Medical treatment of uncomplicated diverticular disease of the colon: any progress?

Clinical evidence supports a therapeutic approach to uncomplicated, symptomatic diverticular disease of the colon by means of increased fiber intake and cyclic administration of the non absorbable antibiotic agent rifaximin polymorph-alpha. Alternate treatments such as mesalazine and probiotics have been recently proposed but no definitive conclusions on their efficacy can be drawn until larger, randomized placebo-controlled studies will be available.

Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomised controlled trial.

BACKGROUND: It has been speculated that midazolam may be effective in reducing the required dose of propofol during sedation. AIM: To evaluate the sparing effect of midazolam during target-controlled propofol infusion. METHODS: Two hundred-seventy patients undergoing upper endoscopic ultrasound were randomised to receive sedation with propofol plus placebo (group A) or plus midazolam (group B). Outcome parameters were the procedure duration, the discharge time and the satisfaction of patients, operator and nurse about the quality of sedation. RESULTS: The mean propofol dose administered was 364+/-207 mg in group A and 394+/-204 mg in group B. Mean procedure duration (group A: 32+/-17 min, group B: 35+/-22 min) and discharge time (group A: 39+/-30 min, group B: 38+/-24 min) were similar in both groups. No severe complications were observed. The quality of sedation was judged satisfactory for all patients by both the endoscopist and the nurse assistant without any difference between the two groups. No patient remembered the procedure or reported it as unpleasant. CONCLUSIONS: Target-controlled propofol infusion provides safe and effective sedation; premedication with low dose of midazolam does not reduce the total amount of propofol administered. Further studies are needed to compare propofol alone with propofol co-administered with opioid.

Probiotic agents in the treatment of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is characterized by abdominal pain and alterations in bowel habits. Several pathogenetic factors, such as altered intestinal motility, visceral hypersensitivity, serotonin system abnormalities and psychic disturbances have been identified. Recently, a pathogenetic role of intestinal microflora has been shown in IBS: viral or bacterial infection can trigger post-infectious IBS; some patients have small intestinal bacterial overgrowth; the composition of patients' enteric flora is altered; and minimal inflammatory changes, consistent with the pro-inflammatory role of bacteria, have been demonstrated. Probiotics may, therefore, offer a rational therapeutic approach to IBS. The data available on the use of probiotics in IBS are still limited and results of controlled clinical trials are contradictory because they have been performed using different species, dosages, treatment durations and end-points for results evaluation. A critical evaluation of the therapeutic role of the various probiotics in IBS is presented in this article.

Comparison of sucralfate and ranitidine in the treatment of chronic nonerosive gastritis. A randomized, multicenter trial.

In a randomized trial involving 20 Italian centers, the effectiveness of 1 g sucralfate three times a day and 150 mg ranitidine twice a day in the treatment of chronic gastritis was assessed and compared. Five hundred outpatients with dyspeptic symptoms and endoscopic evidence of chronic nonerosive gastritis were randomly assigned to either treatment for a period of eight weeks. Endoscopic scores were determined at the beginning and at the end of the study. The severity of dyspeptic symptoms was assessed at Weeks 0, 2, 4, 6, and 8. Four hundred seventy-three patients completed the study. In 331 cases, biopsies were taken during endoscopy, and a histologic evaluation was also performed, according to Whitehead's criteria. Sucralfate was significantly more effective than ranitidine in inducing healing or improvement of both endoscopic (p less than 0.02) and histologic (p less than 0.001) features. At the end of the study, 77.6 percent of the patients in the sucralfate group and 79.4 percent in the ranitidine group were symptom free. Ranitidine was significantly more efficacious at releiving pain during the first four weeks of therapy. Mild side effects were reported by 4.9 percent of patients treated with sucralfate and by 3.6 percent of patients treated with ranitidine. Treatment was withdrawn in one patient treated with sucralfate because of nausea. In conclusion, sucralfate appears significantly superior to ranitidine in improving endoscopic and histologic aspects of chronic nonerosive gastritis. The symptomatic activity of the two drugs is similar, although more rapid relief is obtained with ranitidine.

Gastric toxicity of antiplatelet therapy with low-dose aspirin.

Low-dose aspirin is widely employed as antiplatelet therapy for cardiovascular disorders. However, even in the dosages usually employed for that purpose (75 to 325 mg daily), the drug maintains its ability to damage the gastric mucosa by inducing bleeding ulcers and/or erosions. Pharmacological protection is therefore necessary. Specific long term studies with histamine H2 receptor antagonists or sucralfate are lacking, but data from trials on the prevention of gastric damage by other nonsteroidal anti-inflammatory drugs (NSAIDs) are discouraging. Recent preliminary data suggest that misoprostol, in keeping with its ability to protect both gastric and duodenal mucosa from long term NSAID treatment, seems to be effective also against long term low-dose aspirin therapy in this setting.

Review article: alternative antibacterial agents for Helicobacter pylori eradication.

Standard eradication therapies against Helicobacter pylori appear to be effective in most cases, but in clinical practice a failure rate higher than the 5-10% reported in clinical trials is often observed. Among the various reasons responsible for therapeutic failure, antibiotic resistance is becoming a major issue in some countries. A range of different antibacterial agents is currently under investigation: several macrolides, new fluoroquinolones, furazolidone and rifabutin. Although not formally tested in refractory cases, azithromycin, spiromycin, levofloxacin and furazolidone represent the most promising antibacterial agents for possible inclusion in eradication regimens. Rifabutin has been evaluated in H. pylori infections resistant to standard therapies. Although very effective, the drug is expensive and its use should be restricted to the most difficult cases to avoid the development of rifabutin resistance in Mycobacterium spp.

Effects of cimetropium bromide on gastrointestinal transit time in patients with irritable bowel syndrome.

Cimetropium bromide is a new antimuscarinic compound with strong antispasmodic activity. The aim of this study was to evaluate the effects of oral cimetropium bromide on total gut transit time in patients with irritable bowel syndrome. Forty patients, divided according to their initial total gastrointestinal transit times and presenting symptoms, were treated with cimetropium bromide 50 mg t.d.s. or placebo for 1 month according to a double-blind, parallel group design. Before and after treatment all subjects ingested 24 radio-opaque markers. The total intestinal transit time was determined by evaluating the rate of disappearance of markers from plain X-ray films of the abdomen taken every 24 h for 4 days. Pain and bowel habits were also monitored. Seven patients did not complete the study. Cimetropium bromide significantly (P less than 0.01) shortened the whole gut transit time in patients with prolonged transit time (80.8 +/- 4.0 h before vs 60.8 +/- 6.7 h after treatment) and improved the global clinical condition significantly compared with placebo (P = 0.029). In patients with a short total intestinal transit time, cimetropium bromide had no effect on whole gut transit time and did not significantly improve symptoms. The results of this study indicate that oral cimetropium bromide is effective both objectively and subjectively in a subgroup of irritable bowel syndrome patients with constipation.

Enhancement of gastric mucosal blood flow with sulglycotide.

Twelve patients with dyspepsia whose gastric abnormalities ranged from diffuse reddening of the mucosa to multiple erosions were treated for 4 weeks with oral sulglycotide, a sulphated glycopeptide with known gastroprotective and ulcer-healing properties. Before and after treatment, gastric mucosal blood flow was assessed by means of laser Doppler flowmetry. A significant (P < 0.01) increase in mucosal perfusion was observed after sulglycotide treatment, suggesting that enhancement of mucosal blood flow may contribute to the therapeutic properties of the drug.

Effect of carbenoxolone and cimetidine on gastric mucin.

To determine whether the addition of carbenoxolone to a cimetidine regimen would prevent mucus deficiency in patients with duodenal ulcer, we compared the effect of combined therapy with the effects of treatment with cimetidine alone and carbenoxolone alone. Carbenoxolone proved to be ineffective on gastric mucus induced by cimetidine, the behavior of gastric mucin fractions being similar to that observed in patients treated with cimetidine alone. When used alone, however, carbenoxolone demonstrated mucus-stimulating action.

Gastric effects of a prostaglandin E1-derivate (rioprostil) on acid, alkaline, and mucus secretion.

In a double-blind crossover study, the gastric effects of a single oral dose of rioprostil (150 and 300 micrograms) or placebo were compared in basal conditions and during a 120-minute pentagastrin infusion. A slight decrease in basal acid output and a nonsignificant rise in basal bicarbonate secretion were observed with the 300-micrograms dose. Pentagastrin-stimulated acid secretion was reduced by the prostaglandin derivate, especially with the 300-micrograms dose. Compared with placebo, 300 micrograms of rioprostil significantly stimulated basal mucoprotein secretion and bicarbonate and mucus output during pentagastrin infusion. The results suggest that 300 micrograms of rioprostil exerts both a moderate antisecretory activity and a strengthening effect on the gastric mucus-bicarbonate barrier.

Double-blind trial of pirenzepine versus sucralfate in the treatment of endoscopic duodenitis.

Thirty dyspeptic patients with endoscopic evidence of mild to moderate (nonerosive) duodenitis were randomly assigned to treatment with 50 mg of pirenzepine twice daily or 2 gm of sucralfate twice daily for four weeks. Posttreatment endoscopy revealed normalization of duodenal mucosa in half of the patients in each treatment group. The severity of dyspeptic symptoms was significantly reduced in both groups, with no significant between-group differences.

Pilot trial of nicotine patches as an alternative to corticosteroids in ulcerative colitis.

In ten patients with mild to moderate clinical relapses of ulcerative colitis during treatment with mesalazine (1 g t.i.d.) and with a previous history of poorly tolerated steroid courses, transdermal nicotine (15 mg daily) was added for 4 weeks. Clinical findings were assessed by employing Rachmilewitz's activity index. In 7 of the patients, clinical remission was achieved, the results persisting for up to 3 months after nicotine withdrawal. Endoscopic and histological examination, when performed, confirmed the clinical findings. Nicotine patches may represent a good alternative to steroids in selected patients with mild to moderate relapses of ulcerative colitis. The precise mechanism of action remains unknown.

Assessment of the 'mucus-bicarbonate' barrier in the stomach of patients with chronic gastric disorders.

The composition of gastric mucus and the amount of gastric bicarbonate secretion have been investigated in 26 subjects including healthy controls, duodenal ulcer patients and subjects with chronic gastric disorders (benign gastric ulcer or chronic superficial gastritis). Qualitative changes in gastric mucus (expressed as a reduction in the values of 'mucoprotective index') were found in the gastric ulcer group, but not in patients with chronic superficial gastritis. Basal bicarbonate secretion was significantly reduced (p less than 0.01) in subjects with gastric ulcer and chronic gastritis, compared with healthy controls. Mucus secretion and bicarbonate production proved to be normal in duodenal ulcer patients. Our results support the concept that impairment of the 'mucus-bicarbonate' barrier is an important pathogenetic factor in gastric ulcer and chronic gastritis.

Colloid bismuth versus famotidine in the treatment and prevention of duodenal ulcer relapse: results of a double-blind, double dummy randomized study.

Fifty-three consecutive patients with active duodenal ulcer (DU) were randomly included in a double-blind, double-dummy study to test the healing and relapsing rate of two treatment regimens: famotidine 40 mg nocte for 4-8 weeks, followed by 20 mg for 12 months after healing of the ulcer and colloidal bismuth (CBS) (240 mg bid) for 4-8 weeks, followed by placebo maintenance treatment. The results of the short term period confirmed the efficacy of CBS in healing DU (24/25 in CBS group and 19/23 in famotidine group). However, the relapse rate in the CBS-treated group was higher (77.8% at 12 months) than in the famotidine group (35.7%) (p = 0.041). Only 7 patients (41.2%) were cleared from Helicobacter pylori (HP) after CBS treatment. In conclusion, the high relapse rate observed in CBS treated patients may be related to the high percentage of patients with HP infection in the tested group and support the hypothesis that lack of efficacy of CBS in preventing DU recurrence is related to its poor eradication of HP.

Outcome of ulcerative colitis after treatment with transdermal nicotine.

OBJECTIVE: Transdermal nicotine appears to be of benefit in the short-term treatment of patients with ulcerative colitis. The aim of this study was to determine its long-term effects. DESIGN: A randomized, comparative study. PATIENTS AND METHODS: Patients with mild to moderate clinical relapses of left-sided ulcerative colitis during maintenance treatment with mesalamine 1 g b.i.d. were allocated to an additional treatment with either transdermal nicotine or prednisone for 5 weeks. The first consecutive 15 patients per group, with clinical and endoscopic signs of remission, were followed up for 6 months, while continuing mesalamine maintenance treatment. RESULTS: Relapses of active colitis were observed in 20% of patients formerly treated with nicotine and in 60% of patients in the prednisone group (P = 0.027). Relapses occurred earlier in the latter group. CONCLUSION: Our results confirm that nicotine is useful in cases of ulcerative colitis with mild or moderate activity and suggest that remissions induced by nicotine may last longer than those obtained with oral corticosteroids.

Gastric microcirculation and bicarbonate production in heavy smokers.

OBJECTIVE: To determine the effect of chronic cigarette smoking on gastric mucosal blood flow and bicarbonate secretion. METHODS: Three groups, each consisting of eight dyspeptic patients with normal endoscopic features, were studied: group A contained non-smokers, group B light smokers (< 10 cigarettes/day) and group C heavy smokers (> 10 cigarettes/day). Blood flow was measured in the gastric antrum by laser-Doppler flowmetry, and basal bicarbonate secretion was determined in fasting gastric juice by the method of Feldman. RESULTS: Both mucosal blood flow and bicarbonate secretion were significantly reduced (P < 0.01) in group C. CONCLUSION: In heavy smokers, gastric mucosal perfusion and alkali production are impaired. This can contribute to the noxious effects of smoking on the gastric mucosa. It remains to be determined whether these effects of smoking are causally related.

Luminal leakage of HCO3 in chronic antral erosions.

Gastric bicarbonate content has been determined, under basal conditions, in ten patients with chronic antral erosions, and in ten healthy controls. The former group showed a significantly higher (p less than 0.01) than normal luminal concentration of HCO3. After medical treatment gastric bicarbonate content returned to normal in patients showing endoscopic healing, but not in subjects with persisting erosions. It is suggested that in chronic antral erosions, extensive disruption of mucosal integrity leads to passive leakage of bicarbonate into the gastric lumen.

Effect of sulglycotide on gastric bicarbonate secretion in humans.

The effect of sulglycotide, a cytoprotective agent with a healing effect on ulcers, on gastric bicarbonate secretion in humans was evaluated. Fifteen healthy volunteers were treated with sulglycotide 400 mg t.i.d. for 10 days. Before and after treatment the bicarbonate content of basal gastric juice was determined by Feldman and Barnett's method. Sulglycotide was found to increase significantly (p less than 0.0001) basal HCO3- production from the human stomach, thus strengthening the gastric mucosal defences. It was concluded that the cytoprotective and therapeutic properties of the drug are partially related to stimulation of gastric alkaline secretion.

Measurement of rectal blood flow by laser Doppler flowmetry in inflammatory bowel disease.

BACKGROUND/AIMS: Vascular alterations have been suggested as pathogenic factors in inflammatory bowel disease, particularly Crohn's disease. The aim of our study was to assess rectal blood flow in patients with active inflammatory bowel disease involving the rectum. METHODOLOGY: Endoscopic measurement of rectal blood flow was performed by laser Doppler flowmetry in 45 subjects divided into three groups: healthy controls, ulcerative colitis and rectal Crohn's disease. RESULTS: Rectal perfusion was found to be significantly impaired in patients with ulcerative colitis, but not in those with Crohn's colitis. CONCLUSIONS: Our results confirm the role of local ischemia in ulcerative colitis, but do not support the theory that vascular factors play a key role in the pathogenesis of Crohn's disease.

Helicobacter pylori seroprevalence in Crohn's disease: lack of influence by pharmacological treatment.

BACKGROUND/AIMS: Helicobacter pylori infection has a low prevalence in Crohn's disease, possibly because of sulphasalazine therapy. We investigated Helicobacter pylori seroprevalence in patients with Crohn's disease never treated with sulphasalazine in order to assess the possible role of antibiotic treatment. METHODOLOGY: Two groups of patients with Crohn's disease (group I: subjects treated with ciprofloxacin, metronidazole or both during the last six months; Group II: subjects who were not given antibiotics during the last six months) and a control group of 30 patients with irritable bowel syndrome were considered. IgG anti-H. pylori levels were measured in all patients. RESULTS: Serology was positive respectively in 16.6%, 13.3% and 36.6% of cases in the three groups. CONCLUSIONS: Our findings confirm the Helicobacter pylori infection is infrequent in Crohn's disease. Neither sulphasalazine nor antibiotics appear to play a role.