Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report.

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in the various clinical scenarios.

Review article: the effects of antitumour necrosis factor-α on bone metabolism in inflammatory bowel disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of osteoporosis. A number of studies have emerged in recent years indicating that tumour necrosis factor (TNF) blockade appears to have a beneficial effect on bone mineral density (BMD) in IBD patients. AIMS: To provide a review of the available data regarding the effect of the currently licensed anti-TNF-α therapies on bone metabolism and BMD in IBD patients. METHODS: A Medline search was performed using the search terms 'infliximab', 'bone metabolism', 'IBD', 'BMD', 'bone markers', 'adalimumab', 'bone disease', 'Crohn's disease' and 'ulcerative colitis'. RESULTS: Infliximab has a beneficial effect on bone turnover markers in Crohn's disease (CD) patients in the short term. The longest study to date comprising 24 CD patients showed an overall improvement in two bone formation markers - b-alkaline phosphatase (P = 0.022) and osteocalcin (P = 0.008) at 4 months post-treatment. Moreover, the largest study to date comprising 71 CD patients showed significant improvement in sCTx, a bone resorption marker (P = 0.04) at week-8 post-treatment. There is little data looking at the effect of anti-TNF-α therapy on bone metabolism in ulcerative colitis. Moreover, the long-term effects of anti-TNF-α therapy on bone structure and fracture risk in IBD patients are currently not known. The effect of cessation of anti-TNF-α therapy on bone metabolism is also unknown. CONCLUSION: Properly controlled long-term trials are needed to fully evaluate the impact of TNF blockade on bone mineral density.

Computer-assisted propofol administration.

The use of propofol for sedation in endoscopy may allow for better quality of sedation, quicker recovery and facilitate greater throughput in endoscopy units. The cost-effectiveness and utility of propofol sedation for endoscopic procedures is contingent on the personnel and resources required to carry out the procedure. Computer-based platforms are based on the patients response to stimulation and physiologic parameters. They offer an appealing means of delivering safe and effective doses of propofol. One such means is the bispectral index where continuous EEG recordings are used to assess the degree of sedation. Another is the closed-loop target-controlled system where a set of physical parameters, such as muscle relaxation and auditory-evoked potential, determine a level of medication appropriate to achieve sedation. Patient-controlled platforms may also be used. These electronic adjuncts may help endoscopists who wish to adopt propofol sedation to change current practices with greater confidence.

Early diagnosis of bilateral sub-deltoid bursitis using clinic-based ultrasonography in a patient receiving infliximab therapy for ulcerative pouchitis.

BACKGROUND: Infliximab, a monoclonal chimeric antibody to tumour necrosis factor (TNF)α, is a novel therapy used in the management of chronic refractory pouchitis that is unresponsive to conventional medical therapy. METHODS: This report describes a case of non-infective bursitis following infliximab therapy and documents the role of musculoskeletal ultrasound in detecting soft tissue fluid collections and in guiding aspiration. CONCLUSION: A high index of suspicion is required when assessing new or worsening musculoskeletal pain in patients receiving infliximab and involvement of a rheumatologist at an early stage is essential in order to appropriately diagnose and manage this condition.

Significant psychological morbidity occurs in irritable bowel syndrome: a case-control study using a pharmacy reimbursement database.

BACKGROUND: Psychological problems are associated with IBS but the strength of this association is unclear. AIM: To assess co-prescribing of antispasmodic and CNS-acting drugs through a nested case-control study. METHODS: A national dispensing database identified patients who were first dispensed antispasmodic medicines for a continuous 3-month period or more during 2006, using 2005 as a run-in period. Each patient was matched with four control patients and excluded if they received drugs indicated for IBD. RESULTS: Four hundred and seven patients commenced antispasmodic drugs during 2006. These patients were matched with 1628 controls. In 2005, patients subsequently prescribed antispasmodics were 2-3 times more likely to receive CNS-acting drugs than controls. In the year following commencement of IBS therapy, patients were 2-4 times more likely than controls to be prescribed CNS-acting drugs including antidepressants (35.4% vs. 9.3%), anxiolytics (27.8% vs. 8.8%), antipsychotics (9.8% vs. 3.3%) and hypno-sedatives (32.7% vs. 11.3%; P < 0.0001). The adjusted OR (95% CI) for antidepressant, anxiolytic, hypnosedative and antipsychotic prescribing in IBS patients were 3.81 (2.79-5.20), 2.84 (2.12-3.81), 2.62 (1.91-3.60) and 2.58 (1.80-3.66), respectively. CONCLUSIONS: Patients prescribed ongoing therapy for presumed IBS are 2-4 times more likely to be prescribed CNS-acting drugs than controls, providing evidence of psychological comorbidity in IBS.

Use of Infliximab as rescue therapy in acute severe Ulcerative Colitis with recent norovirus infection.

BACKGROUND AND AIMS: Norovirus infection is a common cause of acute diarrhoeal illness and may occur in the setting of inflammatory bowel disease. METHODS: A patient with an acute severe first presentation of Ulcerative Colitis failed to settle with intravenous steroids and rescue therapy was considered. The isolation of norovirus in his stool caused concern about aggravating the infection if immunosuppression ensued. Following a brief period of watchful waiting and a full discussion between physician, surgeon and patient, Infliximab was administered (5 mg/kg). RESULTS: The patient responded well both clinically and biochemically. CONCLUSIONS: In this case, Infliximab was a safe and efficacious intervention in a patient with acute Ulcerative Colitis and recent norovirus infection.

The role of capsule endoscopy in small bowel Crohn's disease.

UNLABELLED: Video capsule endoscopy is an invaluable tool for examining the small bowel. It is non-invasive and generally well tolerated, however its role in the assessment of the severity and extent of small bowel Crohn's disease has not, to date, been adequately evaluated. METHODS: All capsule endoscopies performed over a two year period in a tertiary referral centre in subjects with known or suspected Crohn's disease were reviewed. RESULTS: Twenty-six capsule endoscopy studies in total were included. These were performed in 15 cases of known Crohn's disease, 5 cases of suspected Crohn's disease, 3 cases of endoscopically diagnosed non-specific terminal ileal inflammation and finally 3 post colectomy cases of indeterminant being considered for IPAA formation. Ten patients known to have small bowel Crohn's disease were prospectively recruited; of 3 with normal small bowel follow through or CT exams, one had an abnormal capsule endoscopy. The other 7 patients had small bowel follow through or abdominal CT scans consistent with small bowel Crohn's disease; additional mucosal abnormalities were detected by capsule endoscopy in 6 cases with capsule retention in the stomach in one. Of 5 with colonic Crohn's disease normal small bowel imaging corresponded with normal capsule endoscopy in all but one. A diagnosis of Crohn's disease was made in 2 out of 5 cases of suspected Crohn's disease on the basis of the capsule endoscopy findings. Three patients with non-specific acute terminal ileal inflammation at ileocolonoscopy were confirmed to have ongoing inflammation. The capsule was retained in four subjects beyond 24 h. CONCLUSION: Capsule endoscopy more accurately determines the severity and extent of the Crohn's disease in the small bowel than traditional imaging modalities.

What is new in the management of Helicobacter pylori?

Since the discovery of Helicobacter pylori in the early 1980s several treatment regimens have been developed to effectively treat this infection. International guidelines have allowed consensus on the best management and improved eradication rates. In recent years increasing antimicrobial resistance and falling eradication rates highlight the need for updated guidelines. In this article we review the most recent European management guidelines and in view of the unavailability of some drugs consider new treatment regimens for the management of H. pylori in Ireland.

Treatment of Helicobacter pylori.

Since the discovery of Helicobacter pylori in the early 1980s many treatment regimes have been developed to effectively treat this infection. International guidelines have allowed consensus on the best management and improved eradication rates. In recent years, increasing antimicrobial resistance has resulted in falling eradication rates with standard therapies. In this article, we review the most recent studies and guidelines in the treatment of H. pylori. Currently, the first-line treatment remains clarithromycin, amoxicillin or metronidazole and proton pump inhibitor twice daily, but a number of recent studies have shown low eradication rates with this treatment. Increased duration of therapy has been recommended to overcome the falling eradication rates. However, conflicting findings have been reported on the benefits of extending the length of traditional therapy. Sequential therapy may be an effective alternative to standard triple therapy in regions of increased antimicrobial resistance. Probiotics reduce side-effects from traditional regimens and may improve eradication rates. A quinolone-based second-line triple therapy appears to be effective and well tolerated. Bismuth-based quadruple therapy is also an effective alternative if available. In the future, regional antimicrobial resistance and eradication rates will determine the best treatment for H. pylori.

Impact of Helicobacter pylori on the management of dyspepsia in primary care.

BACKGROUND: It is unclear what impact Helicobacter pylori infection has had on the management of dyspepsia in primary care and to what extent published guidelines on H. pylori are implemented in routine clinical practice. AIM: To assess the impact of H. pylori infection on the management of dyspepsia in primary care. METHODS: Patients referred by primary care doctors to an open-access 13-carbon urea breath test service over a 2-year period for their first urea breath test were included in the study. Individual breath results were linked with data on prescribing obtained from the General Medical Services prescription database. RESULTS: Of 805 patients, 374 (47%) had a positive urea breath test and 431 (54%) a negative urea breath test. Of positive urea breath test patients, only 245 (64%) were prescribed eradication therapy in the 3 months after the breath test and only 43% were referred back for re-testing. In the year after the urea breath test, there was a significant fall in prescribing of antisecretory therapy which was greatest in the patients who received H. pylori therapy (P < 0.001). CONCLUSIONS: There appears to be under and inappropriate treatment of H. pylori infection in primary care, and a low rate of re-testing after eradication, indicating that current guidelines are not well implemented in practice.

Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia (watermelon stomach): long-term results.

INTRODUCTION: Gastric antral vascular ectasia is a rare but well-recognised cause of occult gastrointestinal bleeding. Various endoscopic treatments have been tried in this condition. We report our experience with argon plasma coagulation in the treatment of gastric antral vascular ectasia. PATIENTS AND METHODS: Twelve patients with endoscopically proved gastric antral vascular ectasia were included. All patients received argon plasma coagulation with power of 40 W at a median interval of 4 weeks. The pre-treatment haemoglobin and transfusion requirements were compared with the post-treatment values. RESULTS: There was a sustained increase in mean haemoglobin levels post-treatment. The mean haemoglobin levels pre- and post-treatment were 8.13 +/- 0.70 and 12.2 +/- 0.32 g/dl, respectively (P = 0.008). All patients were anaemic and 58.3% of the patients were transfusion dependent. The mean number of units of blood transfusion in the period 6 months prior to treatment was 11.3 +/- 5.68. Following argon plasma coagulation, the number of transfusions decreased significantly to 1.1 +/- 0.57 units (P = 0.018). No significant procedure-related complications were identified. CONCLUSION: Argon plasma coagulation is a safe and effective alternative to the currently available endoscopic modalities of treatment for gastric antral vascular ectasia.

Review article: current therapeutic options for gastric antral vascular ectasia.

Gastric antral vascular ectasia, or 'watermelon stomach', is a rare but important cause of gastrointestinal blood loss and anaemia, which has characteristic endoscopic and histological features. The pathogenesis of this condition remains unclear; however, many associated disorders have been documented. Various medical, surgical and endoscopic therapeutic modalities have been attempted with variable success. Leading contenders for the therapeutic modality of choice include hormonal therapy, endoscopic Nd:YAG laser and argon plasma coagulation. Randomized controlled trials to identify the ideal treatment method are lacking at present.

Review article: test and treat or test and scope for Helicobacter pylori infection. Any change in gastric cancer prevention?

A 'test and treat' strategy is advocated for patients with dyspepsia under the age of 45 years, with endoscopy reserved for those with alarm symptoms or aged over 45 years. One of the consequences of this strategy will be a reduction in population infection rates of Helicobacter pylori. It is now clear that H. pylori is one of the prime initiators of gastric cancer with up to 70% of gastric cancers attributable to H. pylori. What remains unclear is if H. pylori reduction will lead to a reduction in gastric cancer.

Clinical and pathological implications of IgG antibody responses to Helicobacter pylori and its virulence factors in non-ulcer dyspepsia.

AIM: To determine whether pre-treatment antibody response to Helicobacter pylori virulence factors predicts eradication success and symptom relief 12 months after triple therapy in non-ulcer dyspepsia. METHODS: H. pylori-positive patients with non-ulcer dyspepsia received 1-week omeprazole-based triple therapy, or omeprazole plus placebos. Symptoms were assessed using a validated Likert scale. Gastric biopsies taken before and 12 months after treatment were used for histological examination. Pre-treatment blood samples were used for the detection of anti-H. pylori immunoglobulin G (IgG) antibodies, and specific IgG antibodies to 19.5-, 26.5-, 30-, 35-, 89- (VacA) and 116-kDa (CagA) antigens of H. pylori. RESULTS: IgG antibodies to the six antigens were detected in 62%, 96%, 88%, 47%, 54% and 78% of patients, respectively. The presence of antibody to 19.5-, 26.5- or 30-kDa antigen was associated with an increased anti-H. pylori IgG absorbance index. IgG absorbance indices were greater in those with H. pylori eradication (vs. persistent infection). The prevalence of antibodies to the six antigens was not significantly different between those with symptom relief vs. those without. The 19.5-kDa antigen (P = 0.018) and VacA (P = 0.001) were independent risk factors for body gastritis. CONCLUSIONS: An increased pre-treatment anti-H. pylori IgG absorbance index may be a useful predictor of the success of eradication therapy. Although the 19.5-kDa antigen and VacA were associated with body gastritis, none of the six antigens tested predicted symptom relief after triple therapy.

Review article: nutrition and adult inflammatory bowel disease.

Major advances in the understanding of the aetio-pathogenesis and genetics of inflammatory bowel disease have been accompanied by an escalation in the sophistication of immunomodulatory inflammatory bowel disease therapeutics. However, the basic 'triple' therapy (5-aminosalicylates, corticosteroids, azathioprine) and nutrition have maintained their central role in the management of patients with inflammatory bowel disease over recent decades. This review provides an overview of the supportive and therapeutic perspectives of nutrition in adult inflammatory bowel disease. The objective of supportive nutrition is to correct malnutrition in terms of calorie intake or specific macro- or micronutrients. Of particular clinical relevance is deficiency in calcium, vitamin D, folate, vitamin B12 and zinc. There is justifiably a growing sense of unease amongst clinicians and patients with regard to the long-term use of corticosteroids in inflammatory bowel disease. This, rather than arguments about efficacy, should be the catalyst for revisiting the use of enteral nutrition as primary treatment in Crohn's disease. Treatment failure is usually related to a failure to comply with enteral nutrition. Potential factors that militate against successful completion of enteral nutrition are feed palatability, inability to stay on a solid-free diet for weeks, social inconvenience and transient feed-related adverse reactions. Actions that can be taken to improve treatment outcome include the provision of good support from dietitians and clinicians for the duration of treatment and the subsequent 'weaning' period. There is evidence to support a gradual return to a normal diet through exclusion-re-introduction or other dietary regimen following the completion of enteral nutrition to increase remission rates. We also review the evidence for emerging therapies, such as glutamine, growth factors and short-chain fatty acids. The future may see the evolution of enteral nutrition into an important therapeutic strategy, and the design of a 'Crohn's disease-specific formulation' that is individually tailored, acceptable to patients, cost-effective, free from adverse side-effects and combines enteral nutrition with novel pre- and pro-biotics and other factors.

Appropriateness of gastric antisecretory therapy in hospital practice.

BACKGROUND: Recent data indicate an exponential increase in proton pump inhibitor (PPI) prescribing, and concerns are raised regarding the appropriateness of these prescriptions and the financial implications. AIM: To survey the appropriateness of PPI prescription in a cohort of patients in a tertiary referral hospital. METHODS: Prescription records of all inpatients on a randomly selected day were reviewed. The appropriateness of prescription and relevant investigations were identified by interview of patients, review of patient records and of a computerised endoscopy records system. RESULTS: Thirty-two per cent (87 of 272) of all patients were on PPIs. A valid indication for therapy was not apparent in 63% of the patients on PPIs with the only predictive factor for inappropriate prescription being increasing age. Only 36 of the 87 patients on PPIs had undergone appropriate investigations for their gastrointestinal symptoms. Gender, age, speciality of admission or duration of hospital stay did not influence the appropriateness of prescription or performance of relevant investigations. CONCLUSION: There appears to be a widespread and inappropriate use of PPIs in hospital practice.

Review article: treatment of Helicobacter pylori infection and factors influencing eradication.

Currently available Helicobacter pylori eradication therapies are considered very effective and safe. The most recent eradication guidelines proposed in the Maastricht 2-2000 Consensus Report recommend the use of proton pump inhibitors (standard b.d.) along with clarithromycin (500 mg b.d.) and amoxycillin (1000 mg b.d.) or metronidazole (500 mg b.d.) for a minimum of 7 days. The combination of amoxycillin and clarithromycin is preferred because it may favour best results with a second-line proton pump inhibitor quadruple therapy. The recommended second-line therapy includes a combination of a proton pump inhibitor (standard b.d.) with bismuth salt (subsalicylate/subcitrate 120 mg q.d.s.), metronidazole (500 mg t.d.s.), and tetracycline (500 mg q.d.s.) for a minimum of 7 days. Extended proton pump inhibitor-based triple therapy can be used if bismuth is not available. Specialists should manage subsequent failures. Based on direct and indirect evidence from well-designed studies and clinical experience, eradication is recommended in gastric and duodenal ulcers, MALToma, atrophic gastritis, postgastric cancer resection, and in first-degree relatives of gastric cancer patients. The most common reason for treatment failure is poor compliance with eradication guidelines. Antibiotic resistance may be a significant factor in certain geographical areas. Proton pump inhibitors are an integral part of the eradication regimens as proved by meta-analyses of clinical trials. Novel agents used in secondary failure are few and depend on the use of new antibiotics. The role of H. pylori-specific antibiotics, probiotics, and vaccines is not established as yet. Widespread acceptance of the eradication guidelines should be regarded as the single most important factor in eradication success.