Trefoil factor family (TFF) proteins as potential serum biomarkers in patients with metastatic colorectal cancer.

Trefoil factor family (TFF) is composed of three secretory proteins (TFF1, TFF2 and TFF3) that play an important role in mucosal protection of gastrointestinal tract. Their overexpression in colorectal tumors seems to be associated with more aggressive disease. We collected serum samples from 79 healthy controls and 97 patients with metastatic colorectal cancer at the time of diagnosis or at progression. Serum levels of TTF1-3, CEA and CA19-9 were measured by ELISA. Serum TFF1 and TFF3 levels were significantly higher in patients with colorectal cancer compared to healthy controls (p < 0.0001). Moreover, serum levels of TFF3 correlated with extent of liver involvement in patient without pulmonary metastases and patients with higher TFF3 levels had significantly worse outcome (p < 0.0001). Compared to CEA and CA19-9, TFF3 had higher sensitivity and the same specificity. Our results indicate that TFF3 is an effective biomarker in patients with metastatic colorectal cancer with higher sensitivity than CEA a CA19-9. TFF3 levels strongly correlate with extension of liver disease and seem to have prognostic value.

[Liver disorders in diabetic patients]. / Onemocnení jater u diabetiku

There is a mutual relationship between diabetes and liver disorders. Diabetic patients suffer from liver disorders more frequently and, vice versa, patients with liver disorders are at a higher risk of developing diabetes. Diabetes is probably the most common cause of chronic liver disorders in developed countries. Liver disorders related to diabetes include a wide spectrum of conditions, from a simple steatosis related to a slight elevation of liver tests through nonalcoholic steatohepatitis with various degrees of fibrosis up to cirrhosis, hepatocellular carcinoma and acute liver failure. Non alcoholic liver steatosis is the most common pathological condition that is, at present, considered to be a component of or to actually be the liver manifestation of metabolic syndrome, accompanied with an insulin resistance and other clinical components, such as central obesity, dyslipidemia, arterial hypertension and the already mentioned type 2 diabetes mellitus. The steatosis itself is a benign condition and the unfavourable development of the liver disorder is related to an inflammatory reaction (steatohepatitis) and subsequent fibrosis. There is no specific treatment for nonalcoholic steatohepatitis. The basic measures include weight reduction, lifestyle changes and treatment of the concurrent conditions, such as diabetes and dyslipidemia. Formerly popular "hepatoprotective" substances do not play an important role in the treatment of steatohepatitis.

[Hepatic cein catheterisation -  selected assessment aspects]. / Katetrizace jaterních zil -  vybrané aspekty hodnocení

INTRODUCTION: Hepatic vein catheterisation and portal hypertension assessment using the value of portal hepatic gradient (HVPG) is currently a method of choice. METHODOLOGY: In our paper we shall compare HVPG with the so called direct gradient -  using the difference in pressure in the portal vein and free hepatic vein in 5 groups of patients with liver cirrhosis. RESULTS: Hepatic vein catheterisation is reliable for assessing the portal hypertension in the group of patients with liver cirrhosis of ethylic etiology. In patients with liver cirrhosis resulting from hepatitis B, Wilsons disease or primary biliary cirrhosis, a statistically significant difference between HVPG and the direct gradient has been found. In patients with liver cirrhosis resulting from hepatitis C the obtained values differed but without statistical significance. CONCLUSION: In catheterisation of hepatic veins the HVPG value in liver cirrhosis with a presinusoidal component may be reduced, which has to be primarily taken into account when assessing the relationship to some critical values of the portal hepatic gradient.

Anemia as a predictor of response to antiviral therapy in chronic hepatitis C.

BACKGROUND: The standard therapy for chronic HCV infection is the administration of pegylated interferons in combination with ribavirin. Anemia is a dose-dependent side-effect of ribavirin administration. The degree of anemia could be indicative of the individual exposure to ribavirin. AIMS: 1) To evaluate the correlation of HGB level decreases at specified time-points with a sustained virological response during the antiviral treatment. 2) To compare these parameters with the virological predictors for responses. METHODS: A retrospective analysis of cohort, which comprised 164 patients treated with standard therapy at a tertiary center in Prague, Czech Republic. RESULTS: We identified several predictive factors for a sustained virological response in females: baseline HGB level ≤140 g/l (p=0.025), maximum drop from baseline >40 g (p=0.039), and a HGB drop in week 4 >30 g (p=0.044). There was only one predictor identified for males: reaching the lowest HGB level after week 19 (p=0.021). The strongest positive predictor of response was a rapid virological response. A low viral load (<600 000 IU/ml) at baseline was not associated with a sustained response in either gender. CONCLUSIONS: The parameters of HGB decrease during antiviral treatment are better correlated with a sustained response in females. None of these response predicting parameters was as significant as that of rapid virological response as that of rapid virological response (Tab. 4, Fig. 1, Ref. 15).

Alcoholic liver disease.

Chronic intake of large quantities of alcohol causes damage to many organs, the liver being the most often affected one. In advanced countries, mortality due to liver diseases is directly proportional to alcohol consumption. 30 g of pure alcohol per day is regarded as a "safe" dose. Alcoholic liver disease may take the form of chronic illness (steatosis, steato-hepatitis, fibrosis and cirrhosis) or acute involvement (alcoholic hepatitis). Whereas steatosis is a relatively benign illness, the presence of cirrhosis of the liver means major life expectancy shortening. The actual stage of cirrhosis depends on the presence of complications--portal hypertension with bleeding oesophageal varices, ascites or hepatic encephalopathy. The median survival time of patients with advanced cirrhosis is 1-2 years. Serious alcoholic hepatitis has a mortality record of up to 50%. Absolute abstinence is a sine qua non condition for any treatment of alcoholic liver disease, the other therapeutic procedure are of a supportive nature and questionable significance. Corticoids can be used in the management of serious alcoholic hepatitis. Treatment in the stage of liver cirrhosis is similar to that in cirrhosis of any other aetiology. Cirrhotic patients who demonstrably abstain can be considered for transplantation leading to a markedly prolonged life expectancy.

[Efficacy of combination treatment with pegylated interferon plus ribavirin in patients chronically infected with HCV]. / Ucinnost terapie pegylovaným interferonem a ribavirinem u pacientu s chronickou HCV infekcí.

THE AIM OF THE STUDY: To evaluate the efficacy of combined antiviral treatment with pegylated interferon alpha plus ribavirin in patients with chronic HCV infection who have not yet been treated with antivirals (treatment-naive patients). To compare the treatment effect in patients with low (< 600,000 IU/ml) and high (> or = 600,000 IU/ml) initial viremia. METHODS AND TREATMENT REGIME: Treatment-naive patients with chronic HCV infection treated with the combination therapy of pegylated interferon-alpha2a plus ribavirin. Treatment response was evaluated at weeks 12, 24 and 48 when treatment was ongoing and at weeks 12, 24 and 48 after the treatment was finished. Commercially available sets from various manufacturers were used for serum and molecular genetic diagnostics of HCV infection. PATIENT SAMPLE: Antiviral treatment was initiated in 175 patients between 2001 and 2007. The complete data sets suitable for statistical analysis were available for 143 patients. End of treatment response and sustained viral response analyses were conducted separately for HCV genotype 1 (n = 124) and genotype 2 + 3 (n = 7). RESULTS: In the genotype 1 group, 76% of patients achieved end of treatment response and 59% of patients achieved sustained viral response. Both types of response were observed in 100% of the genotype 2 and 3 infected patients. When a correlation between initial viremia and sustained viral response was analysed, no statistically significant difference was observed between patients with low (< 600,000 IU/ml) and high (> or = 600,000 IU/ml) initial viremia. CONCLUSION: The results observed in the present study are generally slightly better than comparable results from large registration studies. In contrary to the published literature, the threshold of 600,000 IU/ml for initial viremia did not correlate statistically significantly with SVR.

[Wilson's disease]. / Wilsonova choroba.

Wilson's disease is an inherited disorder leading to accumulation of copper in tissues, mainly in the liver and brain. Genetic defect is in the gene coding ATPase type P (ATP7B). The inheritance is autosomal recessive. Up to now, more then 500 mutations causing Wilson's disease were described. The most frequent mutation in Central Europe is mutation H1069Q. The manifestation of Wilson's disease is usually hepatic or neurologic. Hepatic form is manifested by acute or chronic hepatitis, steatosis or cirrhosis. Neurologic involvement is manifested usually after 20 year of age by motor disturbances (tremor, disturbed speech, problems with writing), which could progress into severe extrapyramidal syndrome with tremor, rigidity, dysartria, dysfagia and muscle contracture. Diagnosis is based on clinical and laboratory examinations (neurologic symptoms, liver disease, low serum ceruloplasmin levels, elevated free copper concentration in serum, high urine copper excretion, and presence of Kayser-Fleischer rings). Confirmation of diagnosis is done by hepatic copper concentration in liver biopsy or by genetic examination. Untreated disease leads to the death of a patient. Treatment is based on chelating agents decreasing the copper content by excretion into urine (D-penicillamine, trientine) or on agents preventing absorption of copper from food (zinc, ammonium-tetrahiomolybdene). Patients with asymptomatic Wilson's disease have to be treated as well. In Czech Republic either penicillamine or zinc are used. Liver transplantation is indicated in patients with fulminant liver failure or decompensated cirrhosis. Screening in families of affected patients (all siblings) is obvious.

[Incidence of hiatal hernias in the current endoscopic praxis]. / Výskyt hiátové hernie v bezné endoskopické praxi.

BACKGROUND: Hiatal hernia represents penetration of the oral part of stomach together with the distal part of oesophagus via oesophageal hiatus into the thoracic cavity. On the basis of endoscopic examination hiatal hernia is defined as circular pull out of the gastric mucosa longer then 2 cm from the diaphragm to Z line, measured at the end of examination during removing the endoscope. Hiatal hernia is usually an acquired state which can worsen oesophagitis by holding refluxate and thus by prolonging the duration of purgation. METHODS AND RESULTS: Endoscopic and radiological studies show that 50 to 94 % of patients with gastroesophageal reflux disease have an axial hiatal hernia while in control persons the incidence fluctuates between 13 % and 59 %. Hiatal hernia is a frequent finding during upper gastrointestinal endoscopy. Hernia can contribute to the development of reflux into the proximal oesophagus. A cohort of one thousand patients (18 to 94 years) who underwent upper gastrointestinal endoscopy was analysed retrospectively. Endoscopy was performed between January and June 2005 at the Endoscopic center of the 4th Medical Department of the University Hospital in Prague. CONCLUSIONS: Presented study has shown that in patients who underwent endoscopy, hiatal hernia occurs in 16.6%, more frequently in men (53.6%). The most common type is an axial hiatal hernia with incidence of 94.58%. In 50% of patients with hiatal hernia the reflux oesophagitis of various degrees was diagnosed.

[Diagnostics and therapy of hepatorenal syndrome. Recommendations of of the working group on portal hypertension of the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]. / Doporuceny postup pro diagnostiku a lécbu hepatorenálního syndromu. Doporucený postup vypracovaný skupinou pro portální hypertenzi pri Ceské hepatologické spolecnosti Ceské lékarské spolecnosti J. E. Purkyne a schválený výborem Ceské hepatologické spolecnosti Ceské lékarské spolecnosti J. E. Purkyne.

Hepatorenal syndrome is a functional renal failure in patients with advanced cirrhosis and portal hypertension or acute liver failure. It is caused by extreme vasoconstriction in renal arterial bed. Type I HRS presents as an acute renal failure, while type II HRS is chronic alteration of renal function in patients with refractory ascites. Prognosis of HRS is very poor with survival reaching several weeks in patients with HRS type I. Causal treatment is liver transplantation, other treatment options include use of splanchnic vasoconstrictors (terlipressin) together with plasmaexpansion (albumin) and TIPS. It is important to exclude nephrotoxic medication (non-steroid anti inflammatory drugs, aminoglycosides) and properly treat all infective complications in prevention of HRS.

[The diagnostics and therapy of hepatic encephalopathy. Recommendations of of the working group on portal hypertension in the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]. / Diagnostika a lécba jaterní encefalopatie. Doporucený postup vypracovaný skupinou pro portální hypertenzi pri Ceské hepatologické spolecnosti Ceské lékarské spolecnosti J. E. Purkyne a schválený výborem Ceské hepatologické spolecnosti Ceské lékarské spolecnosti J. E. Purkyne.

UNLABELLED: Hepatic encephalopathy (HE) is a set of reversible neuropsychic features which occur in connection with hepatic cirrhosis or acute hepatic failure. We distinguish manifest HE (with clinical symptoms) and minimal FE (normal clinical finding, abnormal psychometric or neurophysiologic exam). The diagnosis is clinical or laboratory one. From the auxiliary examinations in common practice the number connection test is sufficient. THERAPY: Presence of hepatic encephalopathy should lead to the consideration of the possibility to solve basic disease by hepatic transplantation. Conservative therapy lies in 1. Basic disease elimination, 2. Measures lowering the ammonia level in blood--optimalization of protein intake, administration of indigestible disaccharides (lactulose, lactitol) and fill sterilisation by antibiotics (Rifaxin, Metronidazol), ornitine-aspartate administration, 3. Influencing the changes in amino acid metabolism (administration of branched chain amino acids--BCAA). Prognosis depends on the advancement of the disease, after hepatic transplantation the clinical symptoms of HE are mostly fully reversible.

[Hepatitis C viral infection at the beginning of twenty-first century]. / Infekce virem hepatitidy C na pocátku 21. století.

The article reviews basic information on the epidemiology, origin, diagnostics and therapy of hepatitis C viral infection. Virus of the hepatitis C was identified in 1989. The most frequent transmission pathway till 1992 was the reception of blood derivatives, after that year, when transfusion centres started to use detection sets to prove anti-HCV antibodies, the incidence of post-transfusion hepatitis C dropped almost to zero. The most common route of transmission at present is the intravenous toxicomany, and significant participation represents the medical care. The basic serological marker of HCV infection is the presence of anti-HCV antibodies. Those antibodies signify markers of the human contact with the virus; they need not automatically mean the encounter of infection. More often it is contrariwise--because the C viral hepatitis develops the chronic stadium up in 85%, the anti-HVC positivity signifies usually the active form of infection. To prove the active form of infection it is necessary to identify viral nucleic acids in the serum of the examined patient. The standard therapy of the chronic form of the C viral hepatitis is at present a combination of pegylated interpherons alpha and ribavirin. Such form of therapy can result the permanent elimination of the virus in about 60% of cases. In the C viral hepatitis neither the specific pre-exposition nor post-exposition prophylaxis is available. The only prevention of the transmission of infection is the avoidance of any risk factor of transmission, namely in the medical care.

[Long-term pharmacological treatment of portal hypertension]. / Dlouhodobá farmakologická lécba portální hypertenze.

Portal hypertension is an unavoidable complication of liver cirrhosis, which usually limits the survival (bleeding from esophageal varices, ascites). Increase in portal pressure is not only due to mechanical obstruction of portal circulation, but there is also a dynamic component (endothelial dysfunction of hepatic microcirculation) and increased blood flow through the splanchnic circulation. For the long-term treatment of portal hypertension two groups of medicaments are available at present: non-selective betablockers (vasoconstriction in splanchnic bed) and nitrates (lowering of intrahepatic resistance). Long-term treatment is necessary in these situations: Primary prophylaxis of bleeding from esophageal varices (in patients, who never bled, but with "risk" varices)--non-selective betablockers; secondary prophylaxis (in patients after variceal bleeding)--non-selective betablockers (possibly with nitrates) or endoscopic treatment. It is clearly documented, that this treatment lowers the risk of the first or repeated bleeding from varices and hence lowers the mortality and morbidity due to this complication in patients with liver cirrhosis. Another serious complication of liver cirrhosis is the spontaneous bacterial peritonitis. All patients after that infection have to receive prophylactic treatment with antibiotics. This treatment should be long life, till the disappearance of ascites or till the liver transplantation.

[Diagnostics and treatment of hepatocellular carcinoma. Recommendations of the Portal Hypertension Working Group of the Czech Hepatology Society and the J.E. Purkinje Czech Medical Society ]. / Diagnostika a lécba hepatocelulárního karcinomu.

Hepatocellular carcionma (HCC) is almost exclusively associated with liver cirrhosis as a significant HCC risk marker in advanced countries. Applicable therapy depends on early diagnosis, and risk patients should be screened for the presence of HCC on a regular basis. Liver ultrasound and determination of alpha-fetoprotein serum levels (AFP) are the screening methods used. Spiral CT is the most often used method for HCC staging. Non-invasive methods may under certain circumstances replace aimed biopsy. There are 3 basic curative therapies for the early stage of HCC: liver transplantation, surgical resection and different methods of local destruction of tumour (i.e., ethanolisation, thermoablation, etc.). Patients at medium stage of HCC may profit from chemoembolisation. Current available systemic chemotherapy is ineffective. Patients with advanced HCC are treated symptomatically. Patient survival prognosis after the application of one of the above treatment methods may be similar with that for HCC free cirrhosis patients, however, prognosis for advanced HCC patients is bad, with survival period from one to nine months.

[Jejunal perforation by a plastic biliary stent after injury]. / Perforace jejuna plastovým biliárním stentem po úrazu.

The authors present case of patient with biliary stent dislocation after chest injury and fracture of VIII. rib. Polymorbid patient with cirrhosis, chronic pancreatitis, portal hypertension (Child Plugh B) and biliary stent insertion came with acute abdominal pain and inflammatory signs. Progressive signs of acute abdomen have led to laparotomy. Perforation of duodeno-jejunal-loop due to dislocated biliary stent, small loop adhesions and thickened intestine wall were found. Postsurgical period was complicated with obstructive ileus, cholecystitis and cholangiolitis and the second biliary stent was inserted. Present-day status of the patient is satisfactory.

[Transhepatic cholangioscopy in the treatment of choledocholithiasis]. / Transhepatální cholangioskopie v lécbe choledocholitiázy.

Endoscopic methods gained the leading position in the treatment of choledocholithiasis. Transhepatic cholangioscopy and contact lithotripsy is used, if standards methods (ERC) are not successful. The transhepatic approach is predominantly used for the therapy of complicated choledocholithiasis. Cholangioscopy and lithotripsy can be performed after PTC, external drainage of bile ducts and dilatation of intrahepatic channel. The success rate for transhepatic methods is 90 to 100%, the major complication rate is 5 to 7.5%.

Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding.

BACKGROUND/AIMS: 1) To compare the effect of 2-day application of 0.2 mg terlipressin i.v. every 4 hours (group I) with that of 5-day application of 1 mg i.v. every 4 hours (group II) in the treatment of bleeding esophageal varices and portal gastropathy. 2) To assess the incidence of adverse events. METHODOLOGY: Eighty-six patients with liver cirrhosis (54 men and 32 women, average age 51 years) were randomized over a period of 2 years into 2 groups. Acute bleeding was diagnosed endoscopically within 24 hours of its onset. The two groups fully comparable; treatment failure rated according to "Baveno II". RESULTS: Success rate in group I was 78% at day 2 and 75% at day 5; in group II 89% and 79%, respectively (no statistical significance). Rebleeding had occurred by day 5 in 15% in group I, and in 16.3% in group II. Transfusion needs by day 2 were significantly lower in group II (2.4 units compare to 3.4 units in I). The 30-day mortality was 17.1% in group I and 20% in group II. No statistical difference between I and II in the occurrence of adverse events. CONCLUSIONS: At a dosage of 1 mg i.v. every 4 hours, the success rate at day 2 was as much as 90% while blood consumption was significantly lower compared with the lower dosage. Rebleeding during first 48 hours occurred almost exclusively at lower dosage. There was no increase in the rate of adverse events relative to the higher dosage.

[Risk factors for transmission of hepatitis C in the the Czech population]. / Rizikové faktory prenosu viru hepatitidy C (HCV) v ceské populaci.

BACKGROUND: Recent reports from all over the world have repeatedly indicated a change in the incidence of individual risk factors for hepatitis C virus (HCV) infection transmission compared with the pattern in the late 1980s and early 1990s. In the Czech Republic, HCV is very often referred to as an addicts' disease, rare in the general population. To establish the incidence of individual risk factors for HCV infection transmission in a group of patients on follow-up at the Department of Internal Medicine I. General University Hospital in Prague 2. METHODS AND RESULTS: The group of patients included 216 individuals (127 men, 89 women) with documented HCV infection. The mean age of the patients was 40.2 years (10-81 years; SD 14.3). The risk factors were identified on the basis of evaluation of the patient's medical history, and/or their medical records if available. The presence of at least one of the following risk factors was regarded as the source of infection (the figure in brackets gives the incidence of the respective factor in the examined group in percent): blood product transmission (15%), intravenous drug injection (16%), inclusion into a regular dialysis program (12%), profession-related risk of transmission (10%), sexual contact with an infected individual (2%), surgery including dental surgery (14%), invasive examination (6%), and tattooing (1%). No risk factor for infection transmission was identified in 24% of cases. CONCLUSIONS: It has been shown a risk factor for infection transmission can be identified, through careful examination of medical history data, in the Czech population in as much as 76% of cases. An important finding is the fact the infection can be regarded as iatrogenic in as much as 57% of cases. Our data clearly show HCV infection is not exclusively a disease of intravenous drug addicts.

[Importance of liver biopsy in chronic hepatitis C virus infection]. / Význam jaterní biopsie pri chronické infekci virem hepatitidy C.

INTRODUCTION: The importance of liver biopsy and knowledge of the histological activity of liver les on in chronic hepatitis C virus (HCV) infections is widely discussed recently. There are attempts to find an alternative evaluation which will make it possible to avoid liver biopsy. The crucial question in patients with chronic HCV infection is to differentiate patients with already developed liver cirrhosis from those with chronic hepatitis. OBJECTIVES: 1. To evaluate the impact of the calculation of the discrimination score of liver cirrhosis (DSC) for prediction of liver cirrhosis in the histological assessment. 2. To assess the correlation of prediction of cirrhosis liver based on clinical signs and actual histological verification. 3. To evaluate the frequency of unexpected histological findings not correlating with the clinical picture. GROUP OF PATIENTS: The group was formed by 139 patients. In all patients during the baseline examination the patient's history data were analyzed as well as possible physical signs of liver cirrhosis. In all patients also, based on laboratory values before liver biopsy, the DSC according to Bonacini was calculated. Furthermore agreement between the histological finding of liver cirrhosis and chronic hepatitis with DSC values was assessed. RESULTS: 1. Based on calculation of DSC it is possible to predict accurately the existence of cirrhosis of the liver or chronic hepatitis only in 31% patients. In 69% patients even comprehensive evaluation of the type of DSC is not a sufficient guide for assessment of the hepatic lesion. 2. Even clinical signs of cirrhosis are not a quite reliable guide for its prediction. In 8% patients of our group the histological finding of liver cirrhosis was a surprise and in 3.5% patients cirrhosis of the liver was not confirmed despite the presence of clinical signs. 3. The frequency of other histological findings participating in the development of the hepatic lesion in chronic HCV infection was minimal. In the authors group as such only steatosis and toxic damage of hepatic tissue by alcohol were identified. These findings were, however, suspected already before biopsy. Steatosis can be however considered also a manifestation of HCV infection. CONCLUSION: The results of the trial support the view that liver biopsy is in the majority of cases irreplaceable for evaluation of the severity of the hepatic affection in chronic HCV infection.

[Double blind randomized multicentre study of a seven-day eradication regime of Helicobacter pylori by omeprazole, clarithromycin and ornidazole vs. omeprazole, clarithromycin and metronidazole]. / Dvojite slepá, randomizovaná multicentrická studie 7denního eradikacního rezimu Helicobacter pylori omeprazolem, clarithromycinem a ornidazolem vs. omeprazolem, clarithomycinem a metronidazolem.

Effective eradication regimes of Helicobacter pylori infections are nowadays based on administration of a substance with a strong suppressive effect on production of gastric HCl combined with two antibiotics. As suppressor of gastric HCl production unequivocally some drug from the group of proton pump blockers is used. As to antibiotics, in first line therapy the following are recommended: clarithromycin, amoxicillin, metronidazole. A problem in the eradication therapy of Helicobacter pylori infection in recent years is the increasing resistance to clarithromycin and apparently also metronidazole. In the Czech Republic the resistance to clarithromycin in relation to Helicobacter pylori is stabilized at a level lower than 3.0 %. Resistance to metronidazole was reported in 1992 within the range of 24 % - 26 %, however in 2001 it was already 36.0 %. Therefore the question arises whether it is possible under our conditions to check the increasing metronidazole resistance by a drug which by its spectrum of action resembles metronidazole while it differs from it as to its chemical structure. This is the reason why the authors implemented a trial where metronidazole was replaced by tinodazole (Avrazor, Léciva Co.). The results revealed that in the group treated with tinidazole eradication was achieved after 7-day administration of ornidazole in 93.0 %, in the group where part of the eradication regime was metronidazole eradication was 82.6 %. The tolerance of both drugs was very good. The authors recommend to include the pattern omeprazole 2 x 20 mg, clarithromycin 2 x 500 mg and tinidazole 2 x 500 mg among first line therapeutic regimes.