[Pulmonary actinomycosis caused by Actinomycesodontolyticus in a two-year-old child]. / Actinomycose pulmonaire à Actinomycesodontolyticus chez un enfant de 2 ans.

INTRODUCTION: Pulmonary actinomycosis due to Actinomyces Odontolyticus is a rare and seldom reported pathology in pediatrics. The unspecific radio-clinical symptomatology and the slow growth of the germ make the diagnosis difficult. CASE REPORT: A 2-year-old boy is admitted to the emergency room for acute respiratory distress in a context of febrile bronchitis that had been evolving for 10days. Quickly, the patient's state deteriorate, invasive ventilation was required. Bronchial fibroscopy was performed immediately and enabled extraction of large mucous filaments, leading to significant improvement. Mechanical ventilation was stopped after 72hours. Five days later, blood culture tested positive for Actinomyces Odontolyticus. In the absence of any other cause and given a compatible clinical picture, the child was treated with long-term antibiotherapy for a total duration of 6months, which was stopped following reassuringly normal endoscopic and radiological control. CONCLUSIONS: This is the second pediatric case of pulmonary actinomycosis due to A. Odontolyticus reported in the literature. The clinical symptoms and imaging are not specific. The presence of sulphide granules on pathological examination or in germ culture at a sterile site confirms the diagnosis. Prolonged antibiotic therapy is still recommended to avoid pulmonary sequels.

Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings.

Both dyspeptic and gastro-oesophageal reflux-like symptoms are frequent in the general population, but their degree of overlap is unknown. In severe functional dyspepsia (FD), symptoms are organized in factors associated with pathophysiological mechanisms. The aims of this study were: (i) to assess the prevalence of dyspeptic symptoms with and without overlapping reflux symptoms in the general population and their impact on daily life and on healthcare utilization; and (ii) to compare symptom groupings in the general population to FD patients. A total of 2025 subjects, representative of the Belgian general population, were used in this study. The subjects were submitted to a questionnaire with validated questions on their dyspeptic and reflux symptoms and with evaluators of impact on daily life and use of healthcare resources. Significant dyspeptic symptoms were found in 417 (20.6%). Overlapping reflux symptoms were present in 141 (33.8%). In this group, symptoms were more frequent and more severe. Dyspeptic symptoms induced weight loss (12.7%) and absenteeism (12.4%), affected daily life (61.2%) and generated use of healthcare resources, such as medical consultations (61.4%) and medication (70.9%). Factor analysis revealed a three-component structure with factor 1 including fullness, bloating and early satiety, factor 2 including nausea and vomiting and factor 3 including discomfort, pain, belching and reflux. If forced in a four-factor model, the analysis separates belching as independent factor. Dyspeptic symptoms are frequent in the general population, with overlapping reflux symptoms and increased symptom burden in about a third.

Observational survey of NSAID-related upper gastro-intestinal adverse events in Belgium.

OBJECTIVES: To evaluate the impact of NSAID use on current routine upper GI endoscopy (UGIE) and to compare the lesions found in NSAID users and non-users. METHODS: Participating gastroenterologists consecutively documented outpatients with and without suspicion of bleeding, referred for upper gastrointestinal endoscopy. Patient characteristics, presence of risk factors, NSAID use and endoscopic findings were reported on standard data collection forms. MAIN RESULTS: A total of 2685 non-bleeding and 159 bleeding patients were enrolled within a time period of 2 months. NSAID therapy was present in 20% of the non-bleeding patients and at least 9% of referrals for endoscopy were directly related to suspected NSAID adverse events. Nearly half of acute bleeding patients (42%) were NSAID users, including aspirin for cardioprevention. Warning digestive symptoms prior to acute bleeding were frequently absent (56%). Oesophagitis was the main endoscopic diagnosis (51% of patients). Gastroduodenal (GD) ulcer was significantly more frequent in NSAID users, whereas oesophagitis and bleeding oesophageal varices were more frequent among non-users. Analysis of odds ratio's demonstrated NSAID use to significantly increase the risk for gastric ulcer in the whole patient group (OR = 2.73; 95% confidence interval (CI): 1.98-3.77; p < 0.001) and, in addition, for duodenal ulcer in the elderly (> 65 y) subgroup (OR = 2.91; 95% CI: 1.52-5.59; p < 0.05). CONCLUSIONS: This survey confirms the high incidence of GD ulcers in NSAID users and the risk for serious gastrointestinal complications, often occurring without warning symptoms. It underlines the impact of NSAID use on the routine endoscopy load, the necessity of careful selection of patients for NSAID prescriptions and the need for gastropreventive measures, particularly in elderly patients and patients associating multiple risk factors.

Severe acute pancreatitis associated with peliosis hepatis in a patient with systemic lupus erythematosus.

Acute pancreatitis is an unusual complication of systemic lupus erythematosus but can also stem from immunosuppressive therapy. Although abnormal liver tests are commonly seen in SLE, peliosis hepatis is very rarely described. We report here the first case of SLE associating a severe acute pancreatitis with peliosis hepatis who responded well to the immunosuppressive therapy. As suggested by the favourable outcome in this case, the presence of peliosis hepatis in SLE cannot not be held as a strong argument against an aggressive immunosuppressive therapy.

[Dyspepsia in general medicine: current diagnostic approach]. / La dyspepsie en médecine générale: approche diagnostique actualisée.

Upper GI tract endoscopy remains a key investigation in dyspepsia. Nevertheless, since the development of non-invasive techniques for Helicobacter pylori (Hp) infection detection and the current trend for immediate prescription of anti secretary drugs in "endoscopy negative gastro-oesophageal reflux disease" (NORD), accurate indications for endoscopy must be reconsidered. Careful recording of the medical history of the patient is crucial. Personal antecedents (diseases and drugs), familial history (especially gastric cancer) must be evidenced and three symptomatic groups must be identified: patients with alarm symptom(s), typical ulcer pain and GORD. Beside those three categories, most patients must be classified in "non specific dyspepsia". Immediate endoscopy is highly recommended in all patients with either alarm symptom(s) or typical ulcer pain (except in suspected relapse of a well documented duodenal ulcer disease). Age is a key determinant in GORD: endoscopy is not necessary in patients under 45 years of age. In case of "non specific dyspepsia" in patients under 45 years, a non-invasive test for Hp infection will favour when positive endoscopic investigation ("test and scope" policy). Nevertheless, in all patients above 45 years and in all patients with either a personal history of gastric ulcer, or a familial history of gastric cancer (whatever the age), endoscopy with biopsies remains the first recommended investigation.

How come I've got it? (A review of Helicobacter pylori transmission).

Numerous epidemiological studies have shown the two main risk factors for Helicobacter pylori acquisition: childhood and low socio-economic level both in developing and developed countries. Nevertheless, in the absence of ubiquitous extra-human reservoir(s), the route(s) for person-to-person transmission remains undetermined. Very recent data favour the oro-oral route: besides gastric mucosa, mouth might be a sanctuary site and the oro-oral transmission hypothesis seems applicable worldwide. Nevertheless, the gastro-oral route (vomiting, gastro-oesophageal reflux) is still possible and deserves further research. In developing countries, feco-oral transmission (perhaps through the water supply) might be a significant mechanism of human contamination both for primary infection in children and perhaps, reinfection in adults.

Noninvasive antigen-based assay for assessing Helicobacter pylori eradication: a European multicenter study. The European Helicobacter pylori HpSA Study Group.

OBJECTIVE: In a recently published multicenter study involving 501 patients undergoing esophagogastroduodenoscopy (EGD) throughout Europe, we showed the high accuracy of a recently developed simple test (HpSA) to detect Helicobacter pylori (H. pylori) antigens in stools of untreated patients. The aim of this study was to assess the diagnostic usefulness of HpSA compared with 13C UBT shortly after H. pylori eradication treatment. METHODS: Of the 501 patients enrolled in the validation study, 279 were found to be H. pylori-positive. These patients were given H. pylori eradicating regimen and asked to return for follow-up EGD with biopsies, 13C UBT and HpSA testing 4 wk after therapy. Follow-up results were available for 235 patients. Of these, 162 consented to all testing and 73 consented only to 13C UBT and HpSA testing. We assessed sensitivity and specificity of both HpSA and 13C UBT compared with biopsy-based methods in the 162 patients, who accepted follow-up EGD. We also assessed sensitivity and specificity of HpSA compared with 13C UBT, arbitrarily chosen as the gold standard, in the whole population of 235 patients. RESULTS: Sensitivity and specificity in 162 patients who consented to a second EGD were 93.8% (CI: 85.4-100%) and 96.9% (CI: 93.9-99.9%) for HpSA, and 90.6% (CI: 80.5-100%) and 99.2% (CI: 97.7-100%) for UBT. Using EGD-based methods as the gold standard, 130 of the 162 treated patients' H. pylori infection were eradicated (125 HpSA-negative, one borderline, and four false-positive; 129 13C UBT-negative, one false-positive), and 32 remained H. pylori-infected (30 HpSA-positive, two false-negative, 29 13C UBT-positive, three false negative). The overall eradication rate was 80.2%. The sensitivity and specificity of HpSA relative to UBT as the gold standard in the overall population (n = 235) were 95.6% (CI: 89.6-100%) and 94.7% (CI: 91.5-97.9%), respectively. CONCLUSIONS: HpSA has proven to be a useful method in posttreatment eradication testing for H. pylori. Its ease of use, speed, and noninvasive nature make HpSA testing an ideal method for post-treatment monitoring where a second EGD may not be justified.

Evidence based medicine and extradigestive manifestations of Helicobacter pylori.

A putative pathogenetic role has been ascribed to Helicobacter pylori in several extradigestive diseases, including vascular (atherosclerosis and ischaemic heart disease, primary Raynaud phenomenon, primary headache), autoimmune (Sjögren's syndrome, Henoch-Schönlein purpura, autoimmune thyroiditis, idiopathic arrythmias, Parkinson's disease, nonarterial anterior optic ischemic neuropathy), and skin diseases (chronic idiopathic urticaria, rosacea, alopecia areata), sideropenic anemia, growth retardation, late menarche, extragastric MALT lymphoma, diabetes mellitus, hepatic encephalopathy, sudden infant death syndrome, and anorexia of aging. We examine critically the strength of the evidence linking these diseases to Helicobacter pylori, using ischaemic heart disease as an example of epidemiological techniques, and skin diseases as an example of treatment studies. By the standards of evidence-based medicine, studies have been often of low quality. The best evidence usually is not indicative of a role for Helicobacter pylori in these diseases.

Diagnosis of Helicobacter pylori infection with a new non-invasive antigen-based assay. HpSA European study group.

BACKGROUND: Helicobacter pylori is a common human pathogen implicated in certain gastrointestinal diseases. In the search for new non-invasive techniques to diagnose H. pylori infection, we evaluated an EIA for H. pylori antigen in stool (HpSA). METHODS: In a prospective multicentre study, stool specimens from 501 patients (276 men, 225 women; age range 17-88 years, mean 52) undergoing gastroscopy in 11 centres throughout Europe were tested with HpSA and the carbon-13-urea breath test. At endoscopy, four biopsy samples were taken for histology (haematoxylin and eosin) and H. pylori detection (giemsa in both antrum and corpus, culture and rapid urease test). Patients were defined as positive for H. pylori if histology (antrum, corpus, or both) and urease test were positive, or if culture was positive. Patients classified as having H. pylori infection received an eradication regimen; 107 were reassessed 4 weeks after therapy. FINDINGS: Of 272 patients with H. pylori infection by the predefined criteria, 256 were positive by HpSA (sensitivity 94.1% [95% CI 90.6-96.6]). Of 219 patients without infection, 201 were negative by HpSA (specificity 91.8% [87.3-95.1]). INTERPRETATION: The stool assay was a reliable and easy-to-use tool for diagnosis of H. pylori infection. The test was accurate even shortly after treatment.

The 1998 national Belgian consensus meeting on HP-related diseases: an extensive summary. The HP Belgian contact group organized in CHU Brugmann, Brussels.

"HP testing must be regarded as ONE of the important elements of the proper diagnostic work-up of a DISEASE, managed in close cooperation between GP's and specialists": that's the key message of the national consensus meeting held in CHU Brugmann on February 6th and 7th 1998. HP testing (usually by 2 direct methods: RUT-histology) and eradication treatment (ER), in infected patients, are strongly recommended in: 1. Past or current GDU (absolute indication), regardless of activity, complication(s), NSAID intake; 2. Low-grade MALT Lymphomas (Stage IE1) unequivocally diagnosed, managed and followed-up in specialised centers; 3. Post endoscopic resection of EGC. ER is advisable in HP carriers with a family history of gastric cancer. Chronic atrophic-, lymphocytic-, giant folds gastritis and hyperplastic polyps are acceptable indications for ER as well as scheduled long-term NSAID treatment in individuals with known HP status. Systematic ER in HP+ patients with fully investigated NUD is not indicated but could be considered in individual patients. Extra alimentary disorders and auto immune gastritis are no indication and there was no consensus for a "test and treat" policy in patients under 45 yrs old without alarm symptoms. Systematic screening of asymptomatic individuals is not recommended. A correct monitoring of eradication after treatment is recommended, mainly by UBT. In severe or refractory PUD, symptom recurrence and follow-up of EGC and Maltomas, endoscopic follow-up with HP testing is mandatory. The recommended first line treatment course (except known allergy or intolerance) is PPI full dose bid, Clarithromycin 500 mg bid Amoxycillin 1000 mg bid (7 days minimal 10 days maximal). RBC-based schemes must be locally validated and quadruple therapy is proposed when retreatment is needed. Culture, optional after the first treatment failure, is strongly recommended after a second failure. Overall, ER therapies are safe and neither the decreased efficacy of acid-lowering drugs, nor the possible increased risk of peptic oesophagitis are considered as contra-indications to eradicate. ER is cost-effective and cost-beneficial in PUD and adjusted number of pills delivered would cut costs. No clear economic data are currently available for a potential benefit of ER in GC prevention or NUD management. A national monitoring of HP resistance (Macrolides and Imidazoles) must be organized by specialised centers.

Eradication of Helicobacter pylori: why does it fail?

Currently, the first therapeutic attempt to eradicate Helicobacter pylori fails in one case out of six in intention to treat analysis. The main causes of failure are bad compliance, partly because of side effects that are severe in 1 to 4% of cases, absence of local validation of the treatment scheme, since some differences do exist between regions and countries, primary and secondary resistance of the strain (stable for Imidazole-derivates, but increasing for Macrolides), and, to a lesser extent, smoking and pre-treatment with proton pump inhibitors. Moreover, in routine medicine, inappropriate treatment cocktails are still prescribed, even by gastroenterologists. Obviously, there is a need for careful medical education and information both as far as concerns doctors and patients, for well-designed prescription, based on local experience and the precise previous history of every patient, as well as for continuous monitoring of the bacterial resistance to antibiotics. Culture of the strain is recommended after eradication failure with the classic one-week triple therapy, but if reliable culture and resistance testing are not available, the quadruple therapy as a second-line treatment is, so far, the best choice.

Economics of Helicobacter pylori eradication therapy.

The annual incidence of peptic ulcer disease in developed countries is around one to three per thousand inhabitants. Since the introduction of acid-secretion inhibitors, the indirect costs of this disease, which has a high rate of relapse, have steadily decreased, although direct costs have been increasing. The possibility of healing the patient through Helicobacter pylori eradication has the potential for a huge economic impact considering the long-term cost: benefit ratio. A recent study has shown that H. pylori eradication therapy can save between US$750,000 and US$1,000,000 per year per million inhabitants in western Europe compared to maintenance or episodic therapy. This paper reviews the cost implications of various management strategies for peptic ulcer disease, comparing the cost: benefit ratios of five different treatment regimens.

Helicobacter pylori eradication in duodenal ulcer disease is cost-beneficial: a Belgian model.

The eradication of Helicobacter pylori in infected patients with gastroduodenal ulcer disease the allows to obtain a definite healing of this chronically relapsing condition for which the direct costs have been steadily increasing (while indirect costs were reduced) for the last two decades. Both short-term studies performed on real time, and prospective simulations using a Markov's model over periods of one, five and up to fifteen years, revealed a significant cost/benefit advantage of an eradication policy: according to the Belgian model, the eradication of HP in patients with peptic ulcer would save between 750,000 and one million US dollars by million inhabitants when compared to maintenance or episodic treatment with anti-secretory drugs. Nevertheless, models are very sensitive to several factors: eradication rate, costs of screening and HP status assessment, frequency of peptic ulcer disease.