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OBJECTIVE: To study the feasibility of tapering long-term acid-suppressant drugs (ASD) use in chronic dyspeptic patients in relation to Helicobacter pylori eradication. DESIGN: Prospective randomised double-blind study. METHOD: Patients from 54 general-practitioner practices in the Amsterdam area were studied in the period 1 April 1997 - 30 September 1999 after selection on the basis of their use of acid suppressants for a period of at least 8 weeks. After gastroscopy the patients with a peptic ulcer (PUD) and H. pylori were treated with eradication therapy and patients without an ulcer but with H. pylori were randomised for eradication or placebo treatment. After a gradual reduction of acid suppressants over a 3-week period following the intervention, the patients kept a diary for 24 weeks of the quantities of acid suppressants and antacids they used. RESULTS: Of the 1083 patients approached, 434 were prepared to undergo the gastroscopy. Data for the follow-up period were available for 186 of the 227 H. pylori-positive patients. Of them 61% stopped ASD use during follow-up. The mean daily ASD dosage per patient decreased by 85% from 1.85 to 0.27 units (p < 0.05), with minimal antacids use. Of the 75 patients with peptic-ulcer disease 86% stopped ASD use. In patients with functional dyspepsia no difference in ASD use was observed after successful H. pylori eradication or placebo. Patients with mild reflux disease (GERD) used more ASD after H. pylori eradication than after placebo (p < 0.05). CONCLUSION. After H. pylori eradication many patients with PUD stopped ADS use, while GERD patients used more ASD than after placebo. A gradual withdrawal of long-term ASD use, supported by antacids and on-demand use of low-dosage ASD, facilitated reduction of ASD use during 6 months

OBJECTIVES: A considerable proportion of the medication budget of Dutch general practitioners is spent on prescribed long-term acid suppressant drugs. We investigated the magnitude of long-term prescription of acid suppressant drugs in general practice and the frequency and means of confirming the primary working diagnosis. STUDY DESIGN: We used a retrospective descriptive study of 24 general practices in the Amsterdam region. POPULATION: We identified those receiving long-term acid suppressant therapy (12 or more weeks/year) from a total of 46,813 patients by extracting data from pharmacy databases. OUTCOMES MEASURED: We measured the amount and duration of prescriptions for each medication, indications for prescription, and investigations performed by general practitioners. RESULTS: Of the 46,813 patients, 922 (2%) received long-term acid suppressant therapy. The duration of prescription varied from 12 weeks in 8% of patients to > 52 weeks in 23% of patients (mean = 33 weeks). In 25% of patients, no investigations were performed; 75% of patients underwent endoscopy or ingested a barium meal. The predominant diagnoses in investigated patients were ulcer disease (39%), gastroesophageal reflux disease (49%), and functional dyspepsia (gastritis, normal aspect; 18%). Helicobacter pylori status was available in 29% of patients with ulcer disease. Eradication therapy was reported in 44% of these patients. CONCLUSIONS: Among patients of physicians in general practice in the Amsterdam region, 2% used long-term acid suppressants. Patients with ulcer disease may stop taking acid suppressants after apparent successful H pylori eradication. Tapering strategies must be developed for patients with mild reflux disease or functional dyspepsia

H. pylori infection is a very common infection of the human stomach, related to various diseases such as gastritis, ulcerative disease of the duodenum and stomach, mucosa associated lymphoid tissue lymphomas and gastric cancer. It is generally accepted that the majority of related diseases is curable once H. pylori infection is successfully eradicated. H. pylori eradication will only be achieved after administration of combination therapies including antibiotics and antacids. Resistance to metronidazole and clarithromycin is an emerging problem, leading to impairment of eradication efficacy, irrespective of the regimen administered. Eradication regimens consisting of three or four anti-H. pylori drugs are the most efficacious. Given the easy use and high convenience to the patients and the high efficacy, 1-week proton pump inhibitor (PPI)-triple therapy is preferred as the first-line therapy. Alternatively, bismuth triple therapy or the combination of antacids and bismuth triple therapy can be prescribed; however, these regimens are less convenient to the patients, the course is prolonged or the side effects occur more frequently compared with PPI-triple therapy

Helicobacter pylori is the causative factor of chronic gastritis and ulcers of duodenum and stomach and relates to mucosa-associated lymphoid tissue (MALT) lymphomas. Host factors, bacterial factors and dietary habits conceivably play a part in the more severe mucosal lesions induced by H. pylori. H. pylori is a heterogeneous bacterial species, the various types differing in possession of a locus with genes coding for products that may intensify the inflammatory reaction. The cytotoxin-associated gene (cagA) protein is a marker for this locus; this protein and the vacuolating-associated cytotoxin A are clearly related to the ulcerative disease. Patients may be colonized by a mixed population of H. pylori consisting of cagA-positive and cagA-negative H. pylori. Also, a patient may be infected by a mixed population of H. pylori sensitive and resistant to metronidazole. Accordingly, a substantial part of the H. pylori population in a patient should be examined to arrive at an adequate conclusion concerning the production of H. pylori factors that may relate to a particular clinical picture and to the sensitivity to antibiotics of the H. pylori

OBJECTIVE: To assess the laser assisted ratio analyser (LARA) system for detection of Helicobacter pylori infection in breath samples. DESIGN: Descriptive. METHOD: Diagnostic gastroscopy with biopsies for histopathology and culture was performed in consecutive dyspeptic patients in the Department of Gastroenterology of the Academic Medical Centre of Amsterdam in January-May 1996. Subsequently, a LARA test was carried out, which measures the degradation by H. pylori of 13C urea using the ratio of 12CO2/13CO2 in the exhaled air. The combination of the results of the examination of gastric biopsies was regarded as the golden standard for the demonstration of H. pylori infection. After this comparison, the cut-off level above which the LARA system demonstrated H. pylori infection was established in the basis of a receiver operator characteristics (ROC) analysis. An area was defined round this value within which the results were inconclusive and outside of which the reliability increased. RESULTS: 208 patients were included in the study; the data of nine of them could not be analysed (CO2 level in the exhaled air too low: 8; withdrawal: 1). The remaining 199 patients were 105 males and 94 females with a mean age of 48 years (range 19-75). Ninety-three of them (47%) were H. pylori positive according to the golden standard. With the breath analysis infection was detected in 86 of them, while in 97 patients breath analysis was correctly negative; it was false-negative in four, false-positive in three and unreliable in nine patients. The sensitivity was 96%, the specificity 97%. The positive and negative predictive values were 97% and 96%, respectively

The aim of this research was to study whether and to what extent Chinese cagA-positive Helicobacter pylori isolates differ from those in The Netherlands. Analysis of random amplified polymorphic DNA (RAPD)-PCR-assessed DNA fingerprints of chromosomal DNA of 24 cagA-positive H. pylori isolates from Dutch (n = 12) and Chinese (n = 10) patients yielded the absence of clustering. Based on comparison of the sequence of a 243-nucleotide part of cagA, the Dutch (group I) and Chinese (group II) H. pylori isolates formed two separate branches with high confidence limits in the phylogenetic tree. These two clusters were not observed when the sequence of a 240-bp part of glmM was used in the comparison. The number of nonsynonymous substitutions was much higher in cagA than in glmM, indicating positive selection. The average levels of divergence of cagA at the nucleotide and protein levels between group I and II isolates were found to be high, 13.3 and 17.9%, respectively. Possibly, the pathogenicity island (PAI) that has been integrated into the chromosome of the ancestor of H. pylori now circulating in China contained a different cagA than the PAI that has been integrated into the chromosome of the ancestor of H. pylori now circulating in The Netherlands. We conclude that in China and The Netherlands, two distinct cagA-positive H. pylori populations are circulating

Primary gastric non-Hodgkin lymphoma of mucosa-associated lymphoid tissue (MALT-NHL) is strongly related to Helicobacter pylori (H pylori) infection. CagA positive H pylori strains appear to be more aggressive, as reflected by a greater degree of gastric inflammation and higher levels of Il-8 production. Using a polymerase chain reaction-based assay, cagA status was determined in H pylori strains of 12 patients with gastric MALT-NHL, 38 patients with peptic ulcer disease, and 39 patients with non-ulcer dyspepsia. CagA-positive H pylori strains were significantly more frequent in peptic ulcer disease than in non-ulcer dyspepsia (Fisher's exact test p

OBJECTIVES: Many of the currently used Helicobacter pylori eradication regimens fail to cure 5-20% of the patients. Those patients will remain at risk of developing a potentially fatal complication of peptic ulcer disease. Therefore, a new attempt to cure H. pylori infection after initial failure of therapy is indicated. We studied the efficacy of three retreatment regimens after initial failure of omeprazole-amoxicillin dual therapy. METHODS: Fifty-three patients whose treatment failed were randomly assigned to receive retreatment with the same regimen of omeprazole 20 mg b.i.d. (group I) or omeprazole 40 mg t.i.d. (group II) plus amoxicillin 750 mg t.i.d. for 14 days. Forty patients in whom the omeprazole-amoxicillin retreatment failed were assigned to receive omeprazole 20 mg b.i.d., amoxicillin 750 mg t.i.d., and metronidazole 500 mg t.i.d. for 14 days (group III) or omeprazole 20 mg b.i.d. plus clarithromycin 500 mg t.i.d. for 14 days (group IV). H. pylori infection was assessed by culture and histology of gastric biopsies before and 4-6 wk after cessation of therapy. Susceptibility of H. pylori to amoxicillin, clarithromycin, and metronidazole was determined by the E test. RESULTS: In groups I (n = 28) and II (n = 25), cure of H. pylori infection was achieved in 21% and 28% of patients, respectively (not significant). In groups III (n = 20) and IV (n = 20), H. pylori infection was cured in 75% and 70%, respectively. CONCLUSIONS: Retreatment with an identical omeprazole-amoxicillin dual regimen is of limited benefit, a result that is independent of the omeprazole dose. In contrast, a third H. pylori eradication attempt with omeprazole-clarithromycin dual therapy or omeprazole-amoxicillin-metronidazole triple therapy provides reasonable cure rates after failure of omeprazole-amoxicillin dual therapy

Mesenteritis is an uncommon condition characterized by a variable clinical course, in which spontaneous remission may occur, but in which uncontrollable disease activity leads to death [corrected]. We describe a construction worker with mesenteritis who presented with vague abdominal discomfort and mucoid diarrhoea. A large, irregular mass was found in the abdomen. Upon explorative laparotomy, a large, rubbery, grey and yellow, irresectable tumorous mass was found, which apparently originated from the mesentery of the small bowel. The large bowel was expanded over the tumorous mass. A defunctioning colostomy was made. Histologic examination of biopsy specimens revealed only fatty necrosis of the mesentery and no evidence of malignancy. It is assumed that a pseudotumour of the mesentery had developed after chronic repetitive abdominal trauma caused by the continuous vibration of a pneumatic jackhammer, on which the patient pressed his abdomen during construction work. In this case of mesenteritis, the clinical course was one of spontaneous and complete recovery