Helicobacter pylori test-and-eradicate versus prompt endoscopy for management of dyspeptic patients: a randomised trial.

BACKGROUND: Strategies based on screening for Helicobacter pylori to manage dyspeptic patients in primary care have been proposed, but the clinical consequences are unclear. We did a randomised trial to assess the efficacy and safety of a test-and-eradicate strategy compared with prompt endoscopy in the management of patients with dyspepsia. METHODS: 500 patients presenting in primary care with dyspepsia (> or = 2 weeks of epigastric pain, no alarm symptoms) were assigned H. pylori testing plus eradication therapy or endoscopy. Symptoms, quality of life, patients' satisfaction, and use of resources were recorded during 1 year of follow-up. FINDINGS: 250 patients were assigned test-and-eradicate, and 250 prompt endoscopy. The median age was 45 years and 28% were H. pylori infected. 1 year follow-up was completed by 447 patients. We found no differences in symptoms between the two groups (median registered days without dyspeptic symptoms=0.63 [IQR 0.27-0.81] in the test-and-eradicate group vs 0.67 [0.36-0.86] in the prompt endoscopy group; mean difference 0.04 [95% CI -0.01-0.10], p=0.12). Nor did we find any difference in quality of life or numbers of sick-leave days, visits to general practitioners, or hospital admissions. In the test-and-eradicate group, 27 (12%) of the patients were dissatisfied with management, compared with eight (4%) in the endoscopy group (p=0.013). After 1 year, the use of endoscopies in the test-and-eradicate group was 0.40 times (95% CI 0.31-0.51) the use in the endoscopy group, the use of H. pylori tests increased by a factor of 8.1 (5.7-13.1), the use of eradication treatments increased by a factor of 1.5 (0.9-2.7), and the use of proton-pump inhibitors was 0.89 (0.59-1.33) times the use in the endoscopy group. 43 (91% [80-98%]) of 47 peptic-ulcer patients would have been identified by endoscopy or treated by eradication therapy. INTERPRETATION: A H. pylori test-and-eradicate strategy is as efficient and safe as prompt endoscopy for management of dyspeptic patients in primary care, although fewer patients are satisfied with their treatment.

Endoscopic sphincterotomy for common bile duct stones in younger patients.

BACKGROUND AND STUDY AIMS: Most follow-up studies of patients with common bile duct stones treated with endoscopic sphincterotomy include older patients. Therefore, the aim of the present study was to do a medium-term follow-up of patients under the age of 60 years, who underwent endoscopic sphincterotomy and removal of common bile duct stones. METHODS: Eighty-six (68 women) consecutive patients less than 60 years of age (median age 47 years) were evaluated. The median observation time after endoscopic sphincterotomy was 27.1 months. Complete follow-up was accomplished in 80 patients. RESULTS: Twenty-five patients had undergone cholecystectomy prior to the endoscopic sphincterotomy. Sixty-one patients were discharged after endoscopic sphincterotomy with gallbladder left in situ. Cholecystectomy was not needed in 27 patients, of whom 23 had gallbladder stones. In 13 of 61 patients subsequent elective cholecystectomy was planned at the time of endoscopic sphincterotomy. Recurrent attacks of biliary colic required elective cholecystectomy in another thirteen patients. Acute cholecystectomy was undertaken in eight patients due to acute cholecystitis (n = 4) or biliary colic (n = 4). Seven of eight acute cholecystectomies were performed within 152 days after the endoscopic sphincterotomy. The overall median time until cholecystectomy was 51 days (25-75 percentiles, 23-103 days). CONCLUSIONS: One third of the patients had been cholecystectomized prior to the endoscopic treatment of their common bile duct stones. Nearly half of the young patients discharged after endoscopic sphincterotomy for common bile duct stones with the gallbladder left in situ at the time of endoscopic sphincterotomy managed well without any need for cholecystectomy.

Randomized trial of stent placed above and across the sphincter of Oddi in malignant bile duct obstruction.

BACKGROUND: Placement of stents above an intact sphincter of Oddi might prevent migration of bacteria and deposition of organic material into the stent. In patients with malignant obstructive jaundice prolongation of function time of the stent would be expected if it is placed above the sphincter of Oddi. METHODS: Thirty-four patients were randomized to stent placement either above (n = 17) or across (n = 17) the sphincter of Oddi. Straight 10F gauge Teflon stents were used. The patients were evaluated clinically and biochemically at monthly intervals during follow-up. RESULTS: The median stent function time (i.e., the time from insertion of the stent until stent replacement, patient death, or study termination) were 110 days (25th to 75th percentiles, 61 to 320 days) for stents placed above the sphincter of Oddi and 126 days (25th to 75th percentiles, 89 to 175 days) for stents placed across the sphincter of Oddi (nonsignificant [NS]). Stent replacement rates were 58.8% (10 of 17) in patients with stents placed above the sphincter and 29.4% (5 of 17) in patients with stents placed across the sphincter (NS). Significantly more patients in the former group experienced stent migration (9 vs. 2, p = 0.026). The median time from stent insertion until replacement of the stents placed above and across the sphincter of Oddi were 82 days (25th to 75th percentiles, 31 to 185 days) and 89 days (25th to 75th percentiles, 13 to 150 days), respectively (NS). CONCLUSIONS: No significant difference in overall stent performance between the two groups was found, although more stents placed above the sphincter of Oddi migrated. The time until dysfunction of the stent might be increased if migration of stents placed inside the common bile duct could be avoided.

[Choledocholithiasis. Endoscopic treatment of 416 consecutive patients]. / Choledocholitiasis. Endoskopisk behandling af 416 konsekutive patienter.

Endoscopic extraction of calculi in the common bile duct has been the treatment of choice for many years. According to international standards a stone-free common bile duct should be achieved in at least 90% of the patients and with an overall complication rate below 20%. We reviewed records of 416 patients who underwent ERC for common bile duct stones between January 1990 and January 1995. The overall success rate of achieving a common bile duct free of stones was 89.0%, and in 94.7% of the patients endoscopic treatment was definitive. The overall complication rate was 9.6% and the 30-day mortality rate was 2.2%. Our study showed that with a medical staff of four to six persons (of which two were trainees), approximately 450 ERCP-examinations per year and with a catchment area of half a million inhabitants (Funen County), it was possible to achieve acceptable results.

Idiopathic pulmonary haemosiderosis. Epidemiology, pathogenic aspects and diagnosis.

Idiopathic pulmonary haemosiderosis (IPH) is a rare clinical entity characterized by recurrent episodes of diffuse alveolar haemorrhage, often presenting with haemoptysis. Many patients have iron deficiency anaemia due to deposition of haemosiderin iron in the alveoli, and eventually develop moderate pulmonary fibrosis. Typically, intensive search for an aetiology ends up negative. There is no evidence of pulmonary vasculitis or capillaritis. The aetiology is obscure, but may be an immunological or toxic mechanism causing a defect in the basement membrane of the pulmonary capillary. IPH affects both children and adults. During an acute episode, a chest X-ray demonstrates bilateral, alveolar infiltrates. Sputum examination discloses haemosiderin-laden alveolar macrophages. Diagnosis is established by lung biopsy (fiber-optic or thoracoscopic), showing large numbers of haemosiderin-laden macrophages in the alveoli and without evidence of capillaritis or deposition of immunoglobulins. Corticosteroids and/or immunosuppressive drugs may be effective during an acute bleeding episode, and may in some patients improve symptoms and prognosis on the long-term, but the response to treatment displays great interindividual variation.

Recovery characteristics of sevoflurane- or propofol-based anaesthesia for day-care surgery.

BACKGROUND: Sevoflurane has a low blood-gas partition coefficient resulting in a rapid recovery. Few studies have examined the maintenance and recovery characteristics of sevoflurane compared with propofol in a standardized outpatient population. METHODS: The study was a multicentre study performed in 10 centres. One hundred and sixty-nine elective outpatients due for knee-arthroscopy received 100 mg diclofenac rectally as pain prophylaxis prior to induction of general anaesthesia with fentanyl 1.0-1.5 micrograms/kg + propofol 2.0-2.5 mg/kg i.v. Anaesthesia was maintained with 60% nitrous oxide in oxygen through a laryngeal mask and continuous administration of either: sevoflurane (group S) or propofol infusion (group P) in order to maintain stable haemodynamics. Data of postoperative function and side-effects were collected in a double-blind design, including a patient interview after 24 h. RESULTS: The sevoflurane patients had a significantly faster emergence from anaesthesia, with response to commands at 6.9 +/- 0.4 min versus 8.2 +/- 0.4 min in the propofol group (P < 0.05, mean +/- SD). At 15 min after surgery, group S had a better score in the digit symbol substitution test and felt less confused in a visual analogue scale test compared with group P (P < 0.05). Peroperative bradycardia, nausea and vomiting and late postoperative dizziness were more common in group S. In the sevoflurane group, 32% had nausea or vomiting in the 24 h observation period compared with 18% for propofol (P < 0.05). There was no difference between group S and group P in postoperative pain, eligibility for recovery room discharge (75 +/- 12 versus 70 +/- 11 min) or home-readiness (155 +/- 12 versus 143 +/- 11 min). CONCLUSION: Maintenance of anaesthesia with sevoflurane results in a more rapid emergence, but a higher incidence of nausea and vomiting compared with propofol. The side-effects were minor in our study, and did not result in any difference in time to discharge from the recovery ward or the hospital.

[Idiopathic pulmonary hemosiderosis]. / Idiopatisk pulmonal haemosiderose.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease characterized by recurrent episodes of intrapulmonary bleeding, chronic iron deficiency anaemia and pulmonary fibrosis. IPH is a diagnosis made by exclusion of other causes. It occurs in both adults and children. Other conditions than IPH can cause pulmonary haemosiderosis. The etiology is unknown, but might be an immunological mechanism causing a defect in the basement membrane of the pulmonary capillary. IPH should be suspected in patients with recurrent episodes of coughing, haemoptysis, dyspnoea and anaemia. Chest X-ray shows pulmonary infiltrates during an acute attack. Examination of sputum or lung biopsy discloses large numbers of haemosiderin-laden pulmonary macrophages. The mortality-rate is high, but the prognosis is difficult to evaluate because many patients survive for a long time either with a course of recurrent attacks or with chronic symptoms, such as dyspnoea and persistent anaemia. Steroids may improve the condition of the patient during a bleeding episode.

[Idiopathic pulmonary hemosiderosis in a 16-year old female]. / Idiopatisk pulmonal haemosiderose hos en 16-årig kvinde.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease of unknown aetiology. The clinical and paraclinical findings consist of recurrent haemoptysis, pulmonary infiltrates and iron deficiency anaemia. Examination of sputum or bronchoalveolar lavage fluid obtained at fiberoptic bronchoscopy discloses large numbers of haemosiderin-laden alveolar macrophages. Pulmonary interstitial fibrosis may develop. As pulmonary haemosiderosis can be observed in association with several diseases, IPH is basically a diagnosis made by exclusion of other causes. The treatment consists of immunosuppression with steroids and cytotoxic drugs.

The influence of nitrous oxide on recovery of bowel function after abdominal hysterectomy.

The influence of nitrous oxide on the recovery of bowel function was studied in 36 patients anaesthetised for elective abdominal hysterectomy with or without salpingo-oophorectomy. Patients were randomly assigned to receive either isoflurane in nitrous oxide and 30% oxygen (N2O group) or isoflurane in air and 30% oxygen (Air group). Anaesthetic management included thiopentone, fentanyl, suxamethonium and atracurium. The lungs were not ventilated prior to intubation. Before closing the abdomen, the surgeon assessed the degree of distension of the intestines and the closing conditions. Postoperative nausea and vomiting was assessed 2, 6, 12 and 24 h after recovery from anaesthesia. The lapse of time before mobilisation and passing of flatus and faeces was recorded. The patients in the Air group were significantly older than the patients in the N2O group (48.9 years versus 44.0 years, P = 0.04); otherwise, there were no differences in the demographic data of the patients. We found no significant differences between the groups with respect to nausea and vomiting, distension of the intestines before closure of the abdomen, closing conditions, time elapsing before mobilisation, constipation before recovery of bowel function or time elapsing before passing of flatus. We found a statistically significant delay of 10.3 h in time elapsing before passing of faeces in the N2O group compared to the Air group (P = 0.04), suggesting a potentially adverse effect of nitrous oxide.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of 94 anaesthetic agent vaporizers in clinical use.

Using the Brüel & Kjaer Anaesthetic Gas Monitor type 1304, we have monitored the output of 94 anaesthetic agent vaporizers (Fluotec 3:58, Enfluratec 3:24, Isotec 3:12), in seven departments of anaesthesia, at different dial settings and flow rates. The range of output, for one type of vaporizer and dial setting (flow: 6 litre min-1) was largest with the Fluotec 3 (0.85-1.55% when dial set to 1%) and smallest with the Isotec 3 (0.85-1.15% when dial set to 1%). In determining the number of vaporizers with unacceptable inaccuracy, we applied acceptance limits of +/- 15% relative on each vaporizer and each dial setting. Using a flow of oxygen 6 litre min-1 17% of Fluotec 3.8% of Isotec 3 and 71% of Enfluratec 3 vaporizers had outputs outside those limits. Even when some specific conditions (vaporizers giving output beyond the limits at any two or more dial settings; output beyond the limits in the clinically relevant range (0.5-2%)) were added, a substantial number of vaporizers did not perform within the limits. We found a significantly greater accuracy of the vaporizers after 3-monthly calibration checks (P < 0.05) compared with vaporizers undergoing service and calibration only annually. Using a questionnaire, we found that fewer than 30% of the anaesthetists using the vaporizers would accept aberrance beyond +/- 10% relative of the dial setting.

[Icterus as an initial symptom in a young man with idiopathic fibrosing chronic pancreatitis]. / Icterus som debutsymptom hos en ung mand med idiopatisk fibroserende kronisk pancreatitis.

Painless idiopathic fibrosing chronic pancreatitis as a cause of obstructive jaundice in childhood and adolescence is extremely rare. Only four patients have been reported earlier in the paediatric literature. We report a case story of a young man with this disease and with jaundice as the primary manifestation. Our report demonstrates the need to consider chronic pancreatitis as cause of jaundice in young patients.

Low-flow isoflurane-nitrous oxide anaesthesia offers substantial economic advantages over high- and medium-flow isoflurane-nitrous oxide anaesthesia.

Isoflurane consumption was studied for three different fresh gas flows in patients scheduled for major elective abdominal, urological or gynaecological surgery under general anaesthesia with an expected duration of 2 h or more. Thirty patients were randomly assigned to either high-flow anaesthesia using a partial rebreathing system without carbon dioxide absorption (Mapleson D) or medium- or low-flow anaesthesia using a circle system with carbon dioxide absorption. Patients were anaesthetised with isoflurane in 40% oxygen and 60% nitrous oxide. The amount of isoflurane consumed was measured with a precision scale. The total consumption of liquid isoflurane (mean +/- s.d.) during the first 2 h was 40.8 +/- 12.2 ml in the high-flow group, 18.5 +/- 5.4 ml in the medium-flow group and 7.9 +/- 2.2 ml in the low-flow group. The corresponding cost of isoflurane for the three groups was 214 Danish kroner (DKK) (19.5 pounds), 97 DKK (8.8 pounds) and 42 DKK (3.8 pounds), respectively. The calculated total cost of anaesthetics was 286 DKK (26 pounds), 155 DKK (14.1 pounds) and 91 DKK (8.3 pounds), respectively. In conclusion, low-flow isoflurane-nitrous oxide anaesthesia offers substantial economic advantages over high- and medium-flow isoflurane-nitrous oxide anaesthesia.

[Acute pancreatitis and gallstones]. / Akut pancreatitis og galdesten.

Gallstones are the most common causative factor in acute pancreatitis in the Western world. The majority of patients experience a mild course of the disease, with no need for acute invasive intervention. In patients with a severe course, acute endoscopic sphincterotomy seems indicated. Acute surgical intervention is not indicated in acute pancreatitis due to gallstones. In order to aim for early endoscopic decompression early detection og gallstones and determination of the severity og acute pancreatitis is essential. For this purpose, a combination of ultrasonography and biochemical tests seems most valid. Because of the high rate of recurrence, it is important that a cholecystectomy is performed during the same admission, after the acute symptoms have subsided. In patients with gallbladder stones an endoscopic sphincterotomy may be sufficient, but this procedure has never been compared to cholecystectomy in a controlled trial. Repeated ultrasonography is necessary, due to the high rate of false negative results of ultrasonography and biochemical tests in the early phase of acute pancreatitis. With a combination of repeated ultrasonography, endoscopic retrograde cholangiopancreaticography and microscopical examination of the bile a reduction in the incidence of acute "idiopathic" pancreatitis is achieved and appropriate treatment may be initiated. Finally, one should be aware of the presence of biliary sludge. Active intervention in patients with acute pancreatitis and biliary sludge significantly reduces the risk of recurrent pancreatitis.

The effect of oral ondansetron in the prevention of postoperative nausea and vomiting after major gynaecological surgery performed under general anaesthesia.

The efficacy and safety of ondansetron in preventing postoperative nausea and vomiting following major gynaecological surgery was evaluated in this multicentre, double-blind study. A total of 243 patients were randomised to receive three doses of oral ondansetron 8 mg or matching placebo at 8-hourly intervals, with the first dose being given an hour before surgery. A standard general anaesthetic technique was employed throughout. Nausea, vomiting and safety assessments were performed continuously during the 24 h postrecovery period. Of the 237 patients evaluated for efficacy, significantly fewer ondansetron 8 mg treated patients (65/117; 56%) experienced postoperative nausea and/or vomiting compared with placebo-treated patients (94/120; 78%) during the study period (p < 0.001). In addition, ondansetron 8 mg reduced the severity of nausea (p < 0.001) and the total number of vomiting episodes experienced (p < 0.001). Overall, ondansetron 8 mg was well tolerated and effective in preventing postoperative nausea and vomiting in this surgical setting.

Endoscopic management of malignant biliary obstruction. Is stent size of 10 French gauge better than 7 French gauge?

This study reviews 139 endoscopic biliary drainage procedures in 89 patients with malignant biliary obstruction. We compared the performance of straight 7 FG (31 patients; 36 procedures) and 10 FG (45 patients; 84 procedures) stents with regard to early complication rate and late clogging. The stent patency of all single 7 FG and all single 10 FG stents were 67 days and 144 days (p = 0.11), respectively. A complication was seen in 13.9% of the procedures with a 7 FG stent and in 16.7% of the procedures with a 10 FG stent inserted. When 2 7 FG stents (13 patients; 19 procedures) were used, the figures were 110 days and 21.1%, respectively. High stenosis was more frequent in this group. We found no significant differences in the performance of a single 7 FG and a single 10 FG stent, but there was a trend towards a longer patency and a higher complication rate of a single 10 FG stent compared with a single 7 FG stent.

[Endoscopic prosthetic treatment in stenosis of the choledochus caused by malignant disease]. / Endoskopisk protesebehandling ved ductus choledochus stenose forårsaget af malign sygdom.

Endoscopic insertion of a biliary endoprosthesis is often the treatment of choice in patients with malignant common bile duct obstruction. In experienced centers the procedure is combined with low risk and high success rates. A well known and unresolved problem is the tendency of the stents to clog within a few months, recessitating their replacement. The best survival of the stents is achieved by using the largest straight teflon stent without sideholes. Long-term treatment with antibiotics, antimicrobial impregnated stents, stents without side holes or intraductally placed stents might increase the survival of the stents. Great experience is necessary in order to ensure optimal endoscopic treatment of all the patients with malignant common bile duct obstruction and the treatment therefore should be performed in few large centers.

[Effect of 0-(beta-hydroxyethyl)-rutoside (Venoruton) on symptomatic venous insufficiency in the lower limbs]. / 0-(beta-hydroxyaetyl)-rutosids (Venoruton) effekt på symptomgivende kronisk venøs insufficiens i underekstremiteterne.

Forty-three patients recruited from general practice with symptom-producing chronic venous insufficiency in the lower limbs participated in a randomized double-blind clinical trial with Venoruton (300 mg x 3) or a placebo for 28 days. Twenty-eight patients were treated with Venoruton and 19 with a placebo. None of the patients received other forms of treatment for chronic venous insufficiency. No differences were observed between the two groups as regards changes in symptoms (swelling, pain, heaviness, restlessness, itching and cramps) the subjective assessment of the discomfort in the extremities or the circumference of the limbs. Venoruton does not appear to have any effect on chronic venous insufficiency in the lower limbs.