Fully covered self-expanding metal stents for benign colonic strictures.

BACKGROUND AND STUDY AIMS: Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures. PATIENTS AND METHODS: All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 - 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence. RESULTS: The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 - 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found. CONCLUSIONS: FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.

Accuracy of computed tomographic colonography in a nationwide multicentre trial, and its relation to radiologist expertise.

OBJECTIVE: Reports on the accuracy of computed tomographic colonography (CTC) mainly involve series from expert institutions. The aims of this study were to assess CTC accuracy in a nationwide population and to relate it to radiologist performance in their initial training. DESIGN: Nationwide multicentre trial. SETTING: Twenty-eight radiologists, working in 26 mostly academic clinical units, were involved in the study after having attended a formal specialised 2-day training session on CTC. They worked through a training set of 52 cases with automatic feedback after an attempt at each case. PATIENTS: The study enrolled 845 patients with average and high risk of colorectal cancer, 737 of whom had both complete CTC and videocolonoscopy data, which constituted the dataset. INTERVENTIONS: Patients underwent same-day CTC followed by videocolonoscopy with segmental unblinding of CTC results. MAIN OUTCOME MEASURES: Sensitivity, specificity and positive and negative predictive values for detection of polyps ≥ 6 mm in per-patient and per-lesion analyses of CTC without computer-aided detection. RESULTS: Sensitivity, specificity and positive and negative predictive values for patients with polyps ≥ 6 mm were 69% (95% CI 61% to 77%), 91% (95% CI 89% to 94%), 67% (95% CI 59% to 74%) and 92% (95% CI 90% to 94%), respectively. Univariate analysis showed that the detection rate for polyps ≥ 6 mm was linked to neither radiologist case volume nor number of polyps, but was related to sensitivity achieved in the training set. Pooled sensitivity was 72% (95% CI 63% to 80%) versus 51% (95% CI 40% to 60%) for radiologists achieving above and below median sensitivity in the training set (61%), respectively. Multivariate analysis showed that sensitivity for polyps ≥ 6 mm in the training set was the only remaining significant predictive factor for subsequent performance. CONCLUSIONS: Radiologist sensitivity CTC for detection of polyps ≥ 6 mm in training was the sole independent predictor for subsequent sensitivity in detection of such polyps.

The efficacy and safety of duodenal stenting: a prospective multicenter study.

BACKGROUND AND STUDY AIMS: Duodenal stenting has become a popular treatment in cases of malignant stenosis. However, a prospective evaluation of the efficacy and morbidity of this procedure has not been performed. A prospective multicenter study of duodenal stenting was conducted by the Société Française d'Endoscopie Digestive (SFED). PATIENTS AND METHODS: A total of 51 patients were selected (mean age 72), the majority (69%) having pancreatic adenocarcinoma. Palliative treatment was chosen because of irresectability (61.2%), inoperability (18.4%), or both (20.4 %). Enteral Wallstent prostheses were used, and the patients were followed up on day 3, after 1 month, and then every month, with weight measurement, and symptomatic and laboratory evaluation. RESULTS: One prosthesis was sufficient in 46 patients. Stent positioning and deployment were correct in 50/51 patients (98%). Twenty patients also underwent biliary stenting in addition to the duodenal stenting. On day 3, 43 patients (84%) were able to tolerate soft solids or a full diet. Six complications were attributed to stenting: three intestinal hemorrhages, two cases of peritonitis due to bowel perforation, and one case of septicemia, and these led to five deaths (mortality 9.8%). Stent dysfunction was observed in 12 cases (23.5%) after a mean delay of 75 days, comprising 11-malignant obstructions and one migration: a new stent was inserted inside the first one and was effective in eight cases; and no treatment was given in the other four patients because of their clinical state. The median survival was 71.5 days. CONCLUSIONS: Palliative endoscopic treatment of malignant duodenal stenosis using metallic prostheses is highly feasible, even with associated biliary stenting. Symptomatic improvement is fast. However, the mortality and the obstruction rate are high, suggesting that a prospective trial comparing this treatment with surgery is still required.

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.

Double vs. single dose of pantoprazole in combination with clarithromycin and amoxycillin for 7 days, in eradication of Helicobacter pylori in patients with non-ulcer dyspepsia.

BACKGROUND: The necessity of increasing intragastric pH during eradication treatment in Helicobacter pylori infected patients is well established. However, the optimal dose of the proton pump inhibitors used in eradication regimen is still a subject of debate. AIMS: To compare the efficacy and tolerability of a double vs. a single daily dose of pantoprazole in a 7-day triple therapy in eradicating H. pylori. METHODS: In this regional, multicentre, comparative, randomized and double-blind study, H. pylori-positive patients with non-ulcer dyspepsia were treated for 7 days with clarithromycin 500 mg b.d. and amoxycillin 1000 mg b.d. and either a double (2 x 40 mg, Group 2PCA) or a single (40 mg, Group 1PCA) daily dose of pantoprazole. H. pylori infection was assessed at entry and at the end (day 38) of the study by histology and culture, or in some cases by 13C-urea breath test. RESULTS: From 203 patients recruited, 192 patients (96 in Group 2PCA and 96 in Group 1PCA) formed the intention-to-treat population. Twenty-six of them judged as major protocol violators were excluded from the per protocol analysis. H. pylori eradication rate was 75% in Group 2PCA and 56% in Group 1PCA in intention-to-treat analysis, and 80% in Group 2PCA and 59% in Group 1PCA in per protocol analysis (P < 0.05). The primary resistance to clarithromycin was 10.5%. The eradication rates for the clarithromycin susceptible strains were 86% for Group 2PCA and 71% for Group 1PCA in per protocol analysis (P < 0.05). Both regimens led to similar improvement of clinical symptoms and were equally well tolerated. CONCLUSION: A double (2 x 40 mg) daily dose of pantoprazole in a 7-day triple therapy is more effective than a single (40 mg) dose of this drug in eradication of H. pylori.

Risk factors for failure of Helicobacter pylori therapy--results of an individual data analysis of 2751 patients.

AIM: To study risk factors for failure of Helicobacter pylori eradication treatment. METHODS: Individual data from 2751 patients included in 11 multicentre clinical trials carried out in France and using a triple therapy, were gathered in a unique database. The 27 treatment regimens were regrouped into four categories. RESULTS: The global failure rate was 25.8% [95% CI: 24-27]. There was a difference in failure rate between duodenal ulcer patients and non-ulcer dyspeptic patients, 21.9% and 33.7%, respectively (P < 10(-6)). In a random-effect model, the risk factors identified for eradication failure in duodenal ulcer patients (n = 1400) were: to be a smoker, and to have received the group 4 treatment, while to receive a 10 day treatment vs. 7 days protected from failure. In non-ulcer dyspeptic patients (n = 913), the group 2 treatment was associated with failure. In both groups, age over 60 was associated with successful H. pylori eradication. There were less strains resistant to clarithromycin in duodenal ulcer patients than in non-ulcer dyspeptic patients. Clarithromycin resistance predicted failure almost perfectly. CONCLUSION: Duodenal ulcer and non-ulcer dyspeptic patients should be managed differently in medical practice and considered independently in eradication trials.

Laser assisted ratio analyser 13C-urea breath testing, for the detection of H. pylori: A prospective diagnostic European multicentre study.

BACKGROUND: Novel technology based on laser optogalvanic spectroscopy called the LARA (Laser Assisted Ratio Analyser) system was developed to measure 12C/13C ratios in breath samples using stable 13C isotopes, to detect Helicobacter pylori infection. AIM: To determine the sensitivity and specificity of the 13C-LARA-urea breath test in the detection of H. pylori infection in a prospective European multicentre trial; FDA-and EMEA-approved. METHODS: Consecutive dyspeptic patients underwent diagnostic gastroscopy with biopsies for culture and histopathology, to detect H. pylori infection (gold standard). Subsequently, the LARA-urea breath test was performed using either a system without a cold trap (part I) or a system with a cold trap (part II). In both instances baseline, 30-min and 60-min breath samples were collected. The optimum cut-off level for 12C/13C ratios was determined by Receiver Operator Characteristics analysis. RESULTS: In part I, 544 out of 604 patients were evaluable (low CO2: 47; withdrawn: 13). 284 out of 544 patients (52%) were H. pylori-positive according to the gold standard. The sensitivity of the LARA-urea breath test was 95% and the specificity 94%. In part II, 257 out of 272 were evaluable (low CO2: 14; withdrawn: 1). Sensitivity and specificity were 93% and 96%, respectively. CONCLUSION: The LARA-technology represents an accurate and non-invasive testing system for the detection of H. pylori infection. Its major advantages are the use of stable 13C isotope, the high throughput of samples and the easy means of collecting, storing and transporting the samples, thus making the system convenient to both patient and clinician.

Second-line treatment for failure to eradicate Helicobacter pylori: a randomized trial comparing four treatment strategies.

AIM: To compare the efficacy of different regimens in patients in whom previous Helicobacter pylori eradication therapy has failed. METHODS: In this study named StratHegy patients (n=287) were randomized to receive one of three empirical triple therapy regimens or a strategy based on antibiotic susceptibility. The empirical regimens were omeprazole, 20 mg b.d., plus amoxicillin, 1000 mg b.d., and clarithromycin, 500 mg b.d., for 7 days (OAC7), clarithromycin, 500 mg b.d., for 14 days (OAC14) or metronidazole, 500 mg b.d., for 14 days (OAM14). In the susceptibility-based strategy, patients with clarithromycin-susceptible strains received OAC14, whilst the others received OAM14. The 13C-urea breath test was performed before randomization and 4-5 weeks after eradication therapy. RESULTS: In the intention-to-treat analysis, the eradication rates for empirical therapies were as follows: OAC7, 47.4% (27/57); OAC14, 34.5% (20/58); OAM14, 63.2% (36/57); it was 74.3% (84/113) for the susceptibility-based treatment (P<0.01 when compared with OAC7 and OAC14). In patients receiving clarithromycin, the eradication rates were 80% for clarithromycin-susceptible strains and 16% for clarithromycin-resistant strains; in patients receiving OAM14, the eradication rates were 81% for metronidazole-susceptible strains and 59% for metronidazole-resistant strains. CONCLUSIONS: Eradication rates of approximately 75% can be achieved with second-line triple therapy based on antibiotic susceptibility testing. If susceptibility testing is not available, OAM14 is an appropriate alternative.

Effect of lansoprazole on Helicobacter pylori.

Helicobacter pylori has been identified as a major factor in duodenal ulcerogenesis. After H pylori eradication, the recurrence rate of duodenal ulcers falls dramatically and cure of this chronic relapsing disease has been claimed by several authors. H pylori eradication was first attempted with bismuth salts alone or with antibiotics. H2-receptor antagonists are not effective against H pylori, although proton pump inhibitors such as omeprazole and lansoprazole are active in vitro against H pylori. Their minimum inhibitory concentration is close to that of the imidazoles (metronidazole, tinidazole): proton pump inhibitors and imidazoles have common structural features. Consequently, lansoprazole has been tested in monotherapy and triple therapy. In monotherapy, the H pylori clearance rate with lansoprazole 30 mg during 4 weeks was 40% in our study and 19% in a study by Jhala et al. No eradication was achieved. These results were in agreement with those of another proton pump inhibitor. In triple therapy, two studies used the same regimen in nonulcer dyspepsia patients: lansoprazole 30 mg/day for 2 weeks, amoxicillin 2 g/day for 2 weeks, and tinidazole 1 g/day for 2 weeks. Pooled data from these two French trials show that H pylori eradication was achieved in 14/17 patients (82.4%). Lansoprazole administered concomitantly with two antibiotics is effective in the eradication of H pylori and is as effective as other triple therapy regimens with bismuth salts, or with other proton pump inhibitors. One of the most important problems is metronidazole resistance of H pylori strains. Antibiotics such as new macrolides (clarithromycin or roxithromycin) should be tested in a triple therapy regimen against H pylori strains with lower primary resistance.

Proximal gastric tone in gastro-oesophageal reflux disease.

BACKGROUND/OBJECTIVE: Abnormal gastric function may be involved in the pathogenesis of several gastrointestinal functional disorders. This study evaluated gastric tone in gastro-oesophageal reflux disease (GORD). METHODS: Proximal gastric tone was measured with an electronic barostat in fasting conditions and after oral ingestion of a 200 ml/200 kcal liquid meal in 10 patients with GORD, with control groups consisting of 10 patients with dysmotility-like dyspepsia and 16 healthy subjects. RESULTS: Minimal distending pressure was increased in GORD patients compared to dyspeptic patients (P < 0.04) and controls (P< 0.001). Maximal postprandial gastric relaxation was significantly increased in GORD patients (430 +/- 95 ml) compared to dyspeptic patients (200 +/- 152 ml, P < 0.0001) and controls (342 +/- 88 ml, P= 0.05). Endoscopy-negative and mild oesophagitis patients had more profound maximal relaxation than patients with moderate or severe oesophagitis, whereas those with dyspepsia had significantly reduced gastric relaxation compared to GORD patients and controls (P < 0.002). CONCLUSIONS: In GORD, the postprandial gastric relaxation is more pronounced than in normal and dyspeptic patients. The pathophysiological relevance of this abnormal motility pattern remains to be determined.

Long-term effects of Helicobacter pylori eradication on gastric antral mucosa in duodenal ulcer patients.

OBJECTIVES: The aim of this study was to assess the consequences of prolonged Helicobacter pylori eradication on gastric antral mucosa in duodenal ulcer patients. PATIENTS AND METHODS: Forty-three duodenal ulcer patients with confirmed H. pylori eradication after one year of follow-up were included in this retrospective study. Before H. pylori eradication and during the follow-up, four antral prepyloric biopsy samples were taken for histopathological examination and culture. Histopathological lesions were graded semi-quantitatively according to the updated Sydney System for activity, chronic inflammation, glandular atrophy and intestinal metaplasia (IM), as well as presence of lymphoid follicles. RESULTS: After a mean follow-up of 43 +/- 23 months, H. pylori eradication statistically improved all gastritis scores, including the atrophy score and the lymphoid follicle score but excluding the IM score. H. pylori eradication resulted in normalization of gastric mucosa in 51.2% of patients and a significantly lower proportion of patients with non-atrophic gastritis and atrophic gastritis without IM. Atrophy totally disappeared in 16/29 patients (55.2%) in whom IM was absent. No predictive factor for regression of atrophy or normalization of gastric mucosa was identified. CONCLUSION: In duodenal ulcer patients, prolonged absence (more than one year) of H. pylori can lead to normalization of the antral mucosa and the disappearance of mucosa-associated lymphoid tissue, as well as the regression of antral atrophy. Long-term studies involving selected patients with atrophy and IM which persist after H. pylori eradication are needed to determine the potential benefits of treating H. pylori gastritis with regard to gastric cancer prevention.

Is Helicobacter pylori eradication a cost-effective treatment of duodenal ulcer disease?

Treatment strategies aimed at eradicating Helicobacter pylori have shown positive results in the management of duodenal ulcer disease. Several cost-effectiveness studies comparing these regimens with traditional therapy have recently been conducted, and results are discussed in this review. Cost comparisons of different treatment strategies cannot be performed without first identifying whether the cost of ulcer diagnosis is included in the study. Assuming that only 20% of patients with dyspepsia actually have ulcer disease, costs may vary, depending on the study population. Importantly, treatment costs should not be compared between a patient population with confirmed ulcer disease and one without confirmed disease. In patients with confirmed ulcer disease, studies consistently show that H. pylori eradication strategies are associated with greater efficacy and lower costs than traditional treatment, and are therefore a more cost-effective alternative to standard therapy. Although all models used in the cost-effectiveness analyses assume that patients discontinue treatment following successful eradication of the microorganism, in clinical practice some patients continue antisecretory treatment beyond this period. Thus, savings as a result of H. pylori eradication may be less substantial than indicated in cost-effectiveness studies.

[Treatment of Helicobacter pylori infection with lansoprazole 30 mg or 60 mg combined with two antibiotics for duodenal ulcers]. / Traitement de l'infection par Helicobacter pylori par lansoprazole 30 mg ou 60 mg associé à deux antibiotiques chez les ulcéreux duodénaux.

OBJECTIVE: The primary objective of the present study was to evaluate the efficacy of 30 and 60 mg of lansoprazole administered in combination with two antibiotics for 7 or 10 days in eradicating Helicobacter pylori in duodenal ulcer patients. METHODS: This multicenter double-blind study randomized for the lansoprazole dose was carried out by 325 gastroenterologists. The H. pylori-positive diagnosis was based on three antral biopsies (one for a rapid urease test and two for histological examination). Eradication was checked by a (13) C-urea breath test. Patients were given 30 or 60 mg of lansoprazole with 2 g of amoxicillin and 1 g of clarithromycin for 10 days or 7 days, followed by 30 mg of lansoprazole daily for 18 or 21 days, i.e. the total duration of antisecretory therapy was 28 days. RESULTS: Out of the 665 patients included, 620 were analyzed on the intent-to-treat basis and 567 on the per protocol basis. The eradication rates were significantly higher in the group receiving 60 mg of lansoprazole than in the 30 mg group in both the intent-to-treat analysis (P=0.003) and the per protocol analysis (P=0.006). In the intent-to-treat analysis 60 mg group, the rates (95% confidence intervals) in the 7-day and 10-day sub-groups were 82.5 (CI: 75.2 - 89.8) and 86.8% (CI: 82.2 - 91.4), respectively, and in the per protocol analysis 84.2 (CI: 76.9 - 91.5) and 91.5% (CI: 87.6 - 95.4), respectively. With either lansoprazole dose, the eradication rates seemed higher when therapy was administered for 10 days. CONCLUSION: The double dose of lansoprazole optimizes H. pylori eradication rates. The highest eradication rates were obtained after 10 days of therapy. Additional studies should be carried out to determine the optimal duration of triple therapy for eradicating H. pylori.

"Campylobacter pyloridis" and epigastric pain: endoscopic, histological, and bacteriological correlations.

Campylobacter pyloridis is a newly discovered bacterium which has been implicated in gastric pathology. C. pyloridis was looked for by hematoxylin and eosin staining and culture (chocolate and brucella blood agar) in gastric antral biopsies in 136 unselected patients suffering from epigastric pain. The distribution of C. pyloridis positive cases according to the endoscopic diagnosis was as follows: duodenal ulcer (19 positive/21 tested), duodenitis (6/10), gastric ulcer (9/21), gastritis (13/26), and normal endoscopy (21/58). The association was statistically significant for duodenal ulcers (p less than 0.001). All of the 68 C. pyloridis positive patients showed histologic signs of gastritis as compared to 29 of the 68 C. pyloridis negative patients. The two techniques detection were comparable in sensitivity: 57 were detected by culture only and 63 by microscopy only. We also looked for C. pyloridis in biopsies of the body of the stomach in 71 patients. Bacteria were found in 33 of 36 cases with C. pyloridis positive antral biopsies (15 had histologic lesions) but only in 2 of 35 C. pyloridis antrum negative cases. Therefore, C. pyloridis was tightly associated with histologic signs of antral gastritis and with duodenal ulcers when diagnosed by endoscopy.

[Perfusion-fixation of liver needle biopsy: technic]. / Perfusion-fixation des biopsies hépatiques à l'aiguille: technique.

Technical details concerning the perfusion-fixation of liver needle biopsies are described. The biopsy (less than or equal to 0,5 cm length) migrated in a Pasteur pipette filled with heparinized Ringer solution and stopped when its diameter corresponded to the internal diameter of the pipette. The pipette was cut above the upper part of the biopsy. The biopsy was perfused with a thin needle (external diameter 0.2 mm) struck in the upper part of the biopsy under binocular microscopy control. Fixation medium, 2.5 p. 100 glutaraldehyde, was aspirated at the inferior extremity of the pipette. The aspiration speed was equal to the perfusion speed (0.15 ml/min). The biopsy was perfused for 5-8 min. This simple technique allows for detailed electron microscopic examination of sinusoids, sinusoidal and perisinusoidal cells as well as of the spaces of Disse.

[Veno-occlusive disease of the liver. Treatment by portocaval shunt]. / Maladie veino-occlusive du foie. Traitement par anastomose porto-cave.

A case of hepatic veno-occlusive disease revealed by abdominal pains and the rapid constitution of ascites in a 33-year old French female is reported. She had taken medicinal plants in order to loose weight. Liver biopsy showed typical histological changes consisting of centrizonal hemorrhagic necrosis and centrolobular vein obstruction with endophlebitis. Owing to an increase of ascites, a side-to-side portacaval shunt was performed. Eight months postoperatively, ascites had completely disappeared and the liver biopsy showed only a moderate centrolobular vein fibrosis. Five years later, the clinical state is normal.

[Hiatal hernia with intrathoracic gastric volvulus as a rare cause of biliary obstruction]. / Hernie hiatale avec volvulus intrathoracique: une cause rare d'ictère obstructif.

Gastric volvulus can complicate paraesophageal hiatal hernia. Acquired gastric torsion results in acute or chronic gastrointestinal symptoms. Biliary complications are possible but exceptional. A case of asymptomatic diaphragmatic hiatal hernia with intrathoracic gastric volvulus presenting as a cholestatic syndrome secondary to stretching and tension of the common bile duct in the diaphragmatic hiatus is reported. This observation emphasizes the possibility of direct relationship between two otherwise frequent diagnostics: hiatal hernia and biliary obstruction. Only one similar case has been reported to date.

[Prevalence of anal incontinence in adults]. / Etude de la prévalence de l'incontinence anale chez l'adulte.

Inquiries were conducted to determine the prevalence of anal incontinence in a) the general population over 45 by a gallup poll studying 1,100 persons (A); b) 3,914 patients seen by their general practitioner or their gastroenterologist during the same week (B); c) 500 patients consulting for urinary stress incontinence (C1); d) 1,136 neurological patients suffering from micturation disorders (C2); and e) 10,157 elderly persons living in retirement homes or in hospital (D). In the general community (A), the prevalence of anal incontinence, including gas and stool incontinence, was 11 percent, the prevalence of fecal incontinence, 6 percent, the prevalence of daily or weekly fecal incontinence, 2 percent; prevalences were respectively 15.5 percent, 7.9 percent, and 3.2 percent in group B, and 27 percent, 9 percent and 3.8 percent in group C1. The prevalence of fecal incontinence was 18 percent in group C2 and 33 percent in group D. Prevalence did not depend on age in group A and C1, but was twofold higher in group C1 than in group A. The prevalence increased with age in groups B and D.

[Follicular gastritis in adults. Relations with Helicobacter pylori, histological and endoscopic aspects]. / Les gastrites folliculaires de l'adulte. Relations avec Helicobacter pylori, aspects histologiques et endoscopiques.

Follicular gastritis (FG) is characterized by lymphoid follicle hyperplasia in the gastric mucosa. The aim of this prospective study was to determine the prevalence of FG in adults, their relation to Helicobacter pylori infection, and their histological and endoscopic features. Of 445 patients (379 men, 66 women), 36.4 years old (range: 18-86), FG was detected in 63 patients (14.2%). This was highly significantly associated with H. pylori infection: 49/138 infected patients (35.5%) versus 14/307 non infected patients (4.6%) (P < 0.001). None of the histological features of the antral mucosa were correlated with FG. The prevalence of FG in patients less than 20 years old (in 45.4%) and between 20 and 40 years (in 41.3%) was higher than in patients aged from 40 to 60 years (in 33%) and older than 60 years (in 23%) (no significant difference). No one endoscopic feature of the gastric mucosa was predictive of the presence of FG. We conclude that FG is highly correlated with H. pylori infection and represents a local immune response to bacterial antigens. Their occurrence is probably multifactorial and related to age, duration of infection, bacterial strains, host immune status.

Antibiotic versus maintenance therapy in the prevention of duodenal ulcer recurrence. Results of a multicentric double-blind randomized trial.

OBJECTIVES: Reduction of gastric acid secretion by maintenance therapy and eradication of Helicobacter pylori by antibiotic treatment have been shown to reduce duodenal ulcer relapse. This study compared the effect of two regimens, a 6-month maintenance on an H2 receptor antagonist versus a one-week antibiotic therapy, on the rate of duodenal ulcer relapse in duodenal ulcer patients with gastric H. pylori infection. METHODS: We conducted a 30-week, double-blind, double-dummy, multicentric clinical trial involving 119 patients (97 M, 22 F, mean age 39 +/- 14 years) randomly assigned to a daily dose of 40 mg famotidine for 6 weeks supplemented with, during the first week, either antibiotics (500 mg amoxicillin q.i.d. and 500 mg tinidazole t.i.d.-antibiotic group) or their placebo (maintenance group). Healed patients after 6 weeks entered the 6-month maintenance phase: the maintenance group received 20 mg famotidine at bedtime and the antibiotic group, a placebo. Endoscopy with antral biopsies was performed to allow a rapid urease test, culture and histological examination upon entry, after 6 weeks, 3 months, and 6 months and, whenever symptoms recurred. H. pylori status was regarded as positive if any one of these three tests was positive, and negative if all tests were negative. RESULTS: The 2 treatment groups were well balanced for all baseline characteristics. After 6 weeks, H. pylori was eradicated in 25 (45%) patients in the antibiotic group, and in 1 (2%) in the maintenance group (P < 0.01). In term of intention-to-treat, there was no significant difference in the healing rate after 6 weeks (93 and 83% in the antibiotic and maintenance groups, respectively; P = 0.15) or in the relapse rate after 6 months (13 and 28% in the antibiotic and maintenance groups, respectively; P = 0.17 Log-rank test). However, the overall failure rate (absence of healing, relapse) was lower (P = 0.04, Log-rank test) in the antibiotic group in which all relapses but one were observed in H. pylori positive patients. The rate of ulcer relapse (1/20) in patients of antibiotic group who remained free of H. pylori during the study, was significantly (P < 0.01) lower compared with that of H. pylori positive patients in the maintenance group (11/44). During the first 6-week period, more side effects were observed in the antibiotic group than in the maintenance group (4 vs 1 patient, respectively). CONCLUSIONS: Our results indicate no significant difference between ulcer relapse rates after 6 months following a one-week antibiotic therapy or long-term maintenance therapy. Short-term antibiotic therapy should be considered as a valuable alternative to the long-term maintenance therapy.