Search

Objectives: Body mass index (BMI) in the range defined as overweight or obese adversely decreases the sustained symptomatic response (SSR) to proton pump inhibitors for patients with reflux esophagitis of Los Angeles grade A or B (RE-AB). We thus investigated whether double-dosed pantoprazole can accelerate SSR in such patients., Methods: A total of 200 overweight or obese patients with RE-AB were evenly randomized into a double-dosed group (receiving 8-week pantoprazole 40 mg twice daily) or a standard-dosed control group (receiving 8-week pantoprazole 40 mg per day and one blank tablet at night). In each patient, demographic factors and the genotype of S-mephenytoin 4'-hydroxylase (CYP2C19) were checked and defined as poor metabolizer (PM), or homologous extensive metabolizer (HomoEM), or heterologous extensive metabolizer (HeteroEM). The cumulative proportions of patients with SSR were compared during the 8-week period., Results: Both intention-to-treat and per-protocol analyses disclosed that the rates of SSR were higher in the double-dosed group than in the standard-dosed group from week 4 (P=0.005) until week 8 (P=0.01). While using standard-dosed pantoprazole, PMs had better rates of SSR during the 8-week period than both HomoEMs and HeteroEMs (P<0.05). By using double-dosed pantoprazole, the cumulative rates of SSR were improved as early as week 4 for both HomoEMs and HeteroEMs (P<0.005, log-rank test)., Conclusions: For RE-AB in overweight and obese patients, double-dosed pantoprazole effectively accelerates the SSR, especially for those with CYP2C19 genotypes as HeteroEM or HomoEM. Accordingly, it offers an earlier shift into on-demand pantoprazole for RE-AB patients with high BMI.

Objectives: This study aimed to determine whether Helicobacter pylori eradication limits the progression of precancerous changes, manifested as intestinal metaplasia (IM), in patients with reflux esophagitis using long-term esomeprazole., Methods: Three hundred twenty-five reflux esophagitis patients were enrolled and randomly assigned to (i) the H. pylori-positive eradication group receiving 1-week triple therapy (n=105); (ii) H. pylori-positive non-eradication controls (n=105); and (iii) H. pylori-negative controls (n=115). All the patients received continuous esomeprazole until sustained symptomatic response, and when possible, shifted to on-demand therapy (ODT) thereafter. Serial gastroscopy was scheduled on enrollment and at the end of the first and second years to assess the prevalence and progression or regression of gastric atrophy (AT) and IM., Results: There were 93 patients in the H. pylori-eradication group, 83 in the non-eradication controls, and 100 in the negative controls to complete the study. The negative controls had no progression of AT and IM during follow-up. For the H. pylori-positive eradication group, there was significant regression of AT and IM during follow-up (P<0.05). In the H. pylori-positive non-treated controls, the prevalence rates of AT and IM were significantly greater on the second year than on enrollment (P<0.05). During the second-year follow-up, the patients in the eradication group achieved more regression and less development of AT and IM than did the non-eradication controls (P<0.001)., Conclusions: In patients using long-term esomeprazole for reflux esophagitis, screening for and eradicating H. pylori infection are necessary in order to limit the progression or cause the regression of gastric precancerous changes.

Aims: This study assessed the endoscopic healing rates of reflux esophagitis with Los Angeles grades C and D (RE-CD) using a 6-month esomeprazole and the demographic factors or genotypes of S-mephenytoin 4'-hydroxylase (CYP2C19) that correlated with the healing of RE-CD., Methods: One hundred thirteen patients with RE-CD received esomeprazole 40 mg daily for 6 months and completed serial follow-ups regarding healing by endoscopies at the 1st month and the 6th month, respectively. In each patient, demographic factors, including body mass index (BMI), and the CYP2C19 genotypes were checked., Results: The endoscopic healing rates of RE-CD were similar among patients with different genotypes of CYP2C19 at the 1st month and the 6th month, respectively (P > 0.05). A lower healing rate of RE-CD at the 1st month was independently related to a higher BMI > 25 kg/m(2), coffee drinking, and the presence of hiatus hernia (P < 0.05), but not with the CYP2C19 genotypes. A higher BMI > 25 kg/m(2) independently had a 2.32-fold decrease of the healing of RE-CD (P < 0.001), but a net decrease of BMI > 1.5 kg/m(2) independently had a 3.65-fold increase of the healing of RE-CD at the 6th month (P= 0.014)., Conclusions: Esomeprazole 40 mg daily can be effective for RE-CD patients with different CYP2C19 genotypes. BMI > 25 kg/m(2) is an independent risk factor to determine the healing of RE-CD by esomeprazole. Reducing BMI > 1.5 kg/m(2), especially for those with an initial BMI > 25 kg/m(2), could be promising to improve the healing of RE-CD by esomeprazole.

Background and Aims: Patients with Los Angeles grade A or B reflux esophagitis (RE-AB) can potentially be switched from active-phase therapy to on-demand esomeprazole as maintenance therapy. Body mass index (BMI) correlates significantly with reflux symptoms. We investigated whether BMI affects the efficacy of esomeprazole in active-phase or subsequent on-demand therapy., Methods: Three hundred fifty patients with RE-AB were prospectively enrolled to receive an 8-wk course of esomeprazole (40 mg/day) as active-phase therapy. Based on the daily severity of acid regurgitation and heartburn, the cumulative proportions of patients with sustained symptomatic response (SSR), defined as free from symptoms for the last 7 days, were compared among different BMI groups (control: BMI <25 kg/m2, overweight: BMI 25-30 kg/m2, obese: BMI >30 kg/m2). In patients who had achieved SSR by week 8, on-demand therapy for 2 months was started. The number of 40-mg esomeprazole tablets used per 4-wk period was recorded., Results: SSR rates were lower in both the overweight and obese groups than in the control group (P < 0.001). During on-demand therapy, the mean number of tablets used per 4-wk period was lower in the control group than in either the overweight or the obese group (13.2 vs 15.3 or 16.2, P < 0.05). The failure rate of on-demand therapy increased with increasing BMI-2.4%, 5.3%, and 14.2%, respectively, for the control, overweight, and obese groups (P= 0.002)., Conclusion: For RE-AB, a higher BMI decreases the rate of SSR after 8-wk of esomeprazole therapy, and increases the need for medication and the failure rate of on-demand therapy.

Objectives: We tested whether the interaction between host gastric Le(x) antigen and the SabA protein of H. pylori determined gastric colonization density., Methods: A total of 145 H. pylori-infected patients were assessed for their bacterial density and gastric Le(b) and sialyl-Le(x) expression. Their corresponding H. pylori isolates were tested for babA2 and sabA genotype by PCR. The sabA-genopositive PCR products were sequenced to check for mutations affecting SabA expression. The BabA and SabA expressions of each isolate were confirmed by Western blotting., Results: All 145 H. pylori isolates were babA2-genopositive and expressed BabA. There were 116 (80%) sabA-genopositive isolates, but only 45 (31%) of the isolates expressed SabA. Sequence of sabA-genopositive PCR products was achieved in 92 isolates, of which 60% had regular CT repeat-pairs and the other 40% had a unique deletion of the CT repeats. Neither the deletion nor the different CT repeat-pairs in the sabA region were totally correlated with SabA expression, defined by Western blotting. H. pylori density was higher in those expressing gastric sialyl-Le(x) antigen (which interacts with SabA) (p < 0.001) only in those patients expressing weak or no gastric Le(b) antigen (which would interact with BabA), not in those with evident expression of gastric Le(b) antigen., Conclusions: In Taiwan, H. pylori isolates are 100% BabA-positive, but only 31% of them express SabA. The interaction between gastric sialyl-Le(x) and SabA of H. pylori determines the colonization density of patients expressing gastric Le(b) weakly or not at all.

Objectives: This study tested whether host genotypes of the tumor necrosis factor-alpha (TNF-alpha) promoter single nucleotide polymorphism (SNP) could determine clinical and histological outcomes after Helicobacter pylori infection., Methods: A total of 524 dyspeptic patients, 424 with and 100 without H. pylori infection, were checked for TNF-alpha promoter SNP over the locus on -1031(T/C), -863(C/A), -857(C/T), -806(C/T), and -308(G/A) by sequence-specific oligonucleotide probe. Each patient received panendoscopy to take gastric biopsy to detect H. pylori infection and its related histology using the updated Sydney's system. Gastric TNF-alpha expressions were stained by immunohistochemistry., Results: In H. pylori-infected patients, -1031C or -863A carriers of TNF-alpha promoter had more severe gastric neutrophil infiltration and TNF-alpha gastric staining than individuals with -1031TT or -863CC genotype, respectively (p<0.05). The multivariate logistic regression verified both -1031C and -863A carriers were independent risk factors to have duodenal ulcers and gastric ulcer without IM in the H. pylori-infected hosts (p<0.05). As compared to -863CC and -1031TT genotype combinations, the ulcer risk after H. pylori infection was 2.46 (95% CI: 1.32-4.59, p

Objective: To ascertain whether triple therapy alters the history of Helicobacter pylori (HP)-related nonulcer dyspepsia (NUD)., Methods: Forty-one young (<45 yr) dyspeptic patients were confirmed to be HP-related NUD by serology, rapid urease test, and antral biopsy. Endoscopy excluded the presence of ulcer. These cases were randomly plotted into control (n = 21) and triple therapy (n = 20) groups. In the former group, H2 blocker was given for 2 months and then intermittent antisecretory agents for up to 1 yr. In the latter group, 20 patients received a course of triple therapy and then were treated like the control group. The symptom scores (range: 0-10) were collected on enrollment, and at the end of 2nd, 6th, and 12th months. Each case had serial tests of HP IgG ELISA titer on start, at weeks 2, 4, and 8, at the 6th month, and at the end of the 1st yr. The second endoscopy was done in the 9th wk for eradication survey, and the third endoscopy, at the end of the 1st yr to resurvey the HP status. The histological gradings of biopsy specimens, sampled on each endoscopy, were compared., Results: In the triple therapy group, the rate of eradication of HP was 75%. At he end of the 2nd month, the HP-eradicated cases of the triple therapy group improved the symptom score more significantly then the noneradicated cases (2.42+/-1.37 vs.4.76+/-1.58, p <0.001). At the ends of the 6th month and 1st yr, the symptom scores of the eradicated cases improved more significantly than those of the control group (6th month, 0.61+/-1.18 vs.] 2.66+/-2.06; 1st yr, 0.82+/-1.17 vs.] 3.56+/-2.89, p <0.001). The decline trend of ELISA titers occurred only in eradicated cases and became significantly evident from the 4th wk (0.30+/-0.15 vs.] 0.49+/-0.07, p <0.05) and thereafter. Both acute and chronic pathological grading was improved in the triple group at the end of the 1st yr (acute, 1.95-0.46; chronic, 1.9-0.92; p <0,01), Conclusion: Compared with control therapy at 1 yr, triple therapy showed greater symptomatic, serological, and histological improvements. Therefore, triple therapy is beneficial to symptomatic HP-related NUD.

Objectives: Choledochoduodenal fistula (CDF) is occasionally found during endoscopic retrograde cholangiopancreatography (ERCP). Cholelithiasis is suspected to be the leading cause in some endemic areas. We focus on this cause of CDF to determine which clinical characteristics are relevant to formation of fistulas and to learn whether CDF of various types would imply different clinical significance., Methods: In 1882 ERCP studies from 1988 to 1993, we found 27 CDF with cholelithiasis in 1066 patients. Their clinical backgrounds and ERCP findings were compared with those of 492 patients who had cholelithiasis but no CDF., Results: The prevalence of CDF was 2.53%. A longer past history of biliary stones, recurrent biliary tract infection (BTI), and the presence of common bile duct stones (CBS) were factors relevant to the formation of fistula. In the case of 24 distal fistulas, including seven of type I and 17 of type II, there was concurrent distal CBS. Three cardinal features of fistula of the distal type were: 1) the length of CDF was less than 1.5 cm, 2) its orifice was just around or on the papillary fold, and 3) all cases of distal type II had prominent pneumobilia, less jaundice, and larger CBS than type I. Aggressive endoscopic or surgical treatment of distal type CDF decreased the recurrence of BTI, as indicated by surveillance for 1 yr. Three fistulas of the proximal type were longer and drained into the duodenum far from the papilla. All of these cases deserved early surgical intervention., Conclusions: CDF really serves as a chronic sequel of cholelithiasis. Different clinical features of CDF of various types help one to establish diagnosis and treatment. To avoid recurrence of BTI, aggressive therapy to correct CDF is mandatory.

Chlormezanone is a widely prescribed muscle relaxant (1-3) whose pharmacology is well known (4-6), but the clinical effect of overdose still remains relatively obscure (1, 7, 8). We here report a recent case of a patient who had severe liver function impairment and other associated findings typical of chlormezanone overdose. The ingested dose (at least 12 g) is much larger than those of previous record (1, 2, 7, 8); thus, her critical presentation deserves to be reviewed.