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Background The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens. Aims To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed. Methods This was a prospective multicenter study including patients in whom a standard triple therapy ( PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy ( PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by 13C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires. Results 200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95% CI = 87-95%) and 90% (95% CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious. Conclusions Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed. [ABSTRACT FROM AUTHOR]

Background Empiric triple therapy for Helicobacter pylori should be abandoned when clarithromycin resistance rate is >15-20%. Optimisation of triple therapy (high-dose acid suppression and 14-day duration) can increase eradication rates by 10%. Aim To compare the efficacy and safety of optimised triple ( OPT- TRI) and nonbismuth quadruple concomitant ( OPT- CON) therapies. Methods Prospective multicentre study in 16 Spanish centres using triple therapy in clinical practice. In a 3-month two-phase fashion, the first 402 patients received an OPT- TRI therapy [esomeprazole (40 mg b.d.), amoxicillin (1 g b.d) and clarithromycin (500 mg b.d) for 14 days] and the last 375 patients an OPT- CON treatment [ OPT- TRI therapy plus metronidazole (500 mg b.d)]. Results Seven-hundred seventy-seven consecutive patients were included (402 OPT- TRI, 375 OPT- CON). The OPT- CON therapy achieved significantly higher eradication rates in the per-protocol [82.3% (95% CI = 78-86%) vs. 93.8% (91-96%), P < 0.001] and intention-to-treat analysis [81.3% (78-86%) vs. 90.4% (87-93%), P < 0.001]. Adverse events (97% mild/moderate) were significantly more common with OPT- CON therapy (39% vs. 47%, P = 0.016), but full compliance with therapy was similar between groups (94% vs. 92%, P = 0.4). OPT- CON therapy was the only significant predictor of successful eradication (odds ratio, 2.24; 95% CI: 1.48-3.51, P < 0.001). The rate of participating centres achieving cure rates ≥90% favoured OPT- CON therapy ( OPT- TRI 25% vs. OPT- CON 62%). Conclusions Empiric OPT- CON therapy achieved significantly higher cure rates (>90%) compared to OPT- TRI therapy. Addition of metronidazole to OPT- TRI therapy increased eradication rates by 10%, resulting in more mild adverse effects, but without impairing compliance with therapy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Balloon dilation (with or without steroid injection) is the endoscopic treatment of choice for short strictures in Crohn's disease (CD). The placement of a stent has only rarely been reported in this setting, and it may be a good alternative. AIMS: To describe the efficacy of temporary placement of a self-expanding metallic stent (SEMS) in the endoscopic treatment of symptomatic strictures in CD. METHODS: We included 17 CD patients treated with SEMS (4 partially covered SEMS and 21 fully covered SEMS) for symptomatic strictures refractory to medical and/or endoscopic treatment. RESULTS: We placed 25 stents in 17 patients with stenosis (<8 cm), in the colon and in the ileocolonic anastomosis. In two cases, two stents were placed in the same endoscopic procedure. All except three cases had previously been unsuccessfully treated with endoscopic dilatation. The stents were maintained for an average of 28 days (1-112). The treatment was effective in 64.7% of the patients after a mean follow-up time of 60 weeks (5-266). In four cases, removal of the stents was technically difficult due to stent impaction (moderate adverse events-AEs) and one patient had a proximal stent migration requiring delayed surgery (severe AE). CONCLUSIONS: The placement of self-expanding metallic stent in Crohn's disease maintained over a period of 4 weeks is a safe, effective treatment for strictures refractory to medical treatment and/or balloon dilatation, and might be an alternative endoscopic treatment in these patients. [ABSTRACT FROM AUTHOR]

A reply to the letter to the editor is presented in response to an article that examines the role of stent in the treatment of Crohn's disease strictures.