Sequential therapy using high-dose esomeprazole-amoxicillin followed by gatifloxacin for Helicobacter pylori infection.

BACKGROUND: The success rate of current anti-Helicobacter pylori triple therapies in now generally 80% or less. Sequential therapy has proved superior. AIM: To test a new sequential therapy for H. pylori eradication. METHODS: This was a pilot study of a sequential therapy consisting of 40 mg of esomeprazole and 1 g amoxicillin t.d.s., for 12 days. On days 6 through 12 gatifloxacin (400 mg in the morning) was added. Outcome was accessed 4 or more weeks after ending antibiotic therapy. Both naive and treatment failures were eligible. RESULTS: Thirty patients were entered in the study. One was lost to follow-up and one stopped early because of side effects. The success rate intention-to-treat was 80% (95% CI: 61-92%). The per-protocol eradication rate was 85.7% (95% CI: 67-95%); two of the four failures had pre-treatment gatifloxacin-resistant H. pylori. Side effects were reported by 13 patients (46%) and were generally mild with diarrhoea being most common (n = 6). Only one patient stopped medicine because of side effects of dizziness (severe) and diarrhoea (mild). CONCLUSIONS: Sequential therapy using the combination of a high dose of proton-pump inhibitor and amoxicillin followed gatifloxacin was effective, but pre-treatment susceptibility testing may become necessary as fluoroquinolone resistance increases.

Effect of different organic acids (citric, malic and ascorbic) on intragastric urease activity.

BACKGROUND: The mechanism of citric acid-enhanced Helicobacter pylori urease activity remains unclear. AIM: To compare ascorbic, citric and malic acid given at the same concentration and pH on intragastric urease activity. METHODS: Volunteers received 40 mg of famotidine the evening prior to breath testing. After an overnight fast volunteers were randomized to receive 100 mL of water or 100 mm citric, malic, or ascorbic acid, pH 2.3 containing 75 mg of 13C-urea. At 15 min a second 100 mL solution of one of the test solutions was taken without added urea. RESULTS: Twelve volunteers were studied (eight men, four women, age 19-57, median 50.7) in a randomized-crossover study. The mean breath test result at 30 min with ascorbic (17.5 +/- 5), malic (25.8 +/- 5) and citric acid (29.5 +/- 5) were all significantly greater than with water (9.5 +/- 3). Citric and malic acid were similar (P = 0.699) and significantly greater than ascorbic acid (P < 0.02). When the ascorbic acid was followed by citric acid, the result was similar to that with citrate alone (25.8 +/- 4) and greater than with ascorbic then ascorbic (P = 0.026). CONCLUSIONS: Enhancement of H. pylori urease activity is not strictly a function of the pH. We propose the effect is related to differential effects of the availability of nickel, which is required for urease activity. Citric acid and malic acid were essentially equivalent such that malic acid could substitute for citric acid in the UBT; ascorbic acid would be a poor choice.

Twice daily (mid-day and evening) quadruple therapy for H. pylori infection in the United States.

BACKGROUND: Quadruple therapy provided inadequate eradication rate when given twice-a-day at breakfast and evening meals. AIM: To test twice daily (mid-day and evening) quadruple therapy for Helicobacter pylori eradication. METHODS: This was a single-centre pilot study in which H. pylori-infected (positive histology and culture and RUT) patients were given 2 x 250 mg of metronidazole and 2 x 250 mg of tetracycline, two Pepto-Bismol tablets, plus one 20 mg rabeprazole tablet twice-a-day for 14 days. H. pylori status was confirmed 4 or more weeks after the end of therapy. RESULTS: Thirty-seven patients including 3 with peptic ulcer disease, 19 asymptomatic infected, 4 GERD, and 11 with NUD. Mid-day quadruple therapy was successful in 92.3% (95% CI: 79-98%) including 96.2% of those with metronidazole-susceptible strains, and in 83.3% (10/12) of those with metronidazole-resistant H. pylori. Compliance was 100% by pill count except in one individual who stopped medication after 12 days because of side-effects and who failed therapy. Moderate or greater side-effects were experienced by five patients. CONCLUSION: Twice-a-day, mid-day, quadruple therapy proved effective using the combination of bismuth subsalicylate and rabeprazole instead of bismuth subcitrate and omeprazole. Detailed studies of different formulations (e.g. 2 x 250 mg versus 1 x 500 mg of metronidazole or tetracycline) and timing of administration (breakfast and evening meal versus mid-day and evening meals) may result in significant improvements in H. pylori eradication regimens.

Prospective, randomized, pathologist-blinded study of disposable alligator-jaw biopsy forceps for gastric mucosal biopsy.

BACKGROUND: Endoscopic biopsy forceps differ in the size and shape of the biopsy cup and the presence or absence of a needle. METHODS: We compared four different "large cup" forceps (three with needles) designed for 2.8mm biopsy channels. A gastric antral and corpus biopsy were obtained with each. Parameters examined included: weight (mg), length (mm), orientation (poor, good), intactness (1, 2, or 3 pieces), depth (superficial, above muscularis mucosae, included muscularis mucosae), crush artefact (yes, no), and overall adequacy (inadequate, suboptimal, adequate). RESULTS: Twenty-four patients were enrolled (191 biopsies). The median length was approximately 5mm (range 1.1-8.2mm). Histologically inadequate specimens were present in 4% with the forceps without needle compared to 16% of those with needles (P=0.061) and there were significantly fewer specimens in three or more pieces than did the forceps with needles 2.1% vs. 12.6% (P<0.05). CONCLUSIONS: Current alligator style forceps provide a high proportion of acceptable specimens with only minor differences between brands. Forceps from one source were least preferred by endoscopy assistants and had the highest rates of inadequate biopsies and biopsies with crush artefact. Forceps without needles provide histologically acceptable samples slightly more frequently than those with needles.