequently, we describe the characteristics that can help to make the differential diagnosis.

Ulcerative colitis treatment : an insight into daily clinical practice.

BACKGROUND: The natural history of ulcerative colitis (UC) is unpredictable. Factors associated with the need for different types of step-up therapy in UC patients failing on 5-aminosalicylic acid (5-ASA) or corticosteroids are understudied. AIMS: Describe step-up therapy in patients with UC the first year after failing on 5-ASA or corticosteroids. METHODS: A Belgian, multi-center, prospective, non-interventional observational study comprising adult UC patients failing on 5-ASA or corticosteroids and naïve to immunomodulators/ biologicals. During a 12 months follow-up, patient characteristics, demography, medical therapy, biomarkers, therapy adherence and quality of life (QoL) were assessed. RESULTS: After 1 year, 35% of the patients were on biological therapy. Use of anti-TNF differed depending on baseline treatment: corticosteroid-refractory patients (55.8%), 5-ASA refractory (20.0%), and corticosteroid-dependent (16.0%) patients (p<0.001). The decision to start a line of therapy was based on the Mayo combined severity but not on biomarkers like faecal calprotectin, haemoglobin, CRP, albumin, platelets, and number of extraintestinal manifestations. At year 1, 84.2% of the patients had only mild UC or remission and a significant improvement of fatigue (p=0.004) and IBDQ scores (p<0.001) were observed implying an improved QoL. CONCLUSION: Treatment step-up, based on clinical scores in immunomodulatory and anti-TNF naïve patients with UC, provides good clinical outcomes and QoL.

Two jenuno-jenunal intussusceptions in a patient with coeliac disease.

We present a case of a 41-year-old woman with severe abdominal pain caused by two jejuno-jejunal intussusceptions. Further investigation showed coeliac disease as the underlying cause. The patient recovered rapidly on a gluten-free diet. So coeliac disease could be the underlying cause of idiopathic intussusception more often than previously thought and intussusception should be suspected in patients with known coeliac disease presenting with abdominal pain. (Acta gastro-enterol. belg., 2016, 79, 000-000).

The early effect of proton pump inhibitor therapy on the accuracy of the 13C-urea breath test.

BACKGROUND: The intake of proton pump inhibitors may interfere with the reliability of the urea breath test. AIM: Prospective study to assess the accuracy of the urea breath test during the first days of therapy with proton pump inhibitors. PATIENTS: Thirty patients who needed to start proton pump inhibitors therapy and 53 volunteers. METHODS: A 13C-urea breath test was performed respectively before starting proton pump inhibitors therapy and every morning before its intake up until 10 days. The test was considered positive for values of 13CO2 > or = 3.0% delta over baseline. The coefficient of reproducibility for 95% interval of confidence of the urea breath test was calculated in both groups. RESULTS: Of the 30 patients receiving proton pump inhibitors, 47% were positive for Helicobacter pylori. Among these, 43% developed false negative breath tests in the first 10 days. False positive results occurred in 37.5% of H. pylori-negative subjects in the first 10 days. The coefficient of reproducibility of the urea breath test was significantly higher in the group treated with proton pump inhibitors (11.0 versus 1.8 for the control group, p < 0.0001). CONCLUSION: The intake of proton pump inhibitors impairs the accuracy of the 13C-urea breath test. False negative and false positive 13C-urea breath tests are common, occur as soon as after 1 day and increase with prolonged duration of treatment. The coefficient of reproducibility of the test in patients receiving proton pump inhibitors is not acceptable for clinical purpose and the test should not be performed once the medication has been started.

How to handle esophageal metaplasia in 2014: a practical guide.

Metaplasia of the esophagus is a precursor of esophageal adenocarcinoma, a cancer with a poor prognosis and an increasing incidence. Guidelines for surveillance are proposed by all professional societies with small differences in timing. However, there is still no consensus on the definition of Barrett's esopaghus (only intestinal metaplasia or all subtypes). The goal of surveillance of esophageal metaplasia has evolved from early detection of cancer to early detection of pre-cancerous metaplasia to allow endoscopic therapy. The endoscopic therapy has the intention to stage, to cure, to prevent progression and to prevent metachronous lesions to develop. Firm indications for endoscopic therapy are high rade dysplasia and mEAC. The actual treatment is EMR/ESD for all visual abnormalities and areas of cancer on biopsies, followed by RFA for the remaining metaplasia. For low grade dysplasia (LGD), surveillance versus RFA is still under discussion. The main reason for this is the wide interobserver variability with large differences in evolution between confirmed and unconfirmed LGD. The endoscopic treatment allows complete remission of dysplasia in most cases and of metaplasia in the majority of cases, with low complication rates and acceptable morbidity (treatable stenosis). However, a median of 3 treatments is usually required to achieve remission, and recurrence is as high as 15% in the following 5 years. Strategies to reduce recurrence like chemotherapy or anti-reflux surgery need to be explored better and can actually not decrease or replace surveillance.

Distal intestinal obstruction in CF patients.

Distal intestinal obstruction syndrome (DIOS) - the incomplete of complete intestinal obstruction by intestinal contents in the terminal ileum and proximal colon- is frequently seen in cystic fibrosis (CF) patients. Diagnosis is based on suggestive symptoms of abdominal pain in the right lower quadrant, a palpable mass on examination and signs of obstruction on plain radiography. Treatment consists of intensive laxative treatment with oral laxatives and enemas. Surgery only serves as the last resort for patients not responding to medical therapy, because of the well-known high rate of peri- and postoperative morbidity of surgery in CF patients. In this article we present 3 cases of DIOS, followed by a review of the relevant literature.

The association of bronchiolitis obliterans organizing pneumonia, systemic lupus erythematosus, and Hunner's cystitis.

An 83-year-old woman with histologically confirmed Hunner's cystitis presented with persistent fever, progressive dyspnea, and pulmonary patchy infiltrates. A transbronchial biopsy specimen revealed bronchiolitis obliterans organizing pneumonia. She progressively had development of renal insufficiency, due to systemic lupus erythematosus, proved by renal biopsy specimen. She recovered under corticosteroid treatment, but irreversible renal failure made long-term hemodialysis necessary.

Importance of precise timing in the simplified 10-min 14C-urea breath test procedure.

This study was performed to assess the impact of precise timing and the repeatability of the simplified 10-min 14C-urea breath test. Thirty-three patients underwent a 14C-urea breath test at 10 and 12 min (test I) and after 24 h (test II). The paired t-test was applied to assess differences between two successive measurements at 10 and 12 min, and the method of Bland and Altman was used to evaluate the repeatability of the test. Only test I (P = 0.004) showed a significant difference between two successive measurements at 10 and 12 min. The coefficients of repeatability at 10 and 12 min were 1.54 and 1.48, respectively. No bias was found. From this study, we can conclude that breath collections, delayed by 2 min (20% error), have no impact on the clinical interpretation of the results. The repeatability of the simplified 10-min 14C-urea breath test is sufficient for clinical use.

Cut-off point, timing and pitfalls of the 13C-urea breath test as measured by infrared spectrometry.

BACKGROUND: The best timing and the best cut-off level of the 13C-urea breath test have not yet been well established. AIMS: To evaluate the cut-off value and the influence of medication on the 13C-urea breath test as measured by infrared spectrometry. METHODS: A series of 223 patients, sent for endoscopy performed 13C-urea breath test in fasting conditions with 75 mg of 13C-urea and 20 ml of citric acid. Breath samples were collected before and then 10, 20, 25 and 30 minutes after ingestion. As gold standard, histological examination of gastric biopsies was used. A questionnaire was completed concerning the intake of medication, likely to influence the test, in the 2 months preceding the test. Sensitivity, specificity, positive predictive value and negative predictive value at 10, 20, 25 and 30 minutes at different cut-off values (3, 3. 5, 4, 4. 5, 5.0 0/00 DOB] were calculated. RESULTS: A total of 182 patients did not take medication. There was no significant difference between the different cut-off levels at different times. Compared with the group of 41 patients who did take medication, likely to influence the test, the differences were significant (Fisher exact test). CONCLUSION: There was no significant difference between the different cut-off values. A 10-minute test with a cut-off level between 4 and 5% delta over baseline (sensitivity: 100%, specificity: 95%) is, therefore, proposed. To avoid false negative results due to unknown intake of medication, every patient submitted to the 13C-urea breath test should fill out a questionnaire.

Is ambulatory 24-h dual-probe pH monitoring useful in suspected ENT manifestations of GERD?

BACKGROUND AND AIMS: The present study is aimed at assessing the relationship between ear, nose and throat manifestations and proximal reflux in gastro-oesophageal reflux disease by using 24-h dual-probe pH monitoring. PATIENTS AND METHODS: Fifty-eight patients were included: (;) 28 patients with suspected ear, nose and throat manifestations of gastrooesophageal reflux disease: (ii) 18 patients with typical symptoms of gastro-oesophageal reflux disease without extraoesophageal manifestations of gastro-oesophageal reflux disease; (iii) 12 healthy volunteers. Ambulatory 24-h dual-probe pH monitoring was performed in all patients. Oesophagogastroscopy was performed in all patients of groups I and II. Ear, nose and throat examination was performed in all patients with ear, nose and throat complaints. RESULTS: At the upper oesophageal sphincter, results of pH monitoring were significantly different between groups I and III (0.009 < P < 0.02) and between groups I and II (0.008 < P < 0.03). When comparing data at the lower oesophageal sphincter, we found a significant difference between groups II and III (0.002 < P < 0.009) and between groups I and III (0.001 < P < 0.002). Endoscopic examination of the oesophagus did not show any significant difference between groups I and II. Laryngoscopy was abnormal in 86% of the patients with ear, nose and throat symptoms. CONCLUSIONS: Ambulatory 24-h dual-probe pH monitoring is useful in the assessment of patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease, especially in the case of abnormal laryngoscopy.

Patient and staff exposure during endoscopic retrograde cholangiopancreatography.

Despite a number of efforts being put into the radiological protection of both patient and staff during interventional radiological (IR) procedures during recent years, information about radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) procedures remains scarce. The purpose of this study was to estimate both patient and staff radiation doses during therapeutic ERCP procedures by direct measurement and to compare these results with data from other IR procedures. For 54 patients, effective dose and skin dose were estimated by measuring the dose-area product. For staff, entrance surface doses to the lens of the eye, thyroid and hands were estimated by thermoluminescent dosemeters. A median effective dose of 7.3 mSv and a median entrance surface dose of 271 mGy per procedure were estimated for patients. The gastroenterologist received a median dose of 0.34 mGy to the lens of the eye, 0.30 mGy to the skin at the level of the thyroid and 0.44 mGy to the skin of the hands, per procedure. When comparing the dosimetric quantities presented in this study with data from other IR procedures, it is clear that patient skin doses and doses to staff are high owing to the use of inappropriate X-ray equipment. ERCP requires the same radiation protection practice as all IR procedures. It should be consistently included in future multicentre IR patient and staff dose survey studies at national or international level.

Influence of the physiological changes of gastric emptying on the simplified single sample 14 C-urea breath test.

The aim of this study was to assess the influence of the physiological changes of gastric emptying on the simplified 14C-urea breath test. Thirty patients performed the test in fasting conditions. Patients were orally administered 0.074 mega Bq of 14C-urea, mixed with 0.0185 mega Bq of 99mTc-S colloids in 25 ml water. A breath sample was taken before and 10 min after intake of the tracers and followed by a 2 min planar anterior scintigraphic image of the abdomen to measure gastric activity. Gastric emptying was estimated by dividing the residual gastric activity at 10 min by the total activity in the abdomen. The procedure was performed twice for each patient after a 24 h interval. The repeatability of both the gastric emptying test and the urea breath test was assessed by the method described by Bland and Altman. The coefficient of repeatability of the urea breath test was 1.18 for a confidence interval of 95%. The coefficient of repeatability of gastric emptying was 27.4. There was no significant correlation (r= 0.08) between the plot of the individual modifications of urea breath test and residual gastric activity in two successive tests. It is concluded that the physiological changes of gastric emptying do not influence the results obtained by the simplified, single-sample 14C-urea breath test.

[Cyanosis and cirrhosis of liver: hepatopulmonary syndrome]. / Cyanose en levercirrose: hepatopulmonaal syndroom.

A 66-year-old man with Child-B alcoholic cirrhosis presented with melaena due to hemorrhagic gastritis. Clinical examination revealed cyanosis and clubbing accompanied by severe hypoxaemia without signs of obstructive or restrictive lung disease. Contrast-enhanced echocardiography showed right to left shunt due to intrapulmonary shunting leading to the diagnosis of hepatopulmonary syndrome. Hypoxaemia in patients suffering from chronic liver disease can have different causes but in the presence of cyanosis and clubbing without signs of lung disease the hepatopulmonary syndrome should be suspected. When presence of intrapulmonary shunts has been proven by contrast-enhanced echocardiography, a 100% oxygen test can determine the need for pulmonary angiography and thus determine the indication for interventional therapy or liver transplantation. The patient described was treated supportively with long-term oxygen therapy 6 l/min. Three months later his clinical condition was stable. An attempt to reduce the need for nasal oxygen failed.

Resolving bile reflux by lanreotide in patients with Roux-en-Y gastrojejunostomy.

Reflux into the esophagus after partial or total gastrectomy is a well known problem. Even a Roux-en-Y reconstruction is not always a definitive solution. Bile reflux might occur and cause disabling symptoms, unresponsive to the classic anti-acid or anti-reflux therapy. Endoscopy and a Tc-99m-BrIDA hepatobiliary (HIDA) scan can be used to make the diagnosis. Clinical studies have shown that lanreotide (somatuline), which strongly inhibits many gastro-intestinal hormones, reduces the bile salts outputs. We present a case of a patient with bile reflux after Roux-en-Y. After administration of lanreotide he had a good clinical improvement and mucosal healing on endoscopy. Lanreotide can be a good treatment option for bile reflux when classic treatment fails, but clinical trials with more patients will have to confirm this.