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.

Public awareness of risk factors and screening for colorectal cancer in Europe.

Colorectal cancer (CRC) is the commonest site for malignancy in Europe. The Commissioner for Health wishes to promote screening for colorectal, breast and cervical cancer in Europe. The aim of this study was to assess public knowledge of CRC in Europe and likely take up of free screening. To this end 20710 members of the public from 21 European countries were interviewed by means of a regular survey amongst consumers (Omnibus survey) using 13 stem questions. Forty-eight per cent thought the population were at equal risk of CRC, only 57% were aware of age and 54% of family history as risk factors. Although 70% were aware of dietary factors, only 30% knew that lack of exercise might be a risk factor. Only 51% had knowledge of CRC screening but 75% were 'very', or 'quite interested, in taking up faecal occult blood (FOB) screening if offered free. Barriers to screening were lack of awareness of risk (31%), youth (22%) and an un-anaesthetic test (19%). There was a big cultural difference in willingness of the public to discuss bowel symptoms: there was a major barrier in Finland (91%), Britain (84%), Luxembourg (82%), Poland (81%) and Portugal (80%); less of a barrier in Spain (49%), Italy (44%) and Iceland (39%). In conclusion, the challenge of achieving high compliance for CRC screening must be a major objective amongst EU member states and non-aligned countries of Europe in the next decade, because it is known that the non-compliant group are those at greatest risk of death from CRC. This study has shown that awareness of CRC is low in Europe and that an educational programme will be essential to achieve high compliance for CRC screening as a means of reducing deaths from bowel cancer.

The European Diploma of Gastroenterology: progress towards harmonization of standards.

The European Diploma of Gastroenterology has now been established by the European Board of Gastroenterology (EBG) and has been awarded to several individual doctors and to training centres. The EBG is a working party of the Gastroenterology Section of the European Union of Medical Specialists. The Diploma can be awarded to individual doctors who have been recognized as specialists in their own countries; trained in approved centres; and satisfied the training criteria of the EBG. The Diploma can also be awarded as a recognition of training competence to hospitals that meet the requirements of the EBG. Hospitals seeking recognition will be visited by members of the EBG and must show evidence that they can provide adequate clinical and technical experience to trainee gastroenterologists.

Gastric ulcers and Helicobacter heilmannii.

OBJECTIVE: To compare 14 patients with gastric ulcer and Helicobacter heilmannii with other patients with gastric ulcer: age and sex matched patients, patients colonized by Helicobacter pylori and patients on nonsteroidal anti-inflammatory drugs (NSAIDs). SETTING: The endoscopy unit of a university-affiliated hospital. PATIENTS AND METHODS: All patients underwent endoscopy with two antral biopsies and smears from biopsies (touch cytology) in addition to biopsies of ulcers. Most patients had fundic biopsies (n = 10), antral biopsies for culture (n = 7) and/or a urease test (n = 9). Serologic determination of antibodies against H. pylori was obtained in nine patients. RESULTS: Patients with H. heilmannii diagnosed on smears from biopsies (touch cytology) had multiple and antral ulcers in 11 samples, and nodular or irregular lesions in five samples. No patient had a history of peptic ulcer disease. Biopsy revealed mild chronic gastritis in all patients, with features of reactive gastritis in nine. No patient had coexistent infection with H. pylori. Only two of ten patients with follow-up endoscopies had persistent H. heilmannii infection on smear or biopsy. No patient had symptomatic recurrence. Patients with H. pylori infection were older and often had recurrent ulceration. The majority of ulcers associated with NSAIDs occurred in elderly women. CONCLUSIONS: Newly diagnosed gastric ulcers are associated with H. heilmannii infection. Healing is associated with the disappearance of H. heilmannii and the regression of reactive gastritis. Ulcers differ from those associated with H. pylori infection or with the use of NSAIDs, suggesting that H. heilmannii is a possible cause of gastric ulcers.

Identification of Campylobacter pylori in gastric biopsy smears.

The use of gastric biopsy imprint smears to diagnose Campylobacter pylori was compared with the use of tissue sections and cultures. Multiple gastric biopsies were taken from the mucosa of 42 patients during endoscopy. Imprint smears were prepared from the samples used to make tissue sections; other samples were used for microbiologic culture. There was a good concordance (93%) between the morphologic diagnosis of C pylori in the air-dried, Giemsa-stained smears and the tissue sections; the cytologic preparations were clearly positive in six cases (14%) whose sections contained low numbers of the organisms. There was a concordance of 83% between the combined morphologic techniques and the bacteriologic culture. Six positive cases were detected only by the morphologic techniques while one positive case was detected only by bacteriologic culture. C pylori was identified in one or more preparations of the antral biopsy specimens in 23 (55%) of the 42 cases, including 23 (74%) of the 31 cases with a final diagnosis of gastritis or ulcer. These results show the usefulness of the cytologic study of gastric biopsy smears in diagnosing C pylori infections.

[Lymphoepithelial cyst of the pancreas]. / Kyste lymphoépithélial du pancréas.

A 66-year-old woman presented with abdominal pain and weight loss. Ultrasonography and computed tomography demonstrated a cystic lesion of the pancreas. After surgical resection, the patient's symptoms disappeared. Microscopic examination of the cyst lining showed mature, keratinizing squamous epithelium, surrounded by lymphoid tissue. Only three cases of this type of lesion, called "lymphoepithelial cyst", have been described previously. Histogenesis of this particular type of cyst is not well know, but can be histologically differentiated from other pancreatic cysts.

[Cystadenoma of the pancreas. Apropos of a case and review of the literature]. / Les cystadénomes du pancréas. A propos d'un cas et revue de la littérature.

With reference to a new case of pancreatic cystadenoma, the authors review the literature on the subject. These tumors are a relatively uncommon form of cystic lesion of the pancreas. They find the origin from pancreatic acinar cells or from ductal epithelium. Histologically, there are two different forms: benign, serous, microcystic adenoma and potentially malignant, mucinous, macrocystic adenoma. The type of the tumor is demonstrated by ultrasonography and computed tomography. but these examinations could not make a difference between benign and malignant form. Treatment of choice is complete tumor resection. Internal or external drainage of these cysts should not be done.

[Cystic dilatations of the bile ducts]. / Les dilatations kystiques des voies biliaries.

Clinical manifestations of cystic dilation of biliary tracts, a rare affection usually detected in young patients, are described and 2 recent cases reported. Surgical treatment is outlined as a function of morphology of cysts, with emphasis on the high risk of cancerization of biliary tracts, even after bypass operations.

Abdominal ultrasonography by the hepato-gastroenterologist: problems, demands, solutions.

This document analyzes the reasons for organizing an abdominal ultrasound training for Belgian trainees in hepatogastroenterology. The hepatogastroenterology speciality should implement, together with the radiology speciality and the national scientific and professional associations, the minimum training requirements which are proposed by the European Board of Gastroenterology and Hepatology and the European Federation of Societies for Ultrasound in Medicine and Biology. Trainees in hepatogastroenterology should acquire the same theoretical and practical training as radiologists, they should be taught and supervised by competent instructors and have their expertise evaluated.

Clinical evaluation of the short half-life injectable benzodiazepine midazolam, and of the specific antagonist flumazenil in upper digestive tract endoscopy.

In a first step, midazolam 0.1 mg/kg, midazolam 0.05 mg/kg and diazepam 0.15 mg/kg administered intravenously were blindly evaluated as a sedating preparation in 3 groups of each 30 patients undergoing gastroscopy. Although amnesia is better with midazolam 0.1 mg/kg, the induced sedation is protracted, which is not to be wished in ambulatory patients. On the other side, diazepam 0.15 mg/kg was locally less well tolerated. Taking into consideration the efficacy and the general and local tolerance, the dose of midazolam 0.05 mg/kg seems the best compromise. In a second step, the specific benzodiazepine antagonist flumazenil was blindly evaluated at two intravenous doses, 1 mg and 0.5 mg, against placebo for reversal of midazolam (0.1 mg/kg) induced sedation in gastroscopy patients. 1 mg of flumazenil (and to a lesser degree 0.5 mg) suppresses the sedation and amnesia induced by midazolam and normalizes attention and sensori-motor functions. However a certain degree of resedation can reappear 45-60 min. after the administration of flumazenil. Though this phenomenon did not alter the tests measuring attention and sensorimotor functions and the recovery of memory (contrary to placebo), it incites to be cautious when the drug is given to ambulatory patients.

Endoscopic resection of an endobronchial hypernephroma metastasis using a polypectomy snare.

A 69 yr old male patient developed an acute respiratory distress. The emergency bronchoscopic examination showed a polypoid tumour obstructing the left main bronchus. A snare used for colorectal polypectomy was introduced through the bronchofibrescope to remove the tumour. The patient then dramatically improved. No side effects were observed. Histopathological examination showed metastasis from a hypernephroma. This simple technique is useful for bronchial deobstruction, when the tumour is accessible with a snare.

[Isotopic method in the demonstration of diaphragmatic defects in a case of pleural effusion associated with cirrhosis: apropos of a case]. / Mise en évidence par méthode isotopique de défects diaphragmatiques en cas d'épanchement pleural associé à une cirrhose: à propos d'un cas.

A 62-year-old woman presented with massive right-sided hydrothorax associated with cirrhosis of the liver. Chest scintigraphy after intraperitoneal injection of labelled tracer showed movement of the tracer from the peritoneal to the pleural cavity. Medical therapy and thoracocentesis were successful in this case.

The 1998 national Belgian consensus meeting on HP-related diseases: an extensive summary. The HP Belgian contact group organized in CHU Brugmann, Brussels.

"HP testing must be regarded as ONE of the important elements of the proper diagnostic work-up of a DISEASE, managed in close cooperation between GP's and specialists": that's the key message of the national consensus meeting held in CHU Brugmann on February 6th and 7th 1998. HP testing (usually by 2 direct methods: RUT-histology) and eradication treatment (ER), in infected patients, are strongly recommended in: 1. Past or current GDU (absolute indication), regardless of activity, complication(s), NSAID intake; 2. Low-grade MALT Lymphomas (Stage IE1) unequivocally diagnosed, managed and followed-up in specialised centers; 3. Post endoscopic resection of EGC. ER is advisable in HP carriers with a family history of gastric cancer. Chronic atrophic-, lymphocytic-, giant folds gastritis and hyperplastic polyps are acceptable indications for ER as well as scheduled long-term NSAID treatment in individuals with known HP status. Systematic ER in HP+ patients with fully investigated NUD is not indicated but could be considered in individual patients. Extra alimentary disorders and auto immune gastritis are no indication and there was no consensus for a "test and treat" policy in patients under 45 yrs old without alarm symptoms. Systematic screening of asymptomatic individuals is not recommended. A correct monitoring of eradication after treatment is recommended, mainly by UBT. In severe or refractory PUD, symptom recurrence and follow-up of EGC and Maltomas, endoscopic follow-up with HP testing is mandatory. The recommended first line treatment course (except known allergy or intolerance) is PPI full dose bid, Clarithromycin 500 mg bid Amoxycillin 1000 mg bid (7 days minimal 10 days maximal). RBC-based schemes must be locally validated and quadruple therapy is proposed when retreatment is needed. Culture, optional after the first treatment failure, is strongly recommended after a second failure. Overall, ER therapies are safe and neither the decreased efficacy of acid-lowering drugs, nor the possible increased risk of peptic oesophagitis are considered as contra-indications to eradicate. ER is cost-effective and cost-beneficial in PUD and adjusted number of pills delivered would cut costs. No clear economic data are currently available for a potential benefit of ER in GC prevention or NUD management. A national monitoring of HP resistance (Macrolides and Imidazoles) must be organized by specialised centers.