Comparison of Vonoprazan vs Intravenous Proton Pump Inhibitor for Prevention of High-Risk Peptic Ulcers Rebleeding After Successful Endoscopic Hemostasis: A Multicenter Randomized Noninferiority Trial.

BACKGROUND & AIMS: High-dose proton pump inhibitor (PPI) therapy has been recommended to prevent rebleeding of high-risk peptic ulcer (PU) after hemostasis. Vonoprazan has been proven to be noninferior to PPIs in various acid-related diseases. This study aimed to compare the efficacy of vonoprazan vs PPI for preventing high-risk PU rebleeding after hemostasis. METHODS: A multicenter, randomized, noninferiority study was conducted in 6 centers. Pre-endoscopic and endoscopic therapy were performed according to standard protocol. After successful hemostasis, patients with high-risk PU bleeding (Forrest class Ia/Ib, IIa/IIb) were randomized into 1:1 to receive vonoprazan (20 mg twice a day for 3 days, then 20 mg once a day for 28 days) or high-dose PPI (pantoprazole intravenous infusion 8 mg/h for 3 days, then omeprazole 20 mg twice a day for 28 days). The primary outcome was a 30-day rebleeding rate. Secondary outcomes included 3- and 7-day rebleeding rate, all-cause and bleeding-related mortality, rate of rescue therapy, blood transfusion, length of hospital stay, and safety. RESULTS: Of 194 patients, baseline characteristics, severity of bleeding, and stage of ulcers were comparable between the 2 groups. The 30-day rebleeding rates in vonoprazan and PPI groups were 7.1% (7 of 98) and 10.4% (10 of 96), respectively; noninferiority (within 10% margin) of vonoprazan to PPI was confirmed (%risk difference, -3.3; 95% confidence interval, -11.2 to 4.7; P < .001). The 3-day and 7-day rebleeding rates in the vonoprazan group remained noninferior to PPI (P < .001 by Farrington and Manning test). All secondary outcomes were also comparable between the 2 groups. CONCLUSION: In patients with high-risk PU bleeding, the efficacy of vonoprazan in preventing 30-day rebleeding was noninferior to intravenous PPI. (ClinicalTrials.gov, Number: NCT05005910).

Thailand guideline 2020 for medical management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is one of the most prevalent and bothersome functional gastrointestinal disorders worldwide, including in Thailand. After a decade of the first Thailand GERD guideline, physician and gastroenterologist encountered substantially increase of patients with GERD. Many of them are complicated case and refractory to standard treatment. Concurrently, the evolution of clinical characteristics as well as the progression of investigations and treatment have developed and changed tremendously. As a member of Association of Southeast Asian Nations, which are developing countries, we considered that the counterbalance between advancement and sufficient economy is essential in taking care of patients with GERD. We gather physicians from university hospitals, as well as internist and general practitioners who served in rural area, to make a consensus in this updated version of GERD guideline focusing in medical management of GERD. This clinical practice guideline was constructed adhering with standard procedure. We categorized the guideline in to four parts including definition, investigation, treatment, and long-term follow up. We anticipate that this guideline would improve physicians' proficiency and help direct readers to choose investigations and treatments in patients with GERD wisely. Moreover, we wish that this guideline would be applicable in countries with limited resources as well.

Efficacy and safety of nortriptyline in functional dyspepsia in Asians: A randomized double-blind placebo-controlled trial.

BACKGROUND AND AIM: Current treatments of functional dyspepsia (FD) are unsatisfied. Tricyclic antidepressants alter visceral hypersensitivity and brain-gut interaction. We assessed the efficacy and safety of nortriptyline in patients with FD. METHODS: Patients diagnosed with FD according to Rome III criteria who failed to respond to proton pump inhibitor and prokinetic treatment were randomly assigned to either once daily 10-mg nortriptyline or placebo. The primary endpoint was the rate of responders defined as > 50% reduction in dyspepsia symptom score after 8 weeks of treatment. The secondary endpoints were improvement in quality of life as assessed by 36-Item Short Form Health Survey score and safety. RESULTS: Sixty-one patients (nortriptyline 28 and placebo 33) were enrolled. Dyspepsia symptom score and duration of symptoms were balanced at entry between both groups. Eight and seven patients in nortriptyline and placebo groups were lost to follow up. Seven patients withdrew due to mild adverse events (nortriptyline 1 and placebo 6). Overall, 19 with nortriptyline and 20 with placebo completed the study. Patients receiving nortriptyline did not achieve higher response rate than those in placebo in both intention-to-treat (53.6% vs 57.6%, P = 0.75) and per-protocol (76.5% vs 73.7%, P = 1.00) analyses. Nortriptyline did not provide improvement in quality of life. The mean difference was 3.8 (P = 0.36) and 0.88 (P = 0.86) by intention-to-treat and 2.9 (P = 0.57) and 3.5 (P = 0.57) by per-protocol analyses in physical and mental component, respectively. All adverse events were minor and similar in both groups. CONCLUSION: Nortriptyline was not superior to placebo in management of patients with FD.

Ten-day high-dose proton pump inhibitor triple therapy versus sequential therapy for Helicobacter pylori eradication.

BACKGROUND AND AIM: Eradication rates of Helicobacter pylori following standard triple therapy are declining worldwide, but high-dose proton pump inhibitor-based triple therapy (HD-PPI-TT) and sequential therapy (ST) have demonstrated higher cure rates. We aimed to compare the efficacy and tolerability of HD-PPI-TT and ST in H. pylori-associated functional dyspepsia (FD). METHODS: One hundred and twenty H. pylori-associated functional dyspepsia patients were randomized to receive 10-day HD-PPI-TT (60 mg lansoprazole/500 mg clarithromycin/1 g amoxicillin, each administered twice daily for 10 days) or 10-day ST (30 mg lansoprazole/1 g amoxicillin, each administered twice daily for 5 days followed by 30 mg lansoprazole/500 mg clarithromycin/400 mg metronidazole, each administered twice daily for 5 days). H. pylori status was determined in post-treatment week 4 by 14 C-urea breath test. Eradication and antibiotic resistance rates, dyspeptic symptoms, drug compliance, and adverse effects were compared. RESULTS: Intention-to-treat eradication rates were similar in the ST and HD-PPI-TT groups (85% vs. 80%; P = 0.47). However, the eradication rate was significantly higher following ST compared with HD-PPI-TT in per protocol analysis (94.4% vs. 81.4%; P = 0.035). ST achieved higher cure rates than HD-PPI-TT in clarithromycin-resistant H. pylori strains (100% vs. 33.3%; P = 0.02). Treatment compliance was similar in the HD-PPI-TT and ST groups, although nausea and dizziness were more common in the ST group. CONCLUSIONS: Sequential therapy achieved better H. pylori eradication than HD-PPI-TT in patients with FD. However, the eradication rate for ST fell from 94.4% in per protocol to 85% in intention-to-treat analysis. Adverse effects might result in poorer compliance and compromise actual ST efficacy (ClinicalTrials.gov: NCT01888237).

Helicobacter pylori management in ASEAN: The Bangkok consensus report.

Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.

Effect of proton pump inhibitor on plasma voriconazole concentration in Thai patients.

BACKGROUND: Voriconazole is an antifungal drug used for treatment of invasive aspergillosis. It is metabolized mainly via the cytochrome P450 isoenzymes CYP2C19, through which its enzymatic activity can be inhibited by proton pump inhibitors (PPI), especially omeprazole. Previous reports demonstrated that omeprazole might be used to boost plasma voriconazole levels in infected patients. However; there was no difference in plasma voriconazole concentration in healthy individuals, who received omeprazole versus placebo. Therefore, the interaction between PPI and voriconazole may be different between healthy and infected individuals. OBJECTIVE: To determine the effects of omeprazole on plasma voriconazole concentration in Thai patients who had invasive fungal diseases. MATERIAL AND METHOD: The present study is a prospective observational study and is a sub-study of the voriconazole therapeutic drug monitoring study. Patients treated with voriconazole admitted at Siriraj Hospital during July 2011 to September 2013 were enrolled. Blood samples were drawn for plasma voriconazole concentration assays at day 0, 3, 7, 14 and 28. Data regarding PPI use were collected and analyzed in correlation with plasma voriconazole concentration. RESULTS: Of 54 patients enrolled, 47 had sufficient clinical data but 46 patients had complete data of voriconazole levels. Patients mean age was 47 years and 60% were male. Thirty-nine patients (83%) had invasive pulmonary aspergillosis. Forty-one patients (87.2%) received PPI, among which 37 (90.2%) were omeprazole. Patients with PPI use had no difference in plasma voriconazole concentration, when compared with those without PPI use, at day 3 (5.89 vs. 5.44 mg/L, p = 0.744), day 7 (5.4 vs. 5.29 mg/L, p = 0.471), day 14 (2.40 vs. 3.13 mg/L, p = 0.372) and day 28 (1.77 vs. 3.23 mg/L, p = 0.314). Although there was a trend toward higher plasma voriconazole concentration in patients receiving higher omeprazole dose (> 20 mg/day), the difference between those treated with high (> 20 mg/day) and low (20 mg/day) doses of omeprazole was not statistically significant at day 3 (6.27 vs. 4.87 mg/L, p = 0.429), day 7 (7.44 vs. 3.78 mg/L, p = 0.166), day 14 (2.52 vs. 1.68 mg/L, p = 0.534) and day 28 (2.51 vs. 1.44 mg/L, p = 0.154). Similarly, the duration of omeprazole use in concurrent with voriconazole treatment was not associated with plasma voriconazole concentration in infected patients. CONCLUSION: Omeprazole does not affect plasma voriconazole concentration in infected patients. However, patients who received higher doses ofomeprazole (> 20 mg/day) tend to have a higher concentrations of plasma voriconazole.

Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand.

Background/Aims: Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM. Methods: This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up. Results: Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). Conclusions: These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.

Treatment outcomes in patients with globus: A randomized control trial of psychoeducation, neuromodulators, and proton pump inhibitors.

BACKGROUND: Globus is a persistent or intermittent nonpainful sensation of a lump or foreign body, which markedly affect patient's quality of life. Treatment options for globus are limited and unsatisfying. This study aims to compare the effects of cognitive-behavioral-theory-based psychoeducation (CBT), neuromodulators (NMD), and proton pump inhibitor (PPI) on treatment outcomes in patients with globus. METHODS: Eligible patients were randomly received CBT, 0.5 mg flupenthixol and 10 mg melitracen; NMD, or omeprazole 20 mg; PPI, for 4 weeks. The primary endpoint was the reduction in symptom scores; Glasgow Edinburgh Throat Scale (GETS). The secondary endpoints included treatment efficacy on Reflux Symptom Index (RSI), Hospital Anxiety Depression Scale (HADS), and quality of life (QoL) based on a 36-item short-form health survey (SF-36). Treatment compliance and adverse effects were recorded. KEY RESULTS: Forty patients were completed study. Baseline characteristics between the groups were comparable. By the end of treatment, both CBT and NMD provided greater reduction in GETS than PPI (CBT vs PPI; 6.46 ± 8.56 vs 0.21 ± 5.42; p = 0.031, NMD vs PPI; 6.92 ± 9.85 vs 0.21 ± 5.42; p = 0.036). The improvement of RSI, HADS, and SF-36 among the groups was similar. Neuromodulators caused more adverse events. CONCLUSIONS & INFERENCES: Both CBT and NMD provided equally effective treatment and better than PPI in patients with globus determined by the reduction in GETS. The improvement in RSI, HADS, and QoL of the three groups was not different. Given less of adverse effect than NMD, CBT should be considered as a substantial treatment.

Acute hemorrhagic rectal ulcer syndrome: the first case series from Thailand.

The term "Acute hemorrhagic rectal ulcer syndrome (AHRUS)" has been denoted as a pathological entity that consists of lower gastrointestinal bleeding with unique clinical features. The common setting can be found in elderly patients who were hospitalized with multiple comorbidities. The typical location is around the dentate line. The predominant feature of these ulcers is profuse and painless rectal bleeding. Currently, this condition has not been established worldwide and it has never been reported in Thailand. The authors reported nine cases of AHRUS. These cases were reviewed from the records of endoscopic procedures which were performed at Siriraj Endoscopy Center between September-December 2006. All underwent complete colonoscopy to evaluate endoscopic appearances. Histopathologic findings were thoroughly reviewed. The characteristics of the ulcers are multiple, round or oval shape located just above the dentate line, with/without evidence of bleeding stigmata. Histopathologic features included superficial necrosis, erosions with acute inflammatory cell infiltration and evidence of recent hemorrhage, all of which were confined to the mucosal layer. No organisms were discovered from the lesions. In conclusion, this is the first review of AHRUS which is an uncommon cause of hematochezia in Thailand. Although this clinical entity is not well established in Western countries, the rising incidence of AHRUS in Asia warrants further investigation into its pathogenesis, treatment and prevention.

Cronkhite-Canada Syndrome: A Rare Case of Chronic Diarrhea With Ectodermal Changes.

Cronkhite-Canada syndrome (CCS) is a rare cause of chronic diarrhea and malabsorption where patients develop multiple polyps throughout the gastrointestinal (GI) tract, accompanied by ectodermal changes. Due to its rarity, early detection and diagnosis are challenging for physicians, inevitably leading to high mortality. CCS patients have a higher prevalence of GI cancer compared to the general population. Therefore, a follow-up endoscopy is necessary. We report a new case of CCS in an 85-year-old male who presented with chronic watery diarrhea, weight loss, and skin changes including alopecia, nail dystrophy, and hyperpigmentation. Laboratory results showed anemia and hypoalbuminemia. He underwent an endoscopy that found diffuse edematous polyposis in the stomach, duodenum, terminal ileum, and large intestine. The biopsy result confirmed the diagnosis of CCS. The patient received supportive treatment with total parenteral nutrition with improvement in his symptoms. He was placed on corticosteroid taper and azathioprine upon discharge. At the one-year follow-up, he was found in endoscopic remission.

Generalized transit delay on wireless motility capsule testing in patients with clinical suspicion of gastroparesis, small intestinal dysmotility, or slow transit constipation.

BACKGROUND: The prevalence of generalized transit delay and relation to symptoms in suspected gastroparesis, intestinal dysmotility, or slow transit constipation are unknown. AIMS: The aims of this study were (1) to define prevalence of generalized dysmotility using wireless motility capsules (WMC), (2) to relate to symptoms in suspected regional delay, (3) to compare results of WMC testing to conventional transit studies to quantify new diagnoses, and (4) to assess the impact of results of WMC testing on clinical decisions. METHODS: WMC transits were analyzed in 83 patients with suspected gastroparesis, intestinal dysmotility, or slow transit constipation. RESULTS: Isolated regional delays were observed in 32% (9% stomach, 5% small bowel, 18% colon). Transits were normal in 32% and showed generalized delays in 35%. Symptom profiles were similar with normal transit, isolated delayed gastric, small intestinal, and colonic transit, and generalized delay (P = NS). Compared to conventional tests, WMC showed discordance in 38% and provided new diagnoses in 53%. WMC testing influenced management in 67% (new medications 60%; modified nutritional regimens 14%; surgical referrals 6%) and eliminated needs for testing not already done including gastric scintigraphy (17%), small bowel barium transit (54%), and radioopaque colon marker tests (68%). CONCLUSIONS: WMC testing defines localized and generalized transit delays with suspected gastroparesis, intestinal dysmotility, or slow transit constipation. Symptoms do not predict the results of WMC testing. WMC findings provide new diagnoses in >50%, may be discordant with conventional tests, and can influence management by changing treatments and eliminating needs for other tests. These findings suggest potential benefits of this method in suspected dysmotility syndromes and mandate prospective investigation to further define its clinical role.

A 10-year cohort study of 175 primary gastrointestinal lymphoma cases in Thailand: clinical features and outcomes in the immunochemotherapy era.

BACKGROUND: Primary gastrointestinal lymphoma (PGIL), an uncommon subtype of lymphoma, accounts for 1%-4% of gastrointestinal cancers. This study, therefore, aimed to investigate the current 10-year epidemiology and outcomes of PGIL. METHODS: This retrospective study involved a hospital-based chart review to analyze the epidemiology, clinical features, predisposing factors, and clinical outcomes of patients diagnosed with, and treated for, PGIL. Data covering 10 years was collected of Thai patients aged ≥ 15 years who had been diagnosed as PGIL with pathological confirmation and treated at Siriraj Hospital, Thailand. RESULTS: A total of 175 PGIL patients were enrolled. Their median age was 60 years (range, 20-98), with a male predominance. The stomach was the most common site of gastrointestinal (GI) organ involvement by lymphoma (38.9%), followed by the small intestine (23.4%) and multiple sites of GI involvement (23.4%). Diffuse large B-cell lymphoma (DLBCL) had the highest proportion of PGIL, accounting for 61.1%. The median patient follow-up time was 13.9 months (range: 0-104.9 months). The median overall survival (OS) of PGIL patients was not reached during the 10 years, with a 5-year OS of 64.4%. The probability of having a better OS was demonstrated in patients with a good performance status who received a rituximab-containing regimen. CONCLUSIONS: The stomach was the most common site of lymphoma involvement in the GI tract, with DLBCL accounting for the highest proportion of those patients. The long-term survival outcome was significantly improved in patients with good performance status and rituximab exposure. Trial registrationNot applicable.

Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand.

OBJECTIVE: Age and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI) malignancies are uncertain. DESIGN: Cross-sectional study. SETTING: Data were extracted from the Gastrointestinal Endoscopy Centre of Siriraj Hospital, Thailand, during 2005-2011. PARTICIPANTS: Consecutive patients underwent a first-time upper endoscopy for dyspepsia. Patients with previous surgery, suspected UGI malignancy by imaging, or indefinite biopsy results on prior examination were excluded. MAIN OUTCOME MEASURES: Alarm features included dysphagia, unintentional weight loss, GI bleeding/anaemia, and persistent vomiting. The diagnostic performance of each alarm feature and different age cut-off values were evaluated. RESULTS: A total of 4664 patients (mean age: 52.0±14.4 years, 66% female) were included. Alarm symptoms were presented in 21.6%. The prevalence of active Helicobacter pylori infection was 26.3%. Fifty-eight (1.2%) patients had UGI malignancy. The prevalence of malignancy significantly increased with increasing age (0.6% in patients aged <50 years, and 1.8% in patients aged >60 years (p<0.001)). Cancer was found in two patients aged <50 years who did not have alarm features. Patients with alarm features had a higher prevalence of malignancy (OR 22.3, 95% CI 10.5 to 47.4; p<0.001) than those without. The pooled sensitivity, specificity, positive predictive value and negative predictive value of alarm features for UGI malignancy were 87.0%, 79.1%, 4.7% and 99.8%, respectively. Among all age groups, persistent vomiting had a positive likelihood ratio (PLR) >10, while dysphagia and GI bleeding/anaemia had a PLR >10 in patients <50 years old. CONCLUSION: Despite the overall limited value of age and alarm features, persistent vomiting, dysphagia, and GI bleeding/anaemia are strong predictors for malignancy in patients aged <50 years. Without these symptoms, cancer prevalence is negligible; thus, they are worthy guidance for endoscopic evaluation in this age group.

Consensus statements and recommendations on the management of mild-to-moderate gastroesophageal reflux disease in the Southeast Asian region.

This paper reports the proceedings from the first consensus meeting on the management of mild-to-moderate gastroesophageal reflux disease (GERD) in the Southeast Asian (SEA) region. Seventeen statements were drawn up by a steering committee that focused on epidemiology, mechanism of action, diagnostic investigations, and treatment. Voting on the recommendations used the Delphi method with two rounds of voting among the 10 panel members. The consensus panel agreed that GERD is mostly a mild disease in the SEA region with predominantly non-erosive reflux disease (NERD). Complicated GERD and Barrett's esophagus are infrequently seen. The panel recommended endoscopy in patients with alarm or refractory symptoms but cautioned that the incidence of gastric cancer is higher in SEA. pH and impedance measurements were not recommended for routine assessment. The acid pocket is recognized as an important pathogenic factor in GERD. Lifestyle measures such as weight reduction, avoidance of smoking, reduction of alcohol intake, and elevation of the head of the bed were recommended but strict avoidance of specific foods or drinks was not. Alginates was recommended as the first-line treatment for patients with mild-to-moderate GERD while recognizing that proton-pump inhibitors (PPIs) remained the mainstay of treatment of GERD. The use of alginates was also recommended as adjunctive therapy when GERD symptoms were only partially responsive to PPIs.

Thailand Dyspepsia Guidelines: 2018.

The management of dyspepsia in limited-resource areas has not been established. In 2017, key opinion leaders throughout Thailand gathered to review and evaluate the current clinical evidence regarding dyspepsia and to develop consensus statements, rationales, levels of evidence, and grades of recommendation for dyspepsia management in daily clinical practice based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline is mainly focused on the following 4 topics: (1) evaluation of patients with dyspepsia, (2) management, (3) special issues (overlapping gastroesophageal reflux disease/irritable bowel syndrome and non-steroidal anti-inflammatory drug/aspirin use), and (4) long-term follow-up and management to provide guidance for physicians in Thailand and other limited-resource areas managing such patients.

Severe enteropathy with villous atrophy in prolonged mefenamic acid users - a currently under-recognized in previously well-recognized complication: Case report and review of literature.

RATIONALE: Mefenamic acid-induced enteropathy may be an under-recognized condition because few reported cases and no review of literature to comprehensively describe all reported cases exist. From inception until February 2017, a systematic literature search identified twenty original reports of cases of mefenamic acid-induced enteropathy. Additional five cases were identified at our hospital. All cases were included in the analyses. PATIENT CONCERNS: Most patients had been regularly taking therapeutic dosages of mefenamic acid for at least three months before symptoms developed. All patients presented with chronic diarrhea with significant weight loss. Approximately one-third of the cases had some degree of anemia and hypoalbuminemia. DIAGNOSES: Endoscopic findings could range from very mild abnormalities, such as mild atrophic mucosa, to marked abnormalities, such as blunted villi with scalloping appearance in the small intestine and inflamed mucosa with a few superficial ulcers in the ileum and colon. Pathological findings included flattened small intestinal villi and mixed inflammatory infiltrates including eosinophils in lamina propria. INTERVENTION: After identifying history of prolong mefenamic acid exposure, all patients were prescribed to stop this medication. Nutritional support and substitutional treatment for mefenamic acid were provided as well. OUTCOMES: All symptoms responded dramatically to drug withdrawal. Some patients could change to use other nonsteroidal anti-inflammatory drugs (NSAIDs) without symptoms reoccurring. LESSONS: Unlike other traditional NSAIDs, mefenamic acid could induce intestinal villous atrophy. An adequate drug history is crucial to identifying the condition. Protracted diarrhea occurring during treatment should be the indication to cease the medicine promptly.

Antimicrobial susceptibility of Clostridium difficile isolated in Thailand.

BACKGROUND: Exposure to antimicrobials is the major risk factor associated with Clostridium difficile infection (CDI). Paradoxically, treatment of CDI with antimicrobials remains the preferred option. To date, only three studies have investigated the antimicrobial susceptibility of C. difficile from Thailand, two of which were published in the 1990s. This study aimed to investigate the contemporary antibiotic susceptibility of C. difficile isolated from patients in Thailand. METHODS: A collection of 105 C. difficile isolated from inpatients admitted at Siriraj Hospital in Bangkok in 2015 was tested for their susceptibility to nine antimicrobials via an agar incorporation method. RESULTS: All isolates were susceptible to vancomycin, metronidazole, amoxicillin/clavulanate and meropenem. Resistance to clindamycin, erythromycin and moxifloxacin was observed in 73.3%, 35.2% and 21.0% of the isolates, respectively. The in vitro activity of fidaxomicin (MIC50/MIC90 0.06/0.25 mg/L) was superior to first-line therapies vancomycin (MIC50/MIC90 1/2 mg/L) and metronidazole (MIC50/MIC90 0.25/0.25 mg/L). Rifaximin exhibited potent activity against 85.7% of the isolates (MIC ≤0.03 mg/L), and its MIC50 (0.015 mg/L) was the lowest among all antimicrobials tested. The prevalence of multi-drug resistant C. difficile, defined by resistance to ≥3 antimicrobials, was 21.9% (23/105). CONCLUSIONS: A high level of resistance against multiple classes of antimicrobial was observed, emphasising the need for enhanced antimicrobial stewardship and educational programmes to effectively disseminate information regarding C. difficile awareness and appropriate use of antimicrobials to healthcare workers and the general public.

Thailand Consensus on Helicobacter pylori Treatment 2015.

Management of Helicobacter pylori infection is an important aspect of many upper gastrointestinal tract diseases, such as chronic gastritis, peptic ulcer disease, gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma. The Thailand Consensus on H. pylori treatment 2015 consisted of 22 national experts who took active roles, discussed all important clinical information and investigated clinical aspects in four workshops, focuising on: (1) Diagnosis (2) Treatment (3) Follow-up after eradication and (4) H. pylori infection and special conditions. Experts were invited to participate on the basis of their expertise and contribution to H. pylori works and/or consensus methodology. The results of each workshop were taken to a final consensus vote by all experts. Recommendations were developed from the best evidence and availability to guide clinicians in management of this specific infection associated with variety of clinical outcomes.