Optimized sequential therapy vs 10- and 14-d concomitant therapy for eradicating Helicobacter pylori: A randomized clinical trial.

BACKGROUND: A cure for Helicobacter pylori (H. pylori) remains a problem of global concern. The prevalence of antimicrobial resistance is widely rising and becoming a challenging issue worldwide. Optimizing sequential therapy seems to be one of the most attractive strategies in terms of efficacy, tolerability and cost. The most common sequential therapy consists of a dual therapy [proton-pump inhibitors (PPIs) and amoxicillin] for the first period (5 to 7 d), followed by a triple therapy for the second period (PPI, clarithromycin and metronidazole). PPIs play a key role in maintaining a gastric pH at a level that allows an optimal efficacy of antibiotics, hence the idea of using new generation molecules. AIM: To compare an optimized sequential therapy with the standard non-bismuth quadruple therapies of 10 and 14 d, in terms of efficacy, incidence of adverse effects (AEs) and cost. METHODS: This open-label prospective study randomized 328 patients with confirmed H. pylori infection into three groups (1:1:1): The first group received quadruple therapy consisting of twice-daily (bid) omeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg for 10 d (QT-10), the second group received a 14 d quadruple therapy following the same regimen (QT-14), and the third group received an optimized sequential therapy consisting of bid rabeprazole 20 mg plus amoxicillin 1 g for 7 d, followed by bid rabeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg for the next 7 d (OST-14). AEs were recorded throughout the study, and the H. pylori eradication rate was determined 4 to 6 wk after the end of treatment, using the 13C urea breath test. RESULTS: In the intention-to-treat and per-protocol analysis, the eradication rate was higher in the OST-14 group compared to the QT-10 group: (93.5%, 85.5% P = 0.04) and (96.2%, 89.5% P = 0.03) respectively. However, there was no statistically significant difference in eradication rates between the OST-14 and QT-14 groups: (93.5%, 91.8% P = 0.34) and (96.2%, 94.4% P = 0.35), respectively. The overall incidence of AEs was significantly lower in the OST-14 group (P = 0.01). Furthermore, OST-14 was the most cost-effective among the three groups. CONCLUSION: The optimized 14-d sequential therapy is a safe and effective alternative. Its eradication rate is comparable to that of the 14-d concomitant therapy while causing fewer AEs and allowing a gain in terms of cost.

An atypical cause of vomiting: Coexisting Wilkie's syndrome and a left renal malformation mimicking a nutcracker phenomenon-A case report.

The superior mesenteric artery syndrome and nutcracker phenomenon are rare vascular disorders due to the abnormal development of the superior mesenteric artery stemming from the abdominal aorta with reduced angle (<22°) and resultant compression of the left renal vein and duodenum. It is an underreported entity due to the absence of specific pathognomonic signs. We report the case of a 59-year-old man, admitted for acute bilious vomiting, who underwent a gastroscopy and a computed tomography scan revealing a Wilkie's syndrome associated with a dilated posterior left renal vein communicating with the left ascending lumbar vein without connection with the inferior vena cava mimicking a nutcracker phenomenon.

Infected Biloma after Endoscopic Ultrasound-Guided Fine-Needle Aspiration.

Biloma is a severe complication that can result from bile duct disruption or hepatic trauma. It can occur after biliary surgery such as cholecystectomy or an endoscopic retrograde cholangiopancreatography manipulation and endoscopic biliary sphincterotomy. We present the case of a 59-year-old man admitted for jaundice, with pain in his right flank and fever, 10 days after an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for an ill-defined pancreatic lesion, associated with an infected biloma. Severe complications can occur after an EUS-FNA; therefore, this diagnosis should not be neglected after the intervention in symptomatic patients, to ensure an early and proper treatment.

An Unusual Cause of Biliary Tract Obstruction: Lemmel Syndrome.

BACKGROUND: Lemmel syndrome is a rare and misdiagnosed etiology of obstructive jaundice due to a periampullary duodenal diverticulum causing a mechanical obstruction of the common bile duct. It represents an obstructive jaundice with the absence of choledocholithiasis or pancreaticobiliary tumors. It is an underreported entity due to the absence of specific pathognomonic signs. CASE PRESENTATION: A 77-year-old-woman admitted for sepsis, due to an ascending cholangitis, underwent a MRCP and a gastroduodenoscopy revealing Lemmel's syndrome. Due to failure of ERCP, the patient underwent surgical derivation. CONCLUSION: Lemmel syndrome represents an uncommon diagnosis of obstructive jaundice, that shouldn't be neglected if no other organic cause is detected. It is usually asymptomatic, however some patients can develop symptoms and complications such as cholangitis, as is the case of our patient. Imaging allows diagnosis, with MRCP as the modality of choice to confirm diagnosis. Endoscopy is the first line treatment.

Saccharomyces boulardii CNCM I-745 plus sequential therapy for Helicobacter pylori infections: a randomized, open-label trial.

AIM: To determine the effect of Saccharomyces boulardii CNCM I-745 (S. boulardii) plus sequential therapy on Helicobacter pylori (H. pylori) eradication rate. METHODS: This open-label prospective study randomized (1:1) patients with confirmed H. pylori infection to standard sequential therapy of twice-daily (bid) omeprazole 20 mg plus amoxicillin 1 g for 5 days, followed by bid omeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg for the next 5 days (control group), or sequential therapy plus bid S. boulardii 250 mg (experimental group). Adverse events (AEs) were recorded throughout the study, and the H. pylori eradication rate was determined 4 weeks after treatment. RESULTS: The study was conducted from May 2013 to May 2016 and included 199 patients (51.3% male; mean age 44.6 ± 13.6 years). The H. pylori eradication rate was higher in the experimental group than the control group (86.0% vs. 74.7%; P = 0.02). Compared with the control group, patients in the experimental group experienced a significantly lower overall incidence of AEs (17.0% vs. 55.7%; p < 0.001) and the incidence of antibiotic-associated diarrhea (2.0% vs. 46.4%; P = 0.02). The experimental group showed improved treatment compliance over the 10-day study period compared with the control group (95.0% vs. 91.2%, P < 0.001). CONCLUSION: Addition of S. boulardii to sequential therapy improved H. pylori eradication rate and reduced the incidence of treatment-associated AEs in Moroccan patients with H. pylori infection.