Gastric Cancer Screening in Common Variable Immunodeficiency.

Individuals with common variable immunodeficiency (CVID) have an increased risk of gastric cancer, and gastrointestinal lymphoma, yet screening for premalignant gastric lesions is rarely offered routinely to these patients. Proposed screening protocols are not widely accepted and are based on gastric cancer risk factors that are not applicable to all CVID patients. Fifty-two CVID patients were recruited for screening gastroscopy irrespective of symptoms or blood results and were compared to 40 controls presenting for gastroscopy for other clinical indications. Overall, 34% of CVID patients had intestinal metaplasia (IM), atrophic gastritis or moderate to severe non-atrophic gastritis, which can increase the risk of gastric cancer, compared to 7.5% of controls (p < 0.01). Focal nodular lymphoid hyperplasia, a precursor lesion for gastrointestinal lymphoma, was seen in eight CVID patients (16%), one of whom was diagnosed with gastrointestinal lymphoma on the same endoscopy. High-risk gastric pathology was associated with increased time since diagnosis of CVID, smoking, Helicobacter pylori, a low-serum pepsinogen I concentration, and diarrhea, but not pepsinogen I/II ratio, iron studies, vitamin B12 levels or upper gastrointestinal symptoms. There was a lower rate of detection of IM when fewer biopsies were taken, and IM and gastric atrophy were rarely predicted by the endoscopist macroscopically, highlighting the need for standardized biopsy protocols. The prevalence of premalignant gastric lesions in patients with CVID highlights the need for routine gastric screening. We propose a novel gastric screening protocol to detect early premalignant lesions and reduce the risk of gastric cancer and gastric lymphoma in these patients.

Management of anticoagulation before and after gastrointestinal endoscopy.

The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.

Outcomes of single-dose peri-procedural antibiotic prophylaxis for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions.

BACKGROUND: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a technique frequently used to diagnose solid and cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended for EUS-FNA of pancreatic cystic lesions but is not universally observed. The most effective antibiotic and the most efficacious route and regimen of administration are also unknown. OBJECTIVE: This cohort study was undertaken to evaluate whether single-dose piperacillin/tazobactam or ciprofloxacin given at the time of the procedure effectively prevents major adverse events and to audit the adherence to this protocol in the setting of EUS-FNA of pancreatic cystic lesions. DESIGN: Consecutive EUS-FNA procedures of pancreatic cystic lesions were performed at Concord Hospital and significant variables regarding the procedure and adverse events were recorded. Patients were also contacted by telephone to follow-up any subacute adverse events they may have experienced. PATIENTS: Over a 30 month period (January 2010-July 2012), a total of 85 EUS-FNAs of pancreatic cysts were performed on 80 different patients. The mean age was 63.2 years (range 17-89 years; 58% females). INTERVENTIONS: Single-dose piperacillin/tazobactam IVs was administered to 87% of patients, while 12% of patients received ciprofloxacin IVs. RESULTS: No patients developed cyst infection, fever, or sepsis (0%) and one patient (1.2%) was hospitalised for self-limited nausea without adverse sequelae. CONCLUSIONS: Single-dose piperacillin/tazobactam at the time of EUS-FNA of pancreatic cysts is an effective prophylaxis of cyst infection or sepsis and can be conveniently given as a single-dose peri-procedurally without further oral antibiotics.

Helicobacter pylori eradication therapy: indications, efficacy and safety.

BACKGROUND: Helicobacter pylori infects up to half of the world's population. It remains the major cause of peptic ulcer disease and is recognised as a carcinogen for its role in gastric carcinogenesis. Successful eradication of the bacteria is associated with improved health outcomes including fewer dyspeptic symptoms, reduced peptic ulcer recurrence and rebleeding, reduced peptic ulcer risk with NSAIDs and as a cure for low-grade gastric MALT lymphoma. The risk of gastric cancer is reduced in those without premalignant mucosal abnormalities at the time of eradication. OBJECTIVE: This review outlines the current indications and options for therapy of H. pylori with particular reference to drug-induced adverse events associated with treatment. METHODS: The indications for H. pylori eradication are evidence-based and in accordance with recent consensus statements and recommendations. The eradication treatment is based on numerous clinical trials and meta-analyses. RESULTS/CONCLUSION: Eradication therapy, in general, is safe and well tolerated. Antibiotic therapy may be associated with significant drug adverse reactions, especially gastrointestinal symptoms.