Effect of Combined Anticoagulation and Low-Dose Aspirin Treatment on Upper Gastrointestinal Bleeding

Multiple studies link the use of nonsteroidalantiinflammatory drugs (NSAIDs) with severe uppergastrointestinal bleeding (UGIB); the incidence of suchbleeding is 2-4%. One common regimen to assure patency after intracoronary stent placement requires ananticoagulant (warfarin) combined with aspirin as anantiplatelet agent. However, a 13-fold increase in therisk of UGIB occurs with long-term use of oral anticoagulants and NSAIDs. We retrospectivelyassessed the rate of UGIB in 138 patients who hadreceived coronary stents (group I, receiving heparinfollowed by warfarin in combination with aspirin) and 109 angioplasty patients without stents (groupII, receiving aspirin alone) between 1990 and 1994. UGIBwas identified by hematemesis or melena, which led togastrointestinal consultation. Patients were analyzed for multiple risk factors. UGIBoccurred in 28 of 138 group I patients (20%; 95% CI13.3-26.7%) and 0 of 109 group II patients (P 0.0001). Esophagogastroduodenoscopy (EGD) findings onthe 28 patients with UGIB included 13 patients with esophagitisor gastritis, 7 patients with gastric or duodenalulcers, and 8 patients with no identifiable source ofbleeding. UGIB occurred within a mean of 2.5 days of initiation of combination therapy. Ofpatients with UGIB, 10 required blood transfusion (meannumber of units 5.3). Previous history of peptic ulcerdisease, smoking, and use of antiulcer medication did not significantly differ between the twogroups. The concurrent use of anticoagulant and aspirinin patients with coronary stents creates a significantpotential for UGIB and should be used only with extreme caution.     

Can Screening for IgG Antibodies Against Helicobacter pylori Be Used in Clinical Practice? (Omit Endoscopy in Seropositive or Seronegative Patients?)

The objective of this study was to test thefeasibility of a screening strategy for IgG antibodiesagainst Helicobacter pylori in patients presenting withupper abdominal complaints. Biopsy specimens were taken for histological and microbiologicalinvestigations from consecutive patients undergoingupper gastrointestinal endoscopy. In addition, a serumsample was taken for detection of IgG antibodies against Helicobacter pylori, using an ELISA technique.Serum samples from 1294 consecutive patients wereavailable. IgG antibodies against Helicobacter pyloriwere present in 622 patients (48%), the remaining 671 (52%) were negative. If endoscopy had beenomitted in seronegative patients below the age of 45years, this would have resulted in 234 patients notendoscoped. However, it can be assumed that 62 of these patients would undergo endoscopy becauseof recurrent complaints due to underlying disease orabnormality. Therefore 182 of 1294 (14%) of endoscopieswould have been avoided. Application of this strategy on the total group of seronegatives would save353 of 1294 (27.3%) endoscopies. If endoscopy had beenomitted in seropositive cases below the age of 45 years,and these patients were treated with anti-Helicobactertherapy, an initial 145 endoscopies would have beenavoided. However, 26 of these patients would undergoendoscopy because of persistent complaints due tounderlying disease. Therefore 119 (9%) endoscopies would have been avoided.Applying this strategy in the total group ofseropositives would have saved 434 of 1294 endoscopies(34%). Applying the IgG screening strategy in allpatients would result in a significant number of endoscopiesbeing avoided in the seropositive group, 434 versus 353(P < 0.001). In conclusion, omitting endoscopy inseropositive cases, regardless of age, can reduce the workload more than omitting endoscopy inseronegative cases: 34% fewer endoscopies versus27%.     

Helicobacter pylori Infection and Gastric Cancer (A Nested Case-Control Study in a Rural Area of Japan)

We conducted a seroepidemiological nested case-control study to determine the association of gastriccancer with Helicobacter pylori infection and atrophicgastritis. A cohort of 2858 participants in an annual multiphasic health check-up werefollowed for eight years. Data for 45 gastric cancercases and 225 sex-, age-, and address-matched controlsubjects were analyzed. Helicobacter pylori infectionwas determined by IgG antibodies, and atrophicgastritis was diagnosed by both serum pepsinogen I level(70 ng/ml) and the pepsinogen I/II ratio (3.0).Univariate analysis showed that Helicobacter pylori and atrophic gastritis were significantlyassociated with gastric cancer. In a multivariateanalysis, atrophic gastritis was associated withsignificantly increased risk of cancer (odds ratio,3.38; 95% confidence interval, 1.54-7.42); however,Helicobacter pylori was not associated with cancer (oddsratio, 1.84; 95% confidence interval, 0.59-5.72). Theseresults suggest that Helicobacter pylori infection alone is not directly associated with gastriccarcinogenesis but has an indirect relation to gastriccancer through the development of atrophicgastritis.     

Prevalence of Upper Gastrointestinal Lesions and Helicobacter pylori Infection in Crohn's Disease

Crohn's disease can affect the upper gut withreported variable frequency, although concurrentHelicobacter pylori infection has been reported to below. We prospectively investigated the prevalence of esophageal, gastric, and duodenal lesions andHelicobacter pylori infection in 67 Crohn's disease, 41ulcerative colitis patients, and 43 controls. Symptoms,esophagogastroduodenoscopy, and multiple biopsies were performed on all patients consecutively.Endoscopic lesions were found in 63% of Crohn's diseasepatients, with a Helicobacter pylori prevalence of 28%. Granulomas were found in three patients. Twenty-two percent of the ulcerative colitis patients hadlesions, with a 29% prevalence of Helicobacter pyloriinfection. Half of the controls had pathologicalendoscopy, and Helicobacter pylori was positive in 40% of the cases. Subjective symptoms did notpredict the presence of endoscopic lesions orHelicobacter pylori infection in inflammatory boweldisease patients. Chronic gastritis and duodenitis arecommon in Crohn's disease patients, and the majorityare not associated with Helicobacter pyloriinfection.     

Helicobacter pylori Infection and Atrophic Gastritis (A Nested Case-Control Study in a Rural Town in Japan)

A seroepidemiologic, nested case-control studywas conducted to evaluate the risk for atrophicgastritis associated with Helicobacter pylori infection.Atrophic gastritis was diagnosed on the basis of serum pepsinogen levels: pepsinogen I level70 ng/ml and pepsinogen I/pepsinogen II ratio3.0. Cases were 23 men and 39 women who were notdiagnosed with atrophic gastritis in 1987, but who were diagnosed with the condition in 1992. Controlswere the 120 men and 282 women who did not meet theserologic criteria for atrophic gastritis in either timeperiod. Neither cases nor controls had a history of upper gastrointestinal operations.Helicobacter pylori infection at the initial survey wasassociated with a significantly increased risk ofatrophic gastritis incidence for both sexes combined(odds ratio = 3.72; 95% confidence interval,1.78-7.79; P = 0.0005). Cigarette smoking andconsumption of alcohol and green-yellow vegetables werenot associated with incidence of atrophicgastritis.     

Helicobacter pylori-Positive Functional Dyspepsia in Elderly Patients Comparison of Two Treatments

The association of Helicobacter pylori andfunctional dyspepsia is not well defined. The role of H.pylori on dyspeptic symptoms is still controversial. Theaim of this study is to confirm the efficacy of H. pylori eradication by two differentcommonly used treatment regimens, as well as to examinethe improvement of the dyspeptic symptoms by eradicatingH. pylori. H. pylori functional dyspepsia is prevalent in people over 60 years old. In this age groupwe treated 126 patients with bismuth plus metronidazoleand amoxicillin (group A, 67 patients) versus omeprazoleplus amoxicillin (group B, 59 patients). Results were statistically analyzed utilizing theWilcoxon signed-rank test, McNemer test and chi-squaretest; P < 0.05 was considered significant. Two monthsafter the end of therapy we observed an eradication rate of 66.1% in group A vs 64.3% in group B.All treated patients showed improvement insymptomatology. Although there was no significantdifference between patients in whom H. pylori was or wasnot eradicated within the respective groups, when examiningall H. pylori-positive patients versus H.pylori-negative posttreatment patients, there was asignificant reduction (P < 0.05) in all four symptomsof functional dyspepsia measured. In conclusion, we suggestthat patients treated with H. pylori-eradicatingtherapeutic regimens have an improvement in functionaldyspepsia symptoms. We shall prefer the dual therapy as compared to the triple therapy. We believethat eradicating treatment to eradicate H. pylori in theelderly patients with H. pylori -related functionaldyspepsia will reduce health care costs by reducing the number of subsequent visits.     

Helicobacter pylori and Mucosal Atrophy in Patients with Gastric Cancer (A Special Study Regarding the Methods for Detecting Helicobacter pylori)

We assessed the sensitivities of several methodsfor detecting Helicobacter pylori (culture, histology,rapid urease test, and serology), and evaluated the H.pylori positivity considering the degree of atrophy in the background mucosa in 202 gastriccancer patients and 101 controls. The positivity of H.pylori determined by culture (81%) was significantlyhigher than that determined by serology (62%) in gastric cancer patients (P < 0.001). Thepositivities of H. pylori determined by biopsy and/orserology in intestinal (84%) and diffuse (95%) types ofgastric cancer were higher than that observed in controls (54%) (P < 0.001).Intestinal-type gastric cancer tended to occur in theatrophic mucosa, in which H. pylori positivity was notdifferent from that in controls after adjusting for thedegree of atrophy, whereas diffuse-type gastric cancerwas observed more often in the nonatrophic mucosa, inwhich H. pylori positivity was higher than that incontrols even after adjusting for the degree ofatrophy.     

Helicobacter pylori Infection Has No Role in the Pathogenesis of Reflux Esophagitis

In a prospective study of consecutive patientswith reflux esophagitis and/or hiatal hernia andBarrett's esophagus, the prevalence of Helicobacterpylori was assessed. Antral biopsy specimens werestudied and a serum sample for detection of IgGantibodies against Helicobacter pylori was taken. As areference group patients presenting with a normalesophagus, stomach, and duodenum were taken. Refluxesophagitis was diagnosed in 118 patients, hiatal herniawithout esophageal inflammation in 109, and Barrett'sesophagus in 13. Helicobacter pylori was present in 74(30%) of these patients and in 204 (51%) of the reference group. Prevalence of Helicobacterpylori was significantly lower in all groups comparedwith the reference group (P < 0.001). There was nodifference when patients with esophagitis, Barrett'sesophagus, or hiatal hernia were compared. Patients withesophagitis and Helicobacter pylori in their antrum aresignificantly older than esophagitis patients withoutconcomitant Helicobacter infection, 61.5 (SD, 17) versus 53 (SD, 17) years (P < 0.001). Itis concluded that the prevalence of Helicobacter pyloriinfection in patients with gastroesophageal refluxdisease is significantly lower than in the reference group, irrespective of the severity ofesophagitis. Helicobacter pylori infection has no rolein the pathogenesis of reflux esophagitis.     

Helicobacter pylori Infection and Peptic Ulcer Disease in Cirrhosis

An increased frequency of peptic ulcer diseaseis noted in patients with cirrhosis, but the role of H.pylori in this disorder remains to be determined. Thediagnosis of cirrhosis was confirmed by a combination of clinical, biochemical, radiological, andhistological methods. The severity of cirrhosis wasassessed by Pugh's modification of Child's criteria.Upper gastrointestinal endoscopy was performedconsecutively to evaluate the presence of varices andgastroduodenal mucosa. H. pylori status was assessed byhistology, urease test, and serology. In all, 130patients with cirrhosis were recruited into the study;there were 86 males and 44 females with a mean (SD)age of 54.4 (12.7) years. The H. pylori prevalence was76.2% . There was no difference in age between the H.pylori-positive and -negative cirrhotics (P = 0.29). The H. pylori prevalence revealed no differenceamong cirrhotics with Child A (77.8%), Child B (72.9%),and Child C (78.6%) (P = 0.8), and neither was there adifference in H. pylori prevalence in cirrhotics with and without congestive gastropathy (77% vs73.7% , P = 0.84). The prevalence of H. pylori incirrhotics with and without varices did not show astatistical difference (75% vs 81.8%, P = 0.68). There also was no difference in the H. pyloriprevalence between cirrhotic patients with and withoutpeptic ulcers (84.4% vs 69.7% , P = 0.09). Inconclusion, the prevalence of H. pylori or peptic ulceris independent of the severity of cirrhotic liver disease. Theassociation between H. pylori infection and peptic ulcerdisease is weak in cirrhosis.     

Touch Cytology (A Reliable and Cost-Effective Method for Diagnosis of Helicobacter pylori Infection)

A variety of reliable methods are available fordetecting Helicobacter pylori (Hp) during uppergastrointestinal endoscopy. We evaluated the clinicalutility and cost-effectiveness of rapid urease test (RUT), touch cytology (TC), and histology (H).Two hundred thirty-eight consecutive patients (178without previous medical treatment and 60 formerlytreated with anti-Hp therapy) were tested for Hpinfection by RUT, TC, and H (H&E stain). Theinfection status for each patient was established by aconcordance of two test results. The time to carry outthe three tests and their cost were also calculated. Sensitivity of TC (100%) was significantlyhigher than that of RUT (86.8%; P < 0.001), but notthan that of H (94.9%). RUT was significantly morespecific than H (100% vs 95.6%; P < 0.05), but not than TC (96.4%). Hp infection was more frequentin the patients with chronic active gastritis than inthose with chronic nonactive gastritis (P < 0.001).No Hp infection was detected in absence of chronic antral inflammation. RUT resulted the cheapestmethod and H the most expensive; TC is faster andcheaper than H. When additional information about theseverity of mucosal damage or the presence of cell atypias is not necessary, histologicexamination can be omitted, and a cost-effectivestrategy for assessing Hp status might consist in takingtwo antral biopsies, the former for performing RUT andthe latter for preparing a slide by TC, whichshould be stained and examined only when the RUT resultis negative.     

Recurrence of Helicobacter pylori Infection After Successful Eradication (Nature and Possible Causes)

Recurrence of Helicobacter pylori infectionafter successful eradication occurs and is associatedwith relapse of gastroduodenal diseases. The aims ofthis paper were to assess the incidence and identify the nature and possible causes of recurrence ofthe infection. A broad-based Medline search wasperformed to identify all related publicationsaddressing recurrence of the infection between 1986 and1995. The 12-month recurrence rate varied among thedifferent studies from 0 to 41.5%. A few studies showed18- to 24-month recurrence rates, which ranged between0 and 21.4%. Limited data, obtained using molecular fingerprinting techniques, have shown that inmost cases recurrence is due to recrudescence of theoriginal strain; a few cases appear to be due toreinfection with a new strain. Recrudescence is mostlikely during the first 12 months after apparenteradication. Despite the high sensitivity andspecificity of the available individual tests fordetecting H. pylori infection in untreated patients, notechnique alone is sensitive enough to monitoreradication when the four-week-rule definition foreradication is used. A combination of two or moretechniques increases sensitivity. Sensitivity andspecificity are increased when biopsies are taken from bothgastric antrum and corpus. The best treatments have thelowest recurrence rates and recurrence is rare when theeradication rate is over 90%. Individual susceptibility and reexposure to H. pylori are suggested astwo major causes of reinfection.     

Suggestion Against an Oral-Oral Route of Transmission for Helicobacter pylori Infection (A Seroepidemiological Study in a Rural Area)

In this study the seroepidemiology of H. pyloriand Epstein-Barr virus was compared in the same setting.A sample of 705 subjects completed a structuredquestionnaire. A serum sample was drawn from each subject and assayed for H. pylori IgG.Antibodies to Epstein-Barr virus were determined in asubgroup of 466 subjects. Cross-tabulation of datashowed that 274 (58.8%) subjects were seropositive and20 (4.3%) were seronegative for both infections,17 (3.6%) were seropositive for H. pylori, and 155(33.3%) were seropositive for Epstein-Barr virus (oddsratio = 2.08, 95% confidence interval: 1.008-4.3).Nevertheless, the agreement between H. pylori andEpstein-Barr virus seropositivity was no better thanchance (kappa = 0.067) and the age-relatedseroprevalence curve of Epstein-Barr virus was similar in H. pylori seropositive and seronegativesubjects. Furthermore, multiple logistic regressionanalysis did not show any risk factor shared by bothinfections. The findings of this study do not support the hypothesis that H. pylori and Epstein-Barrvirus share a common mode of transmission. It can bespeculated that the oral cavity may not be an importantreservoir for H. pylori.     

Case Report: Urticaria During Triple Therapy for Helicobacter pylori Infection (Clinical Implications)

The widespread use of an ever-increasing numberof drugs is responsible for the multiple adversereactions observed by the clinician. Current practiceadvocates eradication of Helicobacter pylori infections, and this is achieved quite well by the use oftriple therapy (1). However, a survey of the recentliterature revealed that the safety of such regimens hasoften been discussed but never properly investigated (1-3). We describe a case in which adverseeffects were noted to each of the three components oftherapy.     

Use of Chopsticks for Eating and Helicobacter pylori Infection

Epidemiological data suggests that ethnic groupsusing chopsticks for eating have a higher prevalence ofH. pylori infection. This study investigated thecarriage of H. pylori in chopsticks after eating. Used chopsticks and saliva were collected fromasymptomatic individuals whose H. pylori status wasdetermined by [¹³C]urea breath test andserology. Both the saliva specimens and chopsticks werecultured and processed by polymerase chain reaction(PCR) for the detection of H. pylori . Furthermore,chopsticks used by hospital staff in the cafeteria werepooled for the detection of H. pylori by bacteriologic culture and PCR. Sixty-nine volunteers wererecruited in the first study and 45 (65%) were diagnosedto have H. pylori infection. While all cultures werenegative, H. pylori was detected by PCR in the saliva from 15 (33%) infected subjects and in thechopsticks from one (2%). Among the 12 sets of pooledchopstick-washing studied, H. pylori was detected by PCRin two sets. This study showed that H. pylori was rarely detected in chopsticks after eating andhence, the risk of contracting this infection via theuse of chopsticks is low.     

Development of Helicobacter pylori Infection Model in BALB/c Mice with Domestic cagA-Positive and-Negative Strains in Taiwan

We aimed to develop an H. pylori-infected mousemodel using clinically stored strains in Taiwan and totest whether development of H. pylori infection in an invivo animal model is related to the status of the cagA gene. A total of 100 male BALB/cmice, 6-8 weeks old, including 80 in the experimentalgroup and 20 in the control group, were used. Twoclinically stored H. pylori isolates, a cagA-positive and a cagA-negative strain, were selected toinduce the H. pylori infection in half (N = 40) of themice in the experimental group. Bacterial isolates of0.8 × 10⁹ CFU/ml were orally inoculatedin each mouse of the experimental group for threeconsecutive days. Ten mice in the control group weresacrificed to confirm the initial absence of H. pylori.Eight weeks after inoculation of the experimental group and no inoculation of the remaining 10mice of the control group, each mouse was killed.Gastrectomy was then performed for rapid urease test(CLOtest) and histology. In the control group, none of 20 mice had positive results from the CLOtestor histology. In contrast, excluding eight of 80 micethat died before the eighth week, 90.3% (65/72) of themice challenged with H. pylori showed persistent presence of H. pylori by histology. Theseverity of gastritis at the eighth week was moreevident in H. pylori-infected mice than in control andnoninfected mice (P < 0.05). Although gastritis wasmore severe in mice inoculated with thecagA-positive strain than with the cagA-negative strain,the rates of H. pylori infection in mice were notdifferent between cagA-positive and -negative strains(91.4% vs 89.2%, P > 0.05). In summary, storedstrains of H. pylori can be applied to induce aninfection model in BALB/c mice. The less virulentcagA-negative strain can induce H. pylori infection inmice as effectively as the cagA-positive strain. Thehigh prevalence of cagA-positive strains in Taiwanesepatients may be related to factors other than only thecagA gene of the bacteria.     

Prevalence of Helicobacter pylori Infection in Children from Urban and Rural West Virginia

Our objective was to evaluate the prevalencerate of Helicobacter pylori (HP) in children from urbanand rural areas of West Virginia. In all, 1164 bloodsamples were collected from children who attended a local health fair, pediatric clinics, andemergency departments of four different hospitalslocated in urban and rural counties. Socioeconomicstatus was determined in 303 children. Serum HP antibody (IgG) was measured by enzyme immunoassay (EIA).A total of 468 (40%) samples were HP positive. HPacquisition correlated with increasing age, familycrowding, and community location (urban/rural) but not with gender, water source used (city/well), orsocioeconomic status. The prevalence rate of HP in thechildren of West Virginia is higher than any datapreviously reported from the United States. The results correlated with only few socioeconomiccriteria, suggesting that other factors may contributeto the increased prevalence of HP infection in thechildren of West Virginia.