Chronic gastritis

Abstract

Prevalence of chronic gastritis has markedly declined in developed populations during the past decades. However, chronic gastritis is still one of the most common serious pandemic infections with such severe killing sequelae as peptic ulcer or gastric cancer. Globally, on average, even more than half of people may have a chronic gastritis at present. Helicobacter pylori infection in childhood is the main cause of chronic gastritis, which microbial origin is the key for the understanding of the bizarre epidemiology and course of the disease. A life-long and aggressive inflammation in gastritis results in destruction (atrophic gastritis) of stomach mucosa with time (years and decades). The progressive worsening of atrophic gastritis results subsequently in dysfunctions of stomach mucosa. Atrophic gastritis will finally end up in a permanently acid-free stomach in the most extreme cases. Severe atrophic gastritis and acid-free stomach are the highest independent risk conditions for gastric cancer known so far. In addition to the risks of malignancy and peptic ulcer, acid-free stomach and severe forms of atrophic gastritis may associate with failures in absorption of essential vitamins, like vitamin B12, micronutrients (like iron, calcium, magnesium and zinc), diet and medicines.     

Chronic pancreatitis

Opinion statement Management of chronic pancreatitis is a difficult endeavor for the clinician due to a variety of reasons. These include the variable presentation of symptoms such as chronic pain, recurrent pain, pain associated with malabsorption due to maldigestion, or even maldigestion alone in 15% of patients. It is paramount that the clinician and patient devise appropriate treatment based on prevailing symptoms, and anatomical/functional alterations in the pancreas. Concentrating on symptoms allows the best opportunity to improve the patient’s quality of life. Having an understanding of the patient’s anatomical and functional derangement will assist the clinician in targeting treatment particular to the individual. Awareness of complications associated with chronic pancreatitis is important to allow detection and treatment as they are encountered. Treatment of chronic pancreatitis involves a stepwise approach. Treatment options that are the least invasive and are proven to work should be tried first, and if they are unsuccessful, appropriate alternative treatments can be employed. First-line therapy involves analgesics, non-narcotic and narcotic, in conjunction with pancreatic enzymes. For the pain-predominant cases, this includes nonenteric-coated enzyme supplements. For the individual with maldigestion as the predominant symptom, this includes entericcoated enzyme supplements. This initial trial should be continued for 3 to 6 months. If this fails to provide adequate improvement, then individualized treatment should involve surgical options and if appropriate in specific instances, endoscopic approaches.     

Chronic Rhinosinusitis

Chronic rhinosinusitis is characterized by nasal purulence accompanied by malaise, postnasal drip and nasal dryness or crusting. It is a condition that is very difficult to treat and can be very disabling to the patients. A clinical diagnosis is based on history and evaluation with endoscopy, and computerized tomographic scanning. The etiology of chronic rhinosinusitis is multifactorial and comprises a vicious cycle of pathophysiological, anatomical, and constitutive factors. Predisposing factors include ciliary impairment, allergy, nasal polyposis, and immune deficiency. Treatment is aimed at reducing mucosal inflammation and swelling, controlling infection, and restoring aeration of the nasal and sinus mucosa. The choice of treatment is influenced by many factors including past medication, duration of symptoms and the presence of allergy/nasal polyps. Pharmacologic treatment, with local or systemic corticosteroids such as mometasone furoate, fluticasone propionate, beclometasone dipropionate or oral prednisolone coupled with nasal lavage with isotonic saline solutions are the cornerstones of disease management. Systemic antibiotics including amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, and trimethoprim/sulfamethoxazole (cotrimoxazole) are often administered to patients with chronic sinusitis and underlying bacterial infection. In patients with underlying allergy, additional treatment with antihistamines should be considered. Aeration of the sinuses may temporarily be improved with local nasal decongestants such as oxymetazoline. If symptoms persist after aggressive medical treatment, surgery should be considered. Surgery should be functional and involve widening the natural drainage openings of the sinuses and preserving the ciliated epithelium as much as possible. In the case of nasal polyposis surgery is more aggressive involving removal of the diseased polypous mucosa. It is recommended that medical treatment should be continued post sinus surgery.     

Chronic pancreatitis

The present article summarizes some of the most important results with potential clinical impact on the diagnosis and management of chronic pancreatitis presented at the last meeting of Digestive Disease Week. Endoscopic ultrasound (EUS) is currently the method of choice for the diagnosis of chronic pancreatitis in clinical practice. However, some new studies suggest that the Rosemont classification is not useful for diagnosis of this disease in the early stages, whereas others show that, in patients with abdominal pain, chronic pancreatitis cannot be excluded even when there are less than three EUS criteria of the disease. In contrast, new studies support the usefulness of endoscopic ultrasound for the diagnosis of autoimmune pancreatitis in the presence of pancreatic ductitis. From the therapeutic point of view, a notable contribution at the congress was a new randomized placebo-controlled clinical trial showing the efficacy of pregabalin for the treatment of pain in chronic pancreatitis.     

Chronic insomnia

Insomnia is a prevalent complaint in clinical practice that can present independently or comorbidly with another medical or psychiatric disorder. In either case, it might need treatment of its own. Of the different therapeutic options available, benzodiazepine-receptor agonists (BzRAs) and cognitive-behavioural therapy (CBT) are supported by the best empirical evidence. BzRAs are readily available and effective in the short-term management of insomnia, but evidence of long-term efficacy is scarce and most hypnotic drugs are associated with potential adverse effects. CBT is an effective alternative for chronic insomnia. Although more time consuming than drug management, CBT produces sleep improvements that are sustained over time, and this therapy is accepted by patients. Although CBT is not readily available in most clinical settings, access and delivery can be made easier through use of innovative methods such as telephone consultations, group therapy, and self-help approaches. Combined CBT and drug treatment can optimise outcomes, although evidence to guide clinical practice on the best way to integrate these approaches is scarce.