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Reduction in the endoscopic workload by means of case selection based on empiric therapies has been advocated in order to reduce the costs for dyspepsia. The present study compares the efficacy of the "H. pylori — Hptest and treat strategy" with an empiric omeprazole trial. Methods: 219 dyspeptic outpatients younger than 45 years without alarm and typical reflux symptoms were considered. They were randomly assigned to 4-weeks treatment with omeprazole 20 mg od (group A n = 109) or to UBT (group B, n = 110) followed by one-week eradication treatment in case of Hp infection (n = 67) or the same therapy as in group A in Hp negative (n = 43). Symptoms were assessed by means of a questionnaire at the first visit, 4 weeks later and then every two months for one year. Lack of improvement or recurrence of symptoms indicated endoscopy. Results: 19 patients of group A (17%) and 32 of group B (29.1%, 20/67 Hp+, 12/43 Hp-) did not improved after the treatment and underwent endoscopy. 77 further patients of group A and 29 of group B (7 Hp+ and 22 Hp-) underwent endoscopy during the follow up because of symptoms recurrence. Overall, 96 patients (88%) of group A and 61 (55.4%) of group B had an endoscopy (p < 0.0001). At endoscopy, peptic ulcers were found only in group A, while in group B the number of esophagitis was significantly higher than in A. About 80% of examinations were normal in both groups, but 9 duodenal scars were found in A. Conclusion: The eradication treatment allows the resolution of symptoms in a large number of dyspeptics with a significant reduction in the endoscopic workload. After a PPI trial, symptoms recur nearly in every patient. Furthermore, such a treatment is likely to mask a significant number of peptic ulcer and esophagitis. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of a "Helicobacter pylori test and treat" strategy with that of an empirical trial of omeprazole in the non-endoscopic management by empirical prescribing of young patients with dyspepsia., Design: Randomised controlled trial., Setting: Hospital gastroenterology unit., Participants: 219 patients under 45 years old presenting with dyspepsia without alarm symptoms., Intervention: Patients received treatment with omeprazole 20 mg (group A) or with a urea breath test followed by an eradication treatment in case of H pylori infection or omeprazole alone in non-infected patients (group B). Lack of improvement or recurrence of symptoms prompted endoscopy., Main Outcome Measures: Improvement in symptoms assessed by a dyspepsia severity score every two months; use of medical resources (endoscopic workload and medical consultation); clinical outcome., Results: 96/109 (88%) patients in group A and 61/110 (55%) in group B (P < 0.0001) had endoscopy: in 19 patients in group A and 32 in group B (20/67 infected and 12/43 non-infected) because of no improvement; in 77 further patients in group A and 29 in group B (7 infected and 22 non-infected) because of recurrence of symptoms during follow up. Endoscopy showed peptic ulcers only in group A; oesophagitis occurred significantly more often in group B than in group A. About 80% of examinations were normal in both groups, but nine duodenal scars occurred in group A., Conclusions: Eradication treatment allows resolution of symptoms in a large number of patients with dyspepsia and reduces the endoscopic workload. After a trial of omeprazole, symptoms recur in nearly every patient. Such treatment is also likely to mask an appreciable number of peptic ulcers and cases of oesophagitis.

Sliding hiatal hernia is a common endoscopic finding with a prevalence that increases with the age of patients. Although nearly all patients with GERD have HH, only a minority of patients with hernia reports reflux symptoms. Our hypothesis is that H. pylori infection may be responsible for the high number of asymptomatic hernias. After exclusion of patients with peptic ulcer, 507 patients with an endoscopic diagnosis of hernia were considered. Patients were divided into three groups: A, < or = 45 years, 141 patients; B, 46-60 years, 144 patients; and C, > or = 61 years, 222 patients. Presence of reflux symptoms (questionnaire) and esophagitis, H. pylori status, and gastric histology were recorded. The prevalence of hernia in the total series was 11% in group A, 23% in B, and 38% in C. Aging was associated with a significant increase in H. pylori prevalence and corpus gastritis scores, and a parallel decrease of GERD symptom prevalence, which was 66.6% in group A, 52.1% in B, and 46.8% in C (P < 0.01). Taking the three groups together, prevalence of H. pylori infection was higher in patients without GERD than with GERD (66.4 vs 57.3%, P < 0.05), and higher in patients with nonerosive GERD than erosive GERD (62.8 vs 48.6%, P = 0.02); corpus gastritis scores were significantly higher in patients without GERD than those with GERD and in those with nonerosive than erosive GERD. In conclusion, H. pylori infection protects against development of GERD in subjects with hiatus hernia. This effect is significantly more evident in the elderly where, in spite of the high prevalence of hernia, only a small number of individuals develop GERD. The development of a corpus-predominant gastritis is probably responsible for this effect.

Background/aim: Aim of the present study is to assess, according to the guidelines of the Maastricht Consensus Conference, the appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system, in order to evaluate the diffusion of knowledge about Helicobacter pylori among different types of physicians., Methods: Patients undergoing endoscopy because of dyspeptic symptoms were prospectively considered in 21 endoscopy services of Campania during two different 1-week periods in 1998 and 2001. The following data were recorded: age, sex, symptoms, history of peptic ulcer with regard to previous endoscopic or radiographic examinations and treatment, endoscopic diagnosis, and H. pylori status. The indication for endoscopy was evaluated according to Maastricht guidelines and current medical knowledge., Results: In the two periods, 1998 and 2001, 706 and 520 patients were, respectively, considered. The two series were matched for demographic characteristics, symptoms, and endoscopic diagnosis. Endoscopy was considered not indicated in 398 patients (56.4%) in 1998 and in 265 patients (50.9%) in 2001 (p = NS). The majority of them, 288/398 (72.3%) in 1998 and 162/265 (61.1%) in 2001 (p = 0.001), had recently undergone endoscopy or radiology and empiric antisecretory treatment or eradication. They had been referred to endoscopy because of recurrence of symptoms or to assess healing. In 110 cases in 1998 (27.6%) and in 103 cases in 2001 (38.9%; p = 0.001) endoscopy was performed in dyspeptic patients younger than 45 years without alarm symptoms., Conclusions: 4 years after the Maastricht Conference, a large number of endoscopic examinations are not indicated and could be avoided following the Maastricht guidelines. In 2001, in comparison to 1998, a larger number of physicians are likely to investigate and treat correctly the H.-pylori-related diseases, but there are still some problems with the application of the 'test-and-treat policy'., (Copyright 2001 S. Karger AG, Basel)

Whipple's disease is a chronic systemic syndrome which typically involves small intestinal mucosa. There is no doubt today about its bacterial etiology and its good response to antibiotic therapy. A peculiar case is reported, in which the failure of a protracted corticosteroidal treatment is demonstrated and a particularly prompt endoscopic healing after therapy with cotrimoxazole is obtained. The value of duodenal biopsy in course of upper gastrointestinal endoscopy in comparison with classic intraluminal jejunal biopsy is confirmed for the diagnosis of Whipple's disease.

On the basis of personal experience (104 LTC and 88 ERCP), the value of direct cholangiography in the diagnosis of biliary lithiasis especially in the event of failure of traditional radiology and in the presence of icterus is confirmed. LTC in 37 patients and ERCP in 18 revealed calculosis of the bile ways, thus correcting a falsely negative echography and i.v. cholangiography to the extent of 70% and 25% respectively. Stress is laid on the importance of direct cholangiography because it is able to establish the site of the stones and, above all, the pathology associated with calculosis, involving not only the bile ways, but the papilla, pancreas and liver too.