The pitfalls of treating anorectal conditions after radiotherapy for prostate cancer.

We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.

Inappropriate colonoscopic surveillance of hyperplastic polyps.

Colonoscopic surveillance of hyperplastic polyps alone is controversial and may be inappropriate. The colonoscopy surveillance register at a university teaching hospital was audited to determine the extent of such hyperplastic polyp surveillance. The surveillance endoscopy records were reviewed, those patients with hyperplastic polyps were identified, their clinical records were examined and contact was made with each patient. Of the 483 patients undergoing surveillance for colonic polyps 113 (23%) had hyperplastic polyps alone on last colonoscopy. 104 patients remained after exclusion of those under appropriate surveillance. 87 of the 104 patients (84%) were successfully contacted. 37 patients (8%) were under appropriate colonoscopic surveillance for a significant family history of colorectal carcinoma. 50 (10%) patients with hyperplastic polyps alone and no other clinical indication for colonoscopic surveillance were booked for follow up colonoscopy. This represents not only a budgetary but more importantly a clinical opportunity cost the removal of which could liberate valuable colonoscopy time for more appropriate indications.

Impact of Helicobacter pylori on the management of dyspepsia in primary care.

BACKGROUND: It is unclear what impact Helicobacter pylori infection has had on the management of dyspepsia in primary care and to what extent published guidelines on H. pylori are implemented in routine clinical practice. AIM: To assess the impact of H. pylori infection on the management of dyspepsia in primary care. METHODS: Patients referred by primary care doctors to an open-access 13-carbon urea breath test service over a 2-year period for their first urea breath test were included in the study. Individual breath results were linked with data on prescribing obtained from the General Medical Services prescription database. RESULTS: Of 805 patients, 374 (47%) had a positive urea breath test and 431 (54%) a negative urea breath test. Of positive urea breath test patients, only 245 (64%) were prescribed eradication therapy in the 3 months after the breath test and only 43% were referred back for re-testing. In the year after the urea breath test, there was a significant fall in prescribing of antisecretory therapy which was greatest in the patients who received H. pylori therapy (P < 0.001). CONCLUSIONS: There appears to be under and inappropriate treatment of H. pylori infection in primary care, and a low rate of re-testing after eradication, indicating that current guidelines are not well implemented in practice.

Oxegen 2004: the impact of a major music festival on the workload of a local hospital.

This prospective observational study was undertaken to assess the impact of a major music festival on the workload of a local hospital. Data were collected on all attendances at Naas General Hospital from the nearby Oxegen 2004 music festival. Patient demographics, disposition and diagnoses were recorded. Emergency department activity levels were compared before, during and after the festival. Seventy-two attendees were referred to Naas emergency department over a 3-day period, representing a 45% increase in the hospital's emergency department attendance rate. Thirty-seven of these attendees (51%) required inpatient or tertiary centre services. Thirty-four attendees (47%) were noted as having consumed alcohol and/or used illicit substances. We conclude that despite the provision of on-site medical facilities, major music events are associated with a significant increase in local health care activity and expenditure.

Helicobacter pylori and dyspepsia: physicians' attitudes, clinical practice, and prescribing habits.

BACKGROUND: Consensus guidelines have been published on the management of Helicobacter pylori infection and it is assumed that these guidelines are adhered to in clinical practice. AIM: To assess the changing attitudes of medical practitioners to H. pylori, and the impact of H. pylori infection on everyday clinical practice and prescribing patterns. METHODS: Data for this review were gathered up to December 2000 from detailed review of medical journals, the biomedical database MEDLINE, and relevant abstracts. RESULTS: Physician surveys show widespread acceptance of H. pylori as a causal agent in peptic ulcer disease. Gastroenterologists adopted H. pylori therapy for peptic ulcer earlier and more comprehensively than primary care physicians. Despite a low level of belief in H. pylori as a causal agent in non-ulcer dyspepsia and gastro-oesophageal reflux disease (GERD), H. pylori therapy is widely prescribed for these conditions. Proton pump inhibitor-based triple therapy is the eradication regimen of choice by all physician groups. In routine clinical practice, there appears to be significant under-treatment of peptic ulcer disease with H. pylori therapy, but extensive use for non-ulcer indications. Prescription of H. pylori treatment regimens of doubtful efficacy appears commonplace, and are more likely in primary care. Despite the advent of H. pylori therapy, the prescription of antisecretory therapy, particularly of proton pump inhibitors, continues to rise. CONCLUSIONS: Publication of consensus guidelines per se is not enough to ensure optimal management of H. pylori infection. Innovative and ongoing educational measures are needed to encourage best practice in relation to H. pylori infection. These measures might be best directed at primary care, where the majority of dyspepsia is managed.

Review article: Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management.

A significant proportion of patients with gastro-oesophageal reflux disease (GERD) have Helicobacter pylori infection, but it is unclear whether or not H. pylori should be treated in this clinical setting. The aim of this review was to critically assess the relationship between H. pylori and GERD and its potential implications for the management of GERD. Data for this review were gathered from the following sources up to April 1998-the biomedical database MEDLINE, a detailed review of medical journals, and a review of abstracts submitted to relevant international meetings. On average, 40% of GERD patients carry H. pylori infection, with a reported infection prevalence ranging from 16% to 88%. To date, there has been no reported controlled trial of effective H. pylori therapy in GERD. GERD has been reported to develop de novo following the cure of H. pylori in peptic ulcer disease. In the presence of H. pylori, proton pump inhibitor therapy appears to accelerate the development of atrophic corpus gastritis, a potentially precancerous condition. Conversely, proton pump inhibitor therapy seems to become less effective after cure of H. pylori. The mechanisms underlying these important contrasting phenomena are poorly understood. The relationship between H. pylori and GERD is complex, and it is difficult to give definitive guidelines on the management of H. pylori infection in GERD. Controlled trials of H. pylori therapy in GERD are urgently needed, as well as further long-term data on both the natural history of gastric histopathological changes in the H. pylori-positive GERD patient treated with proton pump inhibitors, and the impact of H. pylori status on the clinical efficacy of antisecretory therapy. Pending these data, it is perhaps advisable to advocate cure of H. pylori in young patients with proton pump inhibitor-dependent GERD who, in the absence of anti-reflux surgery, are faced with the likelihood of long-term medical therapy.

Symposium: Helicobacter pylori and clinical risks--focus on gastro-oesophageal reflux disease.

Helicobacter pylori is a gastric pathogen that is a major cause of peptic ulcer disease, has a role in mucosa-associated lymphoid tissue (MALT) lymphoma and is associated with gastric cancer. Yet, in a large proportion of the human population, H. pylori infection has no apparent adverse clinical consequences. Furthermore, recent research suggests that H. pylori may even confer protection against gastroesophageal reflux disease. The conflicting evidence surrounding H. pylori infection was discussed at a sponsored symposium in Helsinki, introduced by Professor P. Malfertheiner, with papers presented by Dr H. J. O'Connor, Professor R. M. Genta, Dr P. Unge and Professor A. T. R. Axon. Emerging epidemiological and retrospective evidence suggests that the presence of H. pylori infection may provide some protection against gastroesophageal reflux disease, but there is other evidence that shows no benefit of H. pylori for the protection of the oesophagus. It was felt that prospective, multicentre studies are needed to explore the H. pylori-gastroesophageal disease relationship further, to avoid confusing potential benefits with known risks. Following the symposium, a discussion on the relative risks and benefits for H. pylori eradication was provided by Professor Axon and Professor Blaser. Eradication of H. pylori has been recommended in a series of management guidelines issued by consensus groups. However, accurate estimates of the relative risks and benefits of H. pylori infection in the general population, as well as in specific patient groups, is essential in order to develop a management strategy.

Lansoprazole triple therapy for Helicobacter pylori--is 5 days enough?

BACKGROUND: Seven-day proton pump inhibitor triple therapy is currently the treatment of choice for Helicobacter pylori infection. It is unclear whether triple therapy for less than 7 days might preserve efficacy while at the same time improving patient acceptability and compliance. AIM: To evaluate the Helicobactericidal efficacy, ulcer healing capacity and patient acceptability of a 5-day lansoprazole-based triple therapy regimen. METHODS: Sixty-nine consecutive patients with H. pylori-positive peptic ulcer received lansoprazole 30 mg twice daily in combination with metronidazole 400 mg twice daily and clarithromycin 250 mg twice daily for 5 days. Ulcer healing medication was not continued after the 5-day regimen. H. pylori status was assessed before and at least 4 weeks after therapy by rapid urease test and histology. Adverse events and compliance were assessed by direct questioning. RESULTS: All 69 patients attended for repeat endoscopy and 63 were H. pylori-negative after therapy giving a cure rate of 91%, (95%, Cl: 85-98%). Of the 59 patients with active ulcers, 58 were healed at repeat endoscopy giving an ulcer healing rate of 98% (95% Cl: 92-100%). All patients fully complied with therapy and mild adverse events, mainly gastrointestinal, were reported by 11 patients (16%). CONCLUSIONS: Five-day lansoprazole triple therapy is an effective regimen for H. pylori infection which combines a high cure rate and ulcer healing efficacy with the advantages of excellent patient acceptability and compliance.

Review article: test and treat or test and scope for Helicobacter pylori infection. Any change in gastric cancer prevention?

A 'test and treat' strategy is advocated for patients with dyspepsia under the age of 45 years, with endoscopy reserved for those with alarm symptoms or aged over 45 years. One of the consequences of this strategy will be a reduction in population infection rates of Helicobacter pylori. It is now clear that H. pylori is one of the prime initiators of gastric cancer with up to 70% of gastric cancers attributable to H. pylori. What remains unclear is if H. pylori reduction will lead to a reduction in gastric cancer.

Campylobacter-like organisms and heterotopic gastric mucosa in Meckel's diverticula.

To assess the possibility that Campylobacter pylori might colonise heterotopic gastric mucosa a detailed histological review of 69 cases of Meckel's diverticula resected over 17 years was undertaken. Twenty three were resected incidentally while 46 were excised as the suspected cause of symptoms. Gastric mucosa was found in 13 diverticula (19%), 10 from the symptomatic group and three from the incidental cases, of which eight showed active gastritis affecting the heterotopic mucosa. Specific staining showed spiral bacteria with the typical morphology of C pylori adherent to gastric mucosa in four of the diverticula showing active gastritis. Campylobacter-like organisms were not seen on normal heterotopic gastric mucosa or on adjacent intestinal epithelium. The findings show that Campylobacter-like organisms, identical in appearance, staining, and distribution with C pylori, colonise and possibly inflame heterotopic gastric mucosa in Meckel's diverticulum.

Reflux gastritis: distinct histopathological entity?

A total of 98 patients who had either undergone gastric surgery (23) or who had peptic ulcers (56), or who had normal endoscopic findings (19), all underwent gastric biopsy, together with measurement of pH and total bile acid concentration in their fasting gastric juice. The biopsy specimens were graded "blind" for the presence of foveolar hyperplasia; oedema and smooth muscle fibres in the lamina propria; vasodilation and congestion of superficial mucosal capillaries; and a paucity of both acute and chronic inflammatory cells in the brief that these features constituted a distinctive histological picture related to reflux of alkaline duodenal content into the stomach. We found a strong association between severe grades of each of these histological variables and both hypochlorhydria (pH greater than or equal to 4) and increased bile acid concentrations in the stomach. Furthermore, when the individual grades were added together to give a composite "reflux score," there was a significant difference in the incidence of hypochlorhydria (p less than 0.01) and raised bile acid concentrations (p less than 0.005) between those patients with a reflux score above and below 10. Although we do not claim that reflux is invariably accompanied by a distinctive histological picture, we suggest that recognition of this hitherto poorly documented combination of features as reflux gastritis may assist in the selection of patients for specific treatment and minimise the overdiagnosis of premalignant dysplasia (with which the lesion may be confused) in the postoperative stomach.

Campylobacter like organisms and reflux gastritis.

A total of 98 patients, who had undergone gastric surgery (23), or who had peptic ulcers (56), or who had normal endoscopic findings (19) underwent gastric biopsy, together with measurement of pH and total bile acid concentration, in their fasting gastric juice. The biopsy specimens were stained by the Warthin-Starry method for Campylobacter like organisms and were also graded "blind," as described in the preceding paper, for the five features that we believe may constitute the histological picture of reflux gastritis. The individual grades were added together to give a composite "reflux score" (0-15) for each patient. We found a notable association between the absence of Campylobacter like organisms and previous surgery for peptic ulceration, high reflux scores (greater than 10), hypochlorhydria (pH greater than or equal to 4), and increased bile acid concentrations (greater than or equal to 1 mmol/l) in the stomach. These findings further support our contention that reflux gastritis represents a distinct histopathological entity causally related to the effects of enterogastric reflux on the gastric mucosa and suggest that there may be two major categories of chronic gastritis: chronic superficial, or atrophic gastritis related to Campylobacter like organisms and reflux gastritis. Our data also imply that patients with peptic ulceration may, after gastric surgery, revert from being positive for these organisms to being negative and may undergo a possible transition from Campylobacter related chronic gastritis to reflux gastritis.

Bile reflux and intestinal metaplasia in gastric mucosa.

AIM: To determine associations between enterogastric bile reflux and gastric mucosal pathology. METHOD: A retrospective study using fasting gastric juice bile acid measurements and antral or prestomal biopsy specimens from 350 patients, 66 of whom had previously undergone surgery that either bypassed or disrupted the pyloric sphincter. RESULTS: Bile reflux was positively associated with reactive gastritis and negatively with Helicobacter pylori density. After stratification for previous surgery, age, and H pylori status, the histological feature most strongly associated with bile reflux was intestinal metaplasia, including all its subtypes. The prevalence of intestinal metaplasia was greatest in patients with both H pylori infection and high bile acid concentrations. Bile reflux was also positively associated with the severity of glandular atrophy, chronic inflammation, lamina propria oedema and foveolar hyperplasia. CONCLUSIONS: Bile reflux is a cause of reactive gastritis. It modifies the features of H pylori associated chronic gastritis. The changes are not confined to patients who have had surgery to their stomachs. The positive associations with atrophy and intestinal metaplasia have implications for models of gastric carcinogenesis.

Eradication of Helicobacter pylori.

PURPOSE: To critically review current indications and therapies for Helicobacter pylori eradication. DATA IDENTIFICATION: Studies selected for this review were identified from Medline and a manual search of the literature. RESULTS OF DATA ANALYSIS: The clearest indication for H. pylori eradication is in the treatment of H. pylori-positive duodenal and gastric ulcer since eradication of the infection prevents ulcer relapse, effectively curing the disease. The use of anti-H. pylori therapy in non-ulcer dyspepsia remains controversial and further studies are required. Despite strong circumstantial evidence linking H. pylori and gastric cancer, it is premature to advocate H. pylori therapy for primary prevention of neoplasia. Triple therapy (bismuth, metronidazole, tetracycline) can eradicate H. pylori in over 90% of cases but this multidrug regimen is not ideal because of side effects, possible non-compliance and doubtful efficacy against metronidazole-resistant infection. Proton-pump inhibitor-antibiotic combinations are a promising alternative to triple therapy with few side effects and good compliance, but there is uncertainty about the most effective combination. H. pylori reinfection after successful eradication is unusual (< 1% per year). CONCLUSIONS: H. pylori eradication is now the treatment of choice in H. pylori-positive peptic ulcer disease. The search continues for the ideal H. pylori treatment regimen which will combine high efficacy, safety and patient acceptability, with low cost.

Effect of histamine H2-receptor antagonist therapy on the mutagenic activity of gastric juice.

There is concern at present that treatment with histamine H2-receptor antagonists might promote the development of gastric cancer by producing conditions which favour intragastric formation of N-nitroso compounds. If H2-receptor antagonist therapy causes increased intragastric levels of N-nitroso compounds, an issue not yet resolved by analytical studies, corresponding changes in the mutagenic activity of gastric juice might be anticipated. In this study mutagenic activity and pH were measured in fasting gastric aspirate from 18 peptic ulcer patients before and during the final week of therapy with ranitidine (n = 10) or cimetidine (n = 8). Mutagenic activity was assessed using Salmonella typhimurium TA98 and TA100 in a modified pre-incubation "fluctuation" test. No significant change in mutagenic activity was detected after therapy. Of 15 patients found to have significant mutagenic activity in their fasting gastric juice before treatment, 14 remained mutagenic following treatment. Mutation frequencies (sum of positive wells in duplicate 96-well microtitre plates, mean +/- SD) for TA98 and TA100 were respectively, 20 +/- 34 and 100 +/- 64 before compared with 10 +/- 6 and 102 +/- 65 after therapy (p greater than 0.05). Changes in mutagenic activity were similar in both treatment groups and unrelated to duration of therapy, changes in gastric pH or ulcer healing. In vitro, neither cimetidine in aqueous solution, nor gastric juice preincubated with cimetidine showed significant mutagenic activity. These results provide no evidence that increased intragastric levels of genotoxic chemicals, such as N-nitroso compounds, occur during H2-receptor antagonist therapy.

The mutagenic activity of gastric juice.

The mutagenic activity of fasting gastric juice was assessed in 123 patients including 18 with normal endoscopic findings, 53 peptic ulceration, 9 gastric cancer, 12 pernicious anaemia and 31 patients who had undergone peptic ulcer surgery in the past. Significant mutagenic activity was detected in 96 (78%). Marked variations in mutagenic activity were noted both within and between the patient groups and no significant differences were detected. No correlation was found between mutagenic activity and patient age or sex, gastric pH, bile acid concentrations or bacterial counts, intestinal metaplasia on gastric mucosal biopsy, or intragastric nitrite. About 30% of gastric juice samples showed evidence of a cytotoxic activity towards the Salmonella tester strains in the mutation assay. Preliminary studies on other body fluids showed the presence of significant mutagenic activity in fasting saliva, bile and plasma. These findings demonstrate widespread human exposure to potentially genotoxic substances.

Prevalence of esophagitis in H. pylori-positive peptic ulcer disease and the impact of eradication therapy.

BACKGROUND/AIMS: There have been recent reports of reflux esophagitis apparently occurring de novo after cure of H. pylori in peptic ulcer disease. The possibility that this phenomenon might be explained, at least in part, by unmasking of coexistent disease has not been assessed. The aim of this study was to assess the prevalence of esophagitis in H. pylori-positive peptic ulcer disease and examine the short-term impact of H. pylori therapy on the esophagus. METHODOLOGY: Esophagitis was systematically graded and the presence of hiatal hernia was noted in 244 peptic ulcer patients (duodenal 223; gastric 21) before and at least four weeks after triple therapy. H. pylori status was assessed using CLO test and histology, and esophagitis grade was assigned without knowledge of H. pylori status. RESULTS: Of the 244 patients, 49 (20%) had esophagitis which was grade 2 or more in over two-thirds. The prevalence of esophagitis was similar in duodenal and gastric ulcer patients. The presence of hiatal hernia was strongly associated with the finding of esophagitis (P < 0.001). Of 241 patients evaluable after therapy, 215 (89%) were H. pylori-negative and 26 remained H. pylori-positive. Esophagitis tended to improve or remain stable after H. pylori therapy and worsened in only 2 of the 49 patients (4%). Of 192 patients with a normal esophagus at baseline endoscopy, 14 (7%) showed evidence of esophagitis after therapy. The presence of hiatal hernia, but not cure of H. pylori, was significantly associated with the development of esophagitis. CONCLUSIONS: Our results indicate that esophagitis can coexist with peptic ulcer disease and persists after cure of H. pylori. Development of de novo esophagitis seems uncommon in the short-term after H. pylori therapy. Esophagitis in peptic ulcer disease is strongly associated with the presence of hiatal hernia.

Helicobacter pylori and gastro-oesophageal reflux disease--a prospective study.

In a prospective evaluation of the relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease (GORD), 93 consecutive patients (47 female: 46 male: mean age, 46 years: range 13-93) with symptoms and endoscopic evidence of GORD were studied. A total of 50 patients (54%) were H. pylori-positive on gastric antral biopsies. No significant correlation was detected between H. pylori status and grade of oesophagitis. The prevalence of H. pylori infection showed a gradual increase with age. Of 64 patients with a hiatal hernia, 28 (44%) had histological evidence of H. pylori infection of the hernia mucosa; 27 of these patients (96%) had associated H. pylori in the gastric antrum. Of the 36 patients whose hiatal hernia was H. pylori-negative, only 6 (17%) had antral H. pylori (P < 0.001). Of the 8 patients found to have Barrett's oesophagus, only 1 had H. pylori detected on the Barrett's mucosa. Our results do not support the presence of a significant association between H. pylori infection and GORD.

Six-year follow-up after Helicobacter pylori eradication in peptic ulcer disease.

BACKGROUND: The longterm outlook after Helicobacter pylori (H. pylori) eradication in peptic ulcer disease is unclear. AIM: This study documents H. pylori recurrence, dyspeptic symptoms and anti-secretory therapy in peptic ulcer patients six years or more after H. pylori eradication. METHODS: Peptic ulcer patients with H. pylori eradication between 1990 and 1992 were included. Infection recurrence was diagnosed by 13-carbon urea breath test (UBT). Dyspeptic symptoms and anti-secretory therapy use were assessed by questionnaire. RESULTS: Sixty-one patients completed the study protocol. Mean follow-up after eradication was 6.1 years (range 4.8-8.3). Four patients had a positive UBT. H. pylori recurrence rate was 6.6% or 0.02% per patient per year. Forty-two patients (69%) had dyspeptic symptoms. Heartburn and belching were more common than pain (p<0.001). All four patients with H. pylori recurrence had symptoms compared with 38 of 57 H. pylori-negative patients (p>0.05). Ten of 61 patients (16.4%) were taking anti-secretory therapy and their dyspepsia scores were higher. CONCLUSIONS: Despite a low H. pylori recurrence rate, longterm dyspeptic symptoms were common in peptic ulcer patients after H. pylori eradication. The symptoms are mainly reflux in type and require anti-secretory therapy in only a minority of patients.

Eradication of Helicobacter pylori: the results of a pilot study of 3, 5 & 7 day triple antibiotic regime with bismuth for one month.

In a prospective study designed to assess the effect of duration of antibiotic therapy on the helicobactericidal and ulcer healing efficacy of bismuth therapy, groups of patients, 10 in each group, with H. pylori-positive duodenal ulcer received a triple therapy regimen consisting of colloidal bismuth subcitrate 120 mg 4 times daily for 28 days with metronidazole 400 mg 3 times daily and tetracycline 500 mg 3 times daily for the first 3, 5 or 7 days of therapy. H. pylori infection was assessed by urease test, culture and histology performed before and 4 or more weeks after completion of therapy. Three patients (30 per cent) were H. pylori-negative after therapy in the 3 day compared with 5 (50 per cent) in the 5 day and 9 (90 per cent) in the 7 day treatment groups (3 vs 7, P = 0.01; 5 vs 7, P = 0.14). Healed ulcers were seen in 7 (70 per cent) of the 3 day, in 6 (60 per cent) of the 5 day, and in 10 (100 per cent) of the 7 day treatment groups (5 vs 7, P = 0.04). Bismuth triple therapy incorporating metronidazole and tetracycline for 7 days is associated with superior H. pylori eradication and ulcer healing rates than bismuth triple incorporating antibiotics for 3 or 5 days.