Peptic ulcer disease in south Ethiopia is strongly associated with Helicobacter pylori.

Helicobacter pylori infection was detected in 93% of 174 patients with a peptic ulcer compared with 63% of 116 patients with normal findings (chi 2 = 37.3; P < 0.001) in a cohort of 834 consecutive patients examined by gastroscopy in Yirga Alem Hospital in south Ethiopia. Fourteen patients were given 14 days' treatment with metronidazole 500 mg t.i.d., doxycycline 100 mg b.i.d. and bismuth subnitrate mixture 150 mg q.i.d. Of 10 patients who returned for follow-up, only 2 patients were free from H. pylori and cured. Nineteen strains of H. pylori from 19 consecutive patients in the same hospital were tested for resistance in vitro against metronidazole, doxycycline and ampicillin. All but 1 were highly resistant to metronidazole; 2 were fully and 14 intermediate resistant against doxycycline. All strains were fully sensitive in vitro to ampicillin. Thus, peptic ulcer was strongly associated with H. pylori in south Ethiopia, but eradication of the infection was hampered by antibiotic resistance.

Spiramycin is comparable to oxytetracycline in eradicating H. pylori when given with ranitidine bismuth citrate and metronidazole.

BACKGROUND: We have consistently achieved about 90% eradication of H. pylori with liquid bismuth, metronidazole and oxytetracycline. AIM: To test eradication and adverse events of ranitidine bismuth citrate (RBC) when given with metronidazole and either oxytetracycline or spiramycin. METHODS: One hundred and eighty-three patients were randomized to one of four 10-day regimens: RBC400OM: RBC 400 mg b.d., oxytetracycline 500 mg q.d.s.; RBC400SM: RBC 400 mg b.d., spiramycin 1 g q.d.s.; RBC200OM: RBC 200 mg q.d.s., oxytetracycline 500 mg q.d.s.; RBC200SM: RBC 200 mg q.d.s., spiramycin 1 g q.d.s. Additionally, all patients received metronidazole 400 mg q.d.s. A 14C-urea breath test was performed at 8 weeks. RESULTS: Intention-to-treat eradication rates were 94%, 91%, 94% and 89% with RBC400OM, RBC400SM, RBC200OM and RBC200SM, respectively (P = 0.81). Eradication was significantly higher in ulcer patients (97%) than in those with diagnoses other than ulcer (86%) (P = 0.009). There was a strong tendency to better eradication among those who had never smoked (100%) compared with ex-smokers (93%) and smokers (89%) (P = 0.06). Fifty-three per cent experienced at least one moderate or severe adverse event, and women had more adverse events than men (P = 0.0002). CONCLUSIONS: All four regimens had comparable efficacy and adverse events. Eradication was significantly better in ulcer patients but there was a trend to better eradication in those who smoked less, used less alcohol and exercised more. Adverse events were frequent, perhaps because of the large dose of metronidazole used, but few patients stopped treatment.

HIV infection and malnutrition change the clinical and radiological features of pulmonary tuberculosis.

Patients with HIV infection have atypical clinical features of pulmonary tuberculosis; however, our knowledge on how malnutrition affects the clinical presentation is limited. We studied the influence of malnutrition and HIV infection on the clinical and radiological features of pulmonary tuberculosis (TB). We studied 239 consecutive acid fast bacillus-positive adult patients. Patients were investigated by clinical, radiological, anthropometric and laboratory methods. 78% of the patients were malnourished (BMI < 18.5) and 43% were severely malnourished (BMI < 16). 20% were HIV-positive. HIV-positive TB had significantly more oral candidiasis (OR = 3.72), diarrhoea (OR = 2.71), generalized lymphadenopathy (OR = 2.63), skin disorders (OR = 2.27), neuropsychiatric illness (OR = 2.44), hilar lymphadenopathy (OR = 2.07), but less cavitation (OR = 0.64) and upper lung lobe involvement (OR = 0.70). HIV-negative and severe malnourished patients presented more often with dyspnoea (OR = 1.44), diarrhoea (OR = 1.64), night sweat (OR = 1.83), and less with haemoptysis (OR = 0.58) and cavitation (OR = 0.64). The size of Mantoux was associated with HIV infection and malnutrition. In a logistic regression analysis both HIV status and malnutrition were associated with atypical presentation of pulmonary tuberculosis. Malnutrition and HIV infection both contribute for atypical presentation of pulmonary tuberculosis. The risk of such atypical presentation is particularly high among the severely malnourished HIV-infected patients.

Bismuth-based combination therapy for Helicobacter pylori-associated peptic ulcer disease (metronidazole for eradication, ranitidine for pain).

OBJECTIVES: 180 Helicobacter pylori-positive patients with peptic ulcer disease were randomly allocated to double-blind placebo-controlled treatment with one of four anti-H. pylori regimens consisting of bismuth subnitrate suspension (B), oxytetracycline (OT), metronidazole (M)/metronidazole placebo, or ranitidine (R)/ranitidine placebo. METHODS: Regimen 1: B 150 mg q.i.d., OT 500 mg q.i.d., M 400 mg t.i.d. for 10 days and R 300 mg b.i.d. for 4 wk. Regimen 2: same as regimen 1 except ranitidine. Regimen 3: same as regimen 1 except metronidazole. Regimen 4: same as regimen 1 except metronidazole and ranitidine. Gastroscopy and 14C-urea breath test were performed 4 wk after cessation of therapy, and breath test six months after cessation. RESULTS: According to intention-to-treat analysis, H. pylori eradication rates were 96%, 91%, 20%, and 9% with regimens 1, 2, 3, and 4, respectively. Comparing regimens 1+2 and 3+4, the eradication rates with and without metronidazole were 93% and 14%, respectively (p < 0.0001). Metronidazole increased the occurrence of diarrhea and abdominal pain. Comparing regimens 1+3 with 2+4 ranitidine did not influence H. pylori eradication (58% with and 50% without ranitidine; p = 0.37) or ulcer healing (93% with and 90% without ranitidine; p = 0.72) significantly, but reduced the occurrence of pain (p < 0.01). Six months after treatment, three patients who were H. pylori negative at 4 wk had become positive. These three had all received metronidazole placebo. H. pylori status remained negative in the other 85 patients. CONCLUSIONS: H. pylori eradication with this triple therapy is critically dependent on metronidazole. Adding ranitidine reduces the occurrence of abdominal pain during such therapy.

Follow-up on 242 patients with peptic ulcer disease one year after eradication of Helicobacter pylori infection.

BACKGROUND/AIMS: From Dec. 1990 to Jan. 1993 we treated 306 patients with chronic peptic ulcer disease and gastric Helicobacter pylori infection with one of three triple therapy regimens comprising bismuth subnitrate suspension (B) 15 mg/ml, oxytetracycline (OT), and metronidazole (M). METHODS: Treatment I (101 patients): B 5 ml, OT 500 mg, and M 200 mg, all q.i.d. for 14 days. Treatment II (60 patients): B 10 ml and OT 750 mg q.i.d., M 400 mg t.i.d. for 7 days. Treatment III (145 patients): B 10 ml and OT 500 mg q.i.d., M 400 mg t.i.d. for 10 days. Gastroscopy and 14C-urea breath test were performed 4 weeks and 1 year after cessation of therapy. RESULTS: According to the urea breath test, H pylori eradication rates at 4 weeks were 87.9%, 81.9%, and 95.0% for Treatment I, II and III, respectively. At one year, 4 out of 242 patients, who were H pylori negative at 4 weeks, had become H pylori positive, i.e., H pylori reinfection rate 1.7%, 95% CI 0.5-4.2%. Only one of these "reinfected" patients had ulcer recurrence. Another patient had duodenal ulcer recurrence shortly after cessation of treatment in spite of being H pylori eradicated, i.e., ulcer recurrence rate 0.8%, 95% CI 0.1-3.0%. CONCLUSIONS: During the first year after H pylori eradication by triple therapy, recurrence rates of H pylori infection and peptic ulcer are very low (below 4.2% and 3.0%, respectively).

Raised levels of antibodies to human viruses at the clinical onset of autoimmune chronic active hepatitis.

Patients with autoimmune chronic active hepatitis (AICAH) often have very high titres of antibodies to rubella and/or measles virus. In the present study a young girl at the clinical onset of AICAH exhibited very high titres of antibodies against influenza viruses A and B, parainfluenza viruses, rubella virus and varicella-zoster virus. The titres normalized over 2 months except for rubella and varicella-zoster antibodies. Strong reactivities were seen against the rubella structural proteins E1, E2 and C in Western blot but IgM antibodies were not demonstrated. Total IgG was increased with normal ratios of subclasses. The IgG1 was the dominant antibody to E1 and E2, while IgG4 dominated the anti-C response. There was no significant shift in subclass reactivities over one year from onset. The polymerase chain reaction (PCR), using a nested primer set, was negative for rubella virus RNA in a liver biopsy obtained at the clinical onset and in peripheral blood mononuclear cells (PBMC) 1 year later. Co-cultivation experiments using PBMC and permissive cell lines were also negative for rubella virus. Hence, in the very early phase of AICAH there may be a transiently enhanced antibody response to various unrelated viruses.

[Gastrointestinal diseases--the place of endoscopy in examination, treatment and control]. / Gastrointestinale sykdommer--endoskopiens plass i utredning, behandling og kontroll.

Dyspepsia, defined as discomfort in the upper abdomen after a meal, is the most frequent indication for gastroscopy. Such dyspepsia was earlier considered to be an element of the ulcer disease, Moynihan's disease. Whether examination showed an ulcer or not was of minor importance as long as the treatment was the same. Similar opinions still contribute to a negative attitude towards the need to obtain a more specific diagnosis, especially in young patients where risk of cancer is low. We are of the opinion that dyspepsia is a non-specific symptom of several different diseases, and that curative therapy is often available today provided the diagnosis is correct. It is therefore necessary to make an active effort to diagnose the cause of the dyspepsia, also in younger persons. In practice, this means that there are many different indications for gastroscopy. We try, however, to practice a restrictive policy with respect to control gastroscopy.

[10 days of triple treatment of Helicobacter pylori infection and peptic ulcer. Status after treatment of 4 weeks and of one year]. / Ti dagers trippelkur for Helicobacter pylori-infeksjon og magesår. Status fir uker og ett år etter.

We treated 143 Helicobacter pylori positive ulcer patients (duodenal ulcer 81, gastric ulcer 24, pyloric ulcer nine, previous duodenal ulcer 27, others two) with a ten days regimen of bismuth subnitrate, oxytetracycline and metronidazole. Four weeks after cessation of treatment the 14C-urea breath test showed that the infection was eradicated in 133 out of 140 patients (95%). The ulcer had healed in 129 (97%) of the H. pylori negative patients. Status at one year after treatment showed that 121 (98.4%) of 123 patients who had become H. pylori negative had remained negative. None of the H. pylori negative patients experienced ulcer relapse. The results show that the treatment is effective and that the rate of recurrence of H. pylori during the first year is very low.

[Infections of the upper gastrointestinal tract--more than Helicobacter pylori?]. / Infeksjonar i øvre gastrointestinaltractus--meir enn Helicobacter pylori?

Helicobacter pylori infection is a problem frequently handled by the gastroenterologist, but many other infections may cause symptoms and pathological findings which is of great significance for the endoscopist to recognize. Candida infection is the most common infection in the oesophagus. It may signal an underlying disease like diabetes. When the patient enters Norway from an area where tuberculosis is endemic it is necessary to be aware of possible abdominal tuberculosis. Immuno-compromised patients, and especially AIDS-patients, may have several dangerous gastrointestinal infections. The most frequent agents encountered in this situation include Cytomegalovirus, Mycobacterium avium intracellulare complex and Cryptosporidia. Treatment can be very problematic; both because of the underlying disease and because of the inefficacy of chemotherapy on the infectious agent.

[Diagnosis of Helicobacter pylori infection. Rapid urease test, microscopy of smears and culture from ventricular biopsy compared with the 14C-urea breath test]. / Diagnostikk av Helicobacter pylori-infeksjon. Ureasehurtigtest, mikroskopi av utstryk og dyrking frå ventrikkelbiopsi samanlikna med 14C-urea-pusteprøven.

By employing the 14C-urea breath test as the reference method we determined the specificity and sensitivity of three bioptic methods for diagnosis of Helicobacter pylori infection in 103 subjects. All biopsy specimens were obtained from the gastric antrum. For culture the specificity was 100%. Its applicability was reduced, however, by a low sensitivity (73.8%) and a delay of several days before the final result was available. Microscopy of Loeffler-stained biopsy smears yielded a specificity of 100% and a sensitivity of 92.9%, but the method was regarded time-consuming. The rapid urease test yielded a specificity of 98.4% and a sensitivity of 85.7%. Being quick, simple and inexpensive the rapid urease test is well suited for routine use in gastroscopy.

[Helicobacter pylori and ulcer disease]. / Helicobacter pylori og ulcussykdom.

There is a strong association between Helicobacter pylori and peptic ulcer and chronic gastritis. It has been shown, furthermore, that the relapse rate after a healed duodenal ulcer is much reduced when the treatment has also eradicated H pylori from the antrum ventriculi. We have tried two simple and rapid tests for diagnosing H pylori infection on biopsies taken at gastroscopy. We found a significantly larger number of cases with H pylori among patients with peptic ulcer than among patients with normal gastroscopic findings. Culturing the biopsy proved to be successful, even though transport to the laboratory took about 24 hours. It has been proved simple to diagnose H pylori, but any practical implications of this fact remain to be seen.