Third-line rescue therapy with bismuth-containing quadruple regimen after failure of two treatments (with clarithromycin and levofloxacin) for H. pylori infection.

BACKGROUND: Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin fails in >20 % of cases. A rescue therapy with PPI-amoxicillin-levofloxacin still fails in >20 % of patients. AIM: To evaluate the efficacy and tolerability of a bismuth-containing quadruple regimen in patients with two consecutive eradication failures. METHODS: Prospective multicenter study of patients in whom 1st treatment with PPI-clarithromycin-amoxicillin and 2nd with PPI-amoxicillin-levofloxacin had failed. A 3rd eradication regimen with a 7- to 14-day PPI (standard dose b.i.d.), bismuth subcitrate (120 mg q.i.d. or 240 mg b.i.d.), tetracycline (from 250 mg t.i.d. to 500 mg q.i.d.) and metronidazole (from 250 mg t.i.d. to 500 mg q.i.d.). Eradication was confirmed by (13)C-urea-breath-test 4-8 weeks after therapy. Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated by means of a questionnaire. RESULTS: Two hundred patients (mean age 50 years, 55 % females, 20 % peptic ulcer/80 % uninvestigated-functional dyspepsia) were initially included, and two were lost to follow-up. In all, 97 % of patients complied with the protocol. Per-protocol and intention-to-treat eradication rates were 67 % (95 % CI 60-74 %) and 65 % (58-72 %). Adverse effects were reported in 22 % of patients, the most common being nausea (12 %), abdominal pain (11 %), metallic taste (8.5 %), and diarrhea (8 %), none of them severe. CONCLUSION: A bismuth-containing quadruple regimen is an acceptable third-line strategy and a safe alternative after two previous H. pylori eradication failures with standard clarithromycin- and levofloxacin-containing triple therapies.

Gastric carcinoid tumour. A clinicopathologic and immunohistochemical study of four cases.

Over the last decade a great increase in the frequency of Gastric Carcinoid Tumours has been detected being considered by some authors as the most frequent digestive carcinoid. These have been divided into three types: I) those associated with chronic atrophic gastritis; II) associated with Zollinger-Ellison syndrome, and III) sporadic lesions. We present four cases of gastric carcinoid type I (3 women and 1 man) two of them associated with pernicious anemia and another two with iron deficiency anemia. Three patients were operated upon, and an endoscopy removal was carried out on the fourth patient. The clinical course has been favourable during the follow-up. Multiple lesions were detected in 3 patients, with tumours less than 2 cm in size, except for a 4.5 cm polyp, which invaded the submucous layer. This case presented carcinoid syndrome without evidence of liver metastasis. Argyrophilia. Chromogranin A and Neuronal Specific Enolase tintions were located in the tumor and in the hyperplastic endocrine cells of the mucous.