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Purpose: To assess the effect of eradication therapy for Helicobacter pylori on symptoms of nonulcer dyspepsia.Data Sources: Duplicate searches of bibliographic databases, reviews of proceedings of annual gastroenterology and H. pylori meetings from 1995 to 1999, reviews of reference lists, and contact with primary investigators and pharmaceutical manufacturers.Study Selection: Included studies 1) examined patients with nonulcer dyspepsia and H. pylori infection; 2) used combination therapy for H. pylori and a control therapy without efficacy against H. pylori; 3) were randomized, controlled trials; 4) lasted for at least 1 month after the end of therapy; and 5) assessed symptoms of nonulcer dyspepsia. Ten studies were included.Data Extraction: Independent, duplicate data extraction of the methodologic quality, population, intervention, study design, duration, and outcome of the trials.Data Synthesis: The odds ratio (OR) for treatment success in nonulcer dyspepsia with H. pylori eradication therapy compared with control therapy was 1.29 (95% CI, 0.89 to 1.89; P = 0.18). However, significant heterogeneity (P = 0.04) calls the validity of aggregating the data into question. Heterogeneity resolved with the exclusion of one study (OR, 1.07 [CI, 0.83 to 1.37]; P > 0.2). For predefined analysis of trials that used a specifically stated definition of dyspepsia (that is, upper abdominal pain or discomfort), the OR was 1.04 (CI, 0.80 to 1.35) without heterogeneity. For treatment that resulted in cure rather than persistent infection, the OR was 1.17 (CI, 0.87 to 1.59) without heterogeneity.Conclusion: This meta-analysis provides little support for the use of H. pylori eradication therapy in patients with nonulcer dyspepsia. [ABSTRACT FROM AUTHOR]

Purpose: To compare the effect of endoscopic ligation with that of sclerotherapy in the treatment of patients with bleeding esophageal varices.Data Sources: Strategies to identify published and unpublished research included searches of computerized bibliographic and scientific citations, review of citations in relevant primary articles, searches of services providing information on unpublished studies, contact with primary investigators and the ligation equipment manufacturer, and review of proceedings from pertinent scientific meetings.Study Selection: From 158 potentially relevant articles, duplicate independent review identified 7 relevant randomized trials that compared endoscopic ligation with sclerotherapy for the treatment of patients with bleeding esophageal varices.Data Abstraction: Independent, duplicate data abstraction of the population, intervention, outcome, and methodologic quality of the trials was done.Data Synthesis: Ligation therapy compared with sclerotherapy reduced the rebleeding rate (odds ratio, 0.52 [95% CI, 0.37 to 0.74]), the mortality rate (odds ratio, 0.67 [CI, 0.46 to 0.98]), and the rate of death due to bleeding (odds ratio, 0.49 [CI, 0.24 to 0.996]). Four patients would need to be treated with ligation instead of sclerotherapy to avert one rebleeding episode, and 10 would need to be treated with ligation instead of sclerotherapy to prevent one death. Esophageal strictures occurred less frequently with ligation (odds ratio, 0.10 [CI, 0.03 to 0.29]), but no significant differences were seen between treatments for pulmonary infections or bacterial peritonitis. Additionally, the number of endoscopic treatment sessions required to achieve variceal obliteration was lower with ligation than with sclerotherapy.Conclusions: On the basis of lower rates of rebleeding, mortality, and complications and the need for fewer endoscopic treatments, ligation should be considered the endoscopic treatment of choice for patients with esophageal variceal bleeding. [ABSTRACT FROM AUTHOR]

Study Objective: To assess the efficacy and safety of treatment with endoscopic multipolar electrocoagulation in patients who have ulcers with nonbleeding visible vessels.Design: Prospective, randomized, sham-controlled trial; patients were followed until their discharge from the hospital.Setting: Urban, nonreferral county hospital.Patients: Consecutive sample of 75 patients who had a bloody nasogastric aspirate sample, melena, or hematochezia; unstable vital signs, a transfusion of at least two units of blood in 12 hours, or a drop in the hematocrit of at least 0.06 in 12 hours; and endoscopic evidence of an ulcer with a nonbleeding visible vessel.Intervention: Sham or real multipolar electrocoagulation at the time of diagnostic endoscopy.Measurements and Main Results: Compared with the control group, the group receiving multipolar electrocoagulation showed marked improvement in the following variables; rebleeding (18% compared with 41%, P less than 0.05; difference, 23%; 95% CI, 3% to 43%); need for emergency surgery (8% compared with 30%, P less than 0.05; difference, 22%; CI, 5% to 39%); mean number of hospital days (4.3 +/- 0.4 compared with 6.2 +/- 0.7, P less than 0.05; difference, 1.9; CI, 0.4 to 3.4); and cost of hospitalization ($3790 +/- $410 compared with $5730 +/- $650, P less than 0.05; difference, $1940; CI, $400 to $3480). The mean transfusion requirement in the treatment group was 1.6 +/- 0.3 as compared with 3.0 +/- 0.6 units in the control group (P = 0.13; difference, 1.4; CI, 0 to 2.8). The overall mortality was extremely low: Only 1 (1%) of 75 patients died. Bleeding was induced in 7 (18%) of the 38 patients treated with electrocoagulation, and 1 patient required urgent surgery.Conclusions: Endoscopic treatment with multipolar electrocoagulation is beneficial in patients who present with major upper gastrointestinal hemorrhage and are found to have an ulcer with a nonbleeding visible vessel. [ABSTRACT FROM AUTHOR]

Objective: Comparison of the safety and efficacy of endoscopic sclerotherapy and ligation for the treatment of bleeding esophageal varices.Design: Randomized, controlled trial.Setting: An urban county hospital.Patients: Patients with clinically severe bleeding from esophageal varices.Intervention: A total of 77 patients were randomly assigned to receive sclerotherapy or ligation at the initial endoscopic examination. Treatment was repeated weekly until variceal obliteration was achieved. After eradication, patients had endoscopic examinations every 3 months or for any episode of rebleeding. Recurrent varices were treated with the originally assigned form of endoscopic therapy.Measurements: Patients were assessed for further bleeding, for transfusion requirements, for time in hospital, for variceal eradication, for number of treatment sessions required, for complications, for treatment failure, and for risk of death.Results: Rebleeding tended to be less frequent with ligation than with sclerotherapy: 10 of 38 (26%) compared with 17 of 39 (44%) (difference, 17% [95 CI, -4% to 38%]), but results in the two groups were comparable for blood transfusions, for length of hospital stay, and for risk of death. Comparison of Kaplan-Meier estimates of time to rebleeding and death showed no statistical differences between treatments. Complications were less common in the ligation group: fewer patients in the ligation group had esophageal strictures (0 of 38 compared with 13 of 39 [33%]; P < 0.001) and had complicated esophageal ulcers (1 of 38 [2.6%] compared with 6 of 39 [15%]; P = 0.11). In addition, fewer ligation treatments were required to achieve variceal eradication (4.1 +/- 0.3 compared with 6.2 +/- 0.4; P < 0.001).Conclusion: Endoscopic ligation causes statistically fewer local complications than sclerotherapy and achieves variceal eradication more rapidly. Ligation is a viable alternative to sclerotherapy and may have some advantages as a treatment for bleeding esophageal varices. [ABSTRACT FROM AUTHOR]

Objective: To determine the clinical and endoscopic response of candida esophagitis to antifungal therapy and to compare the two oral antifungal agents, fluconazole and ketoconazole.Design: Multicenter, randomized, double-blind trial.Setting: Fifteen U.S. centers including university, private practice, and county hospital settings.Patients: A total of 169 patients with the acquired immunodeficiency syndrome (AIDS); odynophagia, dysphagia, or retrosternal pain; white esophageal plaques at endoscopy; and pseudohyphae on esophageal brushings or biopsies.Intervention: Patients were randomly assigned to fluconazole (100 mg/d) or ketoconazole (200 mg/d). Doses were doubled at week 1 or 2 if no symptomatic improvement had occurred during the preceding week. Therapy was continued for 2 weeks after resolution of symptoms or for a maximum of 8 weeks.Measurements: Patients were clinically evaluated weekly, and laboratory tests were done every 2 weeks. Endoscopy was repeated within 5 days after the end of therapy.Results: A total of 143 patients were clinically evaluable (assessed within 7 days after therapy), and 129 patients were endoscopically evaluable (endoscopy repeated after therapy). Endoscopic cure occurred in 91% of patients treated with fluconazole and in 52% of those given ketoconazole for a difference of 39% (95% Cl, 24% to 52%; P less than 0.001). Esophageal symptoms resolved in 85% of fluconazole-treated patients and in 65% of ketoconazole-treated patients for a difference of 20% (Cl, 6% to 34%; P = 0.006). Intention-to-treat analyses also yielded statistically significant differences for the comparisons listed above. Side effects were minimal and comparable in the two groups; only one patient in each group had therapy discontinued for adverse effects that were possibly related to the study medications.Conclusions: Fluconazole is associated with significantly greater rates of endoscopic and clinical cure than ketoconazole in patients with AIDS and candida esophagitis. Both drugs appear to be safe and well tolerated. [ABSTRACT FROM AUTHOR]

Background: Proton-pump inhibitor therapy may cause false-negative results on Helicobacter pylori diagnostic testing.Objective: To determine the frequency and duration of conversion of urea breath test results from positive to negative in patients given a proton-pump inhibitor.Setting: Two urban university gastroenterology clinics.Patients: Patients infected with H. pylori who had positive results on urea breath tests.Intervention: Lansoprazole, 30 mg/d for 28 days.Measurements: The urea breath test was repeated at 28 days. If the results were negative, testing was repeated 3, 7, 14, and 28 days after completion of therapy until the results reverted to positive.Results: 31 (33%) of 93 patients in whom H. pylori was not eradicated had a negative breath test result while receiving lansoprazole. The proportions of patients whose breath test results were positive after completion of lansoprazole therapy were 91% (95% CI, 83% to 96%) at 3 days, 97% (CI, 90% to 99%) at 7 days, and 100% (CI, 96% to 100%) at 14 days.Conclusion: Patients should not receive proton-pump inhibitors for 2 weeks before receiving the urea breath test for H. pylori infection. [ABSTRACT FROM AUTHOR]

Description: This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations., Methods: An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional., Recommendations: Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.