Different antibiotic susceptibility between antrum and corpus of the stomach, a possible reason for treatment failure of Helicobacter pylori infection.

AIM: To assess whether antibiotic resistance varies between the antrum and corpus of the stomach of patients that are either Helicobacter pylori (H. pylori) therapy-naive or pre-treated. METHODS: H. pylori strains were isolated from antrum and corpus biopsies from 66 patients that received a diagnostic gastroduodenoscopy for variant clinical indications. Antimicrobial susceptibility to amoxicillin, clarithromycin, tetracycline, metronidazole, levofloxacin and rifabutin was tested with the E-test method on Iso-Sensitest agar with 10 vol% defibrinated horse blood. In patients with a different antibiotic susceptibility pattern between the isolates from the antrum and corpus, DNA fingerprinting via random amplified polymorphic DNA analysis was performed to detect differences among DNA patterns of H. pylori isolates. RESULTS: Primary, secondary and tertiary resistance to clarithromycin was 6.9%, 53.8% and 83.3%, retrospectively. Metronidazole and levofloxacin resistance also increased according to the number of previous treatments (17.2%, 69.2%, 83.3%; 13.8%, 23.1%, 33.3%). Tertiary resistance to rifabutin was detected in 12.5% of patients. In none of the 66 patients a resistance against amoxicillin or tetracycline was detectable. Discordant antibiotic susceptibility between antrum and corpus isolates for different antibiotics was seen in 15.2% (10/66) of the patients. Two out of those ten patients were naive to any H. pylori antibiotic treatment. The remaining eight patients previously received at least one eradication therapy. DNA fingerprinting analysis revealed no substantial differences among DNA patterns between antrum and corpus isolates in the majority of patients suggesting an infection with a single H. pylori strain. CONCLUSION: Different antibiotic susceptibility between antrum and corpus biopsies is a common phenomenon and a possible explanation for treatment failure. Resistant H. pylori strains may be missed if just one biopsy from one anatomic site of the stomach is taken for H. pylori susceptibility testing.

Antibiotic susceptibility of Helicobacter pylori in central Germany and its relationship with the number of eradication therapies.

OBJECTIVES: Helicobacter pylori eradication rates show a constant decline over the last few years. The main reason for H. pylori treatment failure is the increasing antibiotic resistance.We assessed antibiotic susceptibility of H. pylori in a region of mid-Germany and analyzed the relationship of antibiotic resistance with the number of eradication therapies over a period of 7 years (2005-2012). METHODS: H. pylori strains were isolated from 436 patients who underwent gastroscopy for different clinical indications. Susceptibility to amoxicillin, clarithromycin, metronidazole, tetracycline, levofloxacin, and rifabutin was determined using the E-test. RESULTS: Primary, secondary, and tertiary resistances against clarithromycin were 7.5, 63.2, and 75.4%, respectively. Primary, secondary, and tertiary resistances to levofloxacin were 11.7, 17.6, and 36.4% and to metronidazole were 32.7, 63.2, and 80.1%, respectively. The resistance rates against tetracycline and rifabutin were comparatively low (<5%), even in patients with previous exposure to these antibiotics. Resistance to rifabutin increased to 6.2% in patients who received more than two previous eradication therapies. Amoxicillin resistance was not detectable in all patients. CONCLUSION: In our region, we observed a stable, but constantly increasing, resistance rate to antibiotics commonly used for the treatment of H. pylori infection. Knowledge of the local antibiotic resistance rates is essential for developing successful treatment strategies for H. pylori eradication.

Sorafenib therapy in patients with advanced hepatocellular carcinoma in advanced liver cirrhosis.

BACKGROUND AND AIM: Sorafenib has become the treatment standard for patients with advanced hepatocellular carcinoma (HCC). It is not clear whether patients with advanced liver function impairment (Child B) and patients undergoing additional locoregional therapy may tolerate treatment with sorafenib and benefit. We aimed to evaluate the tolerability and efficiency of sorafenib in patients with advanced HCC and different stages of liver cirrhosis, and in combination with locoregional therapy. METHODS: In 50 patients with advanced HCC treated with sorafenib tolerability and efficiency of the therapy with respect to stage of liver cirrhosis, existence of extrahepatic tumor spread, and additional locoregional therapy were evaluated. RESULTS: Fifty patients with advanced HCC were treated with sorafenib, and 13 received additional locoregional therapy. Tolerability of the systemic treatment was moderate in all patients, with no significant differences between the subgroups, while the median survival was better in patients with Child A than Child B cirrhosis. CONCLUSION: Tolerability and toxicity of a systemic treatment with sorafenib are moderate in patients with liver cirrhosis in Child A or B. Prospective randomized studies are required to evaluate the efficacy and tolerability of combined systemic and locoregional treatment approaches in patients with advanced HCC.

[Fulminant duodenal bleeding as first manifestation of a neuroendocrine carcinoma of the pancreatic head]. / Fulminante Duodenalblutung als Erstmanifestation eines neuroendokrinen Pankreaskopfkarzinoms.

CASE REPORT: A 73-year-old male patient presented with upper gastrointestinal bleeding. The reason was an arterial hemorrhage from a duodenal tumor that could only be stopped by an angiographic intervention. In the further staging, there was evidence for a neuroendocrine carcinoma of the pancreatic head with infiltration of the duodenum and hepatic metastases. Due to good differentiation (G1) a systemic biotherapy with octreotide LAR was induced. After recurrent bleeding with arrosion of a branch of the superior mesenteric artery, a duodenum-preserving pancreatic head resection was performed. Afterwards, the systemic therapy was changed to a palliative chemotherapy with streptozotocin and 5-fluorouracil due to local progression of the disease and a Ki-67 index of 4% in the primary tumor. CONCLUSION: In about 0.7% of patients with neuroendocrine tumors, the lesion is located in the pancreas. At this site these entities are very heterogeneous. The majority are nonfunctional tumors without secretion of bioactive substances and the associated symptoms. About 60% of the patients present with advanced metastasized disease. The therapy depends on the local spread and histological grading as well as symptoms of the patient. The only curative option represents surgical resection. However, even in a palliative situation, there can be benefit for the patient in case of a tumor mass reduction of > 90%. Alternative therapies in the palliative situation are somatostatin analogs, a classic systemic chemotherapy, or locoregional interventional procedures.

Hepatocellular carcinoma--epidemiological trends and risk factors.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related deaths worldwide with about 600,000 patients dying from the disease annually. In 70-90%, HCC develops on the background of chronic liver cirrhosis or inflammation. Risk factors and etiologies vary among geographical regions. In regions with a high incidence the majority of cases are related to HBV and HCV hepatitis. In developed countries, in addition to virus-related HCC, high consumption of alcohol as well as non-alcoholic fatty liver disease often in the context of metabolic syndromes are the prevalent causes. Improvement in clinical management of patients with liver cirrhosis and the control of related complications are the key for the rising incidence of HCC. This review gives an overview on epidemiological trends and risk factors and their mechanisms involved in the hepatocarcinogenesis. Knowledge of these factors will help to improve current concepts for prevention, screening and treatment of this disease.

Hepatocellular carcinoma and liver cirrhosis: assessment of the liver function after Yttrium-90 radioembolization with resin microspheres or after CT-guided high-dose-rate brachytherapy.

PURPOSE: To identify changes of liver function after single-fraction irradiation or yttrium-90 radioembolization ((90)Y-RE) of hepatocellular carcinoma associated with liver cirrhosis on the basis of laboratory data. METHODS AND MATERIALS: 24 patients with primary liver carcinoma and liver cirrhosis classified Child-Pugh A or B were treated either by image-guided high-dose-rate brachytherapy (HDR-BT) (12 patients) or by (90)Y-RE (12 patients). The following laboratory parameters were assessed 1 day before and 3 days, 6 weeks and 3 months after the intervention: total bilirubin and gamma-glutamyl transpeptidase (GGTP) as parameters of detoxification function, albumin and cholinesterase (ChE) as direct synthesis parameters, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (AP) as indicators of liver tissue damage. Preinterventional values were taken as baseline, following values were calculated as percentage changes from the baseline value. Statistical analysis was performed using the Wilcoxon-matched pairs test, comparing postinterventional with preinterventional values. Differences were considered statistically significant with a p value <0.05. RESULTS: In all patients the median bilirubin, ALT, AP and albumin values remained within normal limits at any time of follow-up. AST levels in the RE group and GGTP in both groups have been already elevated over a normal range before the intervention, and in both groups both parameters showed a slight increase after interventions. ChE activity was lowered already in the baseline values and showed a further decrease 3 days after BT as well as 3 days and 6 weeks after RE, with final reconstitution to baseline values. All liver function test parameters showed mild changes shortly after radiation therapy but floating laboratory values recovering within 12 weeks to baseline values. Radiation or RE-induced liver disease was recorded in no patient. CONCLUSIONS: Liver function parameters show only mild changes shortly after intervention with recovery within 6-12 weeks to baseline values.