Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres.

BACKGROUND AND AIM: We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis. METHODS: We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group. RESULTS: On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST. CONCLUSIONS: The FSSG score reflects the severity of the endoscopic findings of GERD.

[Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease]. / Ulcère duodénal perforé: traitement coelioscopique de la perforation et de la maladie ulcéreuse.

STUDY AIM: The aim of this retrospective study was to report a continuous series of 44 perforated duodenal peptic ulcers operated on through laparoscopic approach with curative treatment of the peptic ulcer disease for socioeconomic purpose. PATIENTS AND METHOD: From February 1995 to May 1996, 44 patients were operated on laparoscopically. There were 42 men and two women (mean age: 36 years). All patients had peritonitis with pneumoperitoneum in 68%. Duodenal peptic ulcer was known in 12 patients and antecedent of episodic epigastric pain were present in 27. Four trocads were used. The diagnosis was confirmed by abdominal exploration and peritoneal lavage was performed with physiological serum. RESULTS: The procedures were: suture of perforated ulcer associated with posterior vagotomy and anterior seromyotomy (n = 6), with troncular vagotomy and pyloroplasty (n = 24) and single suture (n = 1). A conversion into laparotomy was necessary in 13 patients (29.5%). There was no mediastinitis, no postoperative death. Peritonitis by leakage occurred in two patients who were reoperated by laparotomy; mean duration of hospital stay was 5.5 days. With a one-year follow-up, all patients were in good condition, free of pain. CONCLUSION: With laparoscopic surgery, diagnosis of peptic ulcer perforation was confirmed, peritoneal lavage was perfectly done, duodenal perforation was sutured and surgical treatment of the peptic ulcer disease was performed, which is important in poor countries.

Interobserver agreement in the assessment of gastritis reversibility after Helicobacter pylori eradication.

AIM: Our aim was to determine interobserver agreement in the application of the Sydney system to assess reversibility of gastritis after Helicobacter pylori eradication. METHODS AND RESULTS: Forty-three patients with a Helicobacter pylori-positive duodenal ulcer disease were included in the study. All patients included had successful H. pylori eradication after different antimicrobial drug combinations. Biopsy samples were collected from antrum and body, according to the Sydney recommendations, before antimicrobial therapy, 2 months after and at yearly intervals during 2-4 years of follow up. Three pathologists, who were blind to clinical data, evaluated histological changes in 221 antral and 219 body specimens stained with haematoxylin and eosin and with Warthin Starry. The percentage of pairwise agreement, kappa and weighted kappa statistic were used. Agreement in recognizing the presence of H. pylori colonization of the gastric mucosa, activity of inflammation and intestinal metaplasia was over 90%. Agreement in recognizing chronic inflammation in the body and atrophy in the antrum was between 78 and 89% respectively. The kappa values were excellent (more than 0.75) for the grade of H. pylori in the body, good (between 0.50 and 0.75) for the grade of H. pylori in the antrum, grade of inflammatory activity and intestinal metaplasia in the antrum and moderate to good (0.38-0.53) for the grade of chronic inflammation. Kappa values were poor to good (from 0.17 to 0.57) only in evaluation of the grade of atrophy. CONCLUSION: Interobserver agreement in the application of the Sydney system to reversibility of gastritis after H. pylori was good. More strict criteria should be used for atrophy and to differentiate normal and mild chronic inflammation.

[Post-treatment assessment of Helicobacter pylori eradication, by polymerase chain reaction in gastric biopsies]. / Evaluación de la erradicación postratamiento del Helicobacter pylori por reaccion en cadena de la polimerasa en biopsias gástricas.

BACKGROUND: The pre-treatment detection of H.p. in the stomach of patients is easily achieved with routine methods. Conversely, with conventional methods, it is difficult to detect the presence of H.p. after treatment. OBJECTIVE: To estimate the actual percentage of successfully treated patients by using a more sensitive and specific technique (PCR) in the same biopsies where standard methods were negative for H.p. MATERIALS AND METHODS: We selected 97 treated patients (31 Gastric Ulcers/66 Duodenal Ulcers, 62 male/35 female, age: 49 +/- 14 years), in whom success of treatment was defined by histological means and CLO Test. In the same gastric biopsies H.p-DNA PCR was performed. Different therapeutic schemes were utilized, but all included Proton Pump Inhibitors + ATB. Eight weeks after the end of the treatment, without medication, the patients were controlled as follows: 5 biopsies per patient, 2 of antrum, 2 of corpus (in different zones) and 1 for CLO Test. H.p. eradication was defined on histological grounds (gastric biopsy histology: 10% formaldehide buffer fixation, paraffin inclusion, Giemsa, HE staining and inmunohistochemistry), CLO Test (Delta West Pty. Ltd. Bentley, Australia) and by the absence of H.p.-DNA by PCR (amplification of a 296 bp of the species-specific antigen of H.p. and visualization of the amplified product in agarose gel with Ethidium Bromide and UV light). RESULTS: [table: see text] CONCLUSIONS: The higher sensitivity of PCR (10(3) fold more than conventional methods) allowed us in this group of patients to detect 13% of false eradication. It would be necessary to follow up this group of patients in order to know whether they develop or not clinical symptoms and/or histological evidence of disease. If such a case PCR could become an important tool for treatment evaluation.

Gastroduodenal mucosa in peptic ulcer: endoscopic and histological assessment.

This study aimed to assess the prevalence of endoscopic and histological gastroduodenitis as well as helicobacter-like organisms in patients with peptic ulcer. After diagnostic endoscopy, gastroduodenal biopsy specimens were taken from thirty patients (n = 30) with clinical and endoscopic diagnosis of peptic ulcer (duodenal ulcer = 25, gastric ulcer = 5). Endoscopic gastroduodenitis occurred in 18 patients (60%). Histological gastritis was detected in the gastric body or antrum in 25 (83%) and duodenitis in 17 (57%) patients. There was significant correlation between endoscopic and histological gastritis (p < 0.05). Helicobacter-like organisms occurred in 73% of the patients with peptic ulcer and in 88% of the antral biopsy specimens showing antral gastritis. Presence of helicobacter-like organisms was in particular associated with acute on chronic gastritis compared to chronic gastritis (p < 0.01). Moreover the patients with gastritis were found to belong to the older age group and 81.8% had blood group O +ve (p < 0.01 and p < 0.05 respectively). We conclude that presence of helicobacter-like organisms in patients with peptic ulcer is significantly associated with acute on chronic gastritis.

Endoscopic assessment of blood flow in duodenal ulcers.

The importance of blood flow in duodenal ulcer healing is unclear. Endoscopic reflectance spectrophotometry measures the index of oxygen saturation (ISO2), which is significantly correlated with blood flow. In 97 consecutive patients who presented with duodenal ulcer bleeding, the difference in the index of oxygen saturation (delta ISO2: ulcer margin ISO2 minus adjacent mucosa ISO2) was determined during the initial endoscopic examination. Endoscopic examinations were repeated until the ulcers had healed (n = 86). Relative to the adjacent mucosa, 78% of the ulcer margins had increased blood flow (positive delta ISO2) and 22% had decreased blood flow (negative delta ISO2). Stepwise multi-linear regression analysis selected delta ISO2, ulcer size, and stigmata of recent hemorrhage as predictors of delayed healing. A significant negative linear correlation between delta ISO2 and ulcer healing time (r = -0.35, p < 0.001, n = 86) was demonstrated. The scatter in the data precludes prediction of ulcer healing based on delta ISO2 measurement in an individual patient. Multi-variate logistic regression analysis selected concurrent medical illness, duodenal deformity, frequent use of non-steroidal anti-inflammatory drugs, and stigmata of recent hemorrhage as factors significantly associated with delayed (longer than 5 weeks) ulcer healing. The results support the hypothesis that prognostic factors are identifiable at the time of ulcer diagnosis, even in patients who present with bleeding. Blood flow remains an equivocal factor that deserves to be re-studied taking multiple measurements around the ulcer and including a larger number of slow healers.

[Morphometric assessment of chronic gastritis in peptic ulcer and stomach cancer]. / Morfometricheskaia otsenka khronicheskogo gastrita pri iazvennoi bolezni i rake zheludka.

The authors propose a new method of morphometric evaluation of the gastric mucosa in chronic gastritis. Five morphometric criteria are the basis for differential diagnosis of chronic gastritis. Results are analyzed of examination of 192 histological specimens from the gastric lesser curvature in ulcer and cancer of the stomach. The nonspecificity is shown of chronic gastritis of the lesser gastric curvature in the mentioned diseases.

Symptomatic cimetidine treatment of duodenal and prepyloric ulcers.

In a randomized trial, 75 patients with an endoscopically confirmed and symptomatic duodenal (N = 50) or prepyloric (N = 25) ulcer were allocated to cimetidine treatment (1 g/day) either regularly for four weeks (standard treatment group) or regularly for a minimum of one week and thereafter only until the symptoms were controlled (symptomatic treatment group). The four-week healing frequencies in the standard and symptomatic treatment groups were 72 and 67%, respectively. The difference +/- 95% confidence limits was 5 +/- 21%. Prospective recording of pain revealed that the two treatment regimens were about equally effective in relieving symptoms during weeks 2-4. Patients with unhealed ulcers reported pain during the day and night significantly more often than those with healed ulcers. In the symptomatic treatment group the average patient saved 11 days of cimetidine medication during weeks 2-4. We believe that disappearance of symptoms might be a valuable means of deciding when treatment for peptic ulcers can be discontinued. Provided its efficacy and safety can be further confirmed, symptomatic treatment might become a practical and possibly a money-saving mode of ulcer management, which should also be applicable to the ulcer regimens of tomorrow.