AIM:The clinical evaluation of patients with chronic diarrhea and/or abdominal pain requires a complex work-up. The aim of the study was to evaluate whether routine duodenal biopsy sampling of macroscopically normal mucosa of patients with irritable bowel syndrome-like symptoms undergoing upper endoscopy assists in diagnosis and management.METHODS:Consecutive adults scheduled for upper endoscopy for evaluation of uninvestigated dyspepsia and abdominal pain and/or chronic diarrhea based upon the history, were enrolled. Gastric biopsies and 3 duodenal biopsies were taken for histological evaluation.RESULTS:A total of 786 sets of biopsies from 262 consecutive patients (200 females and 62 males, mean age 46 years; range: 15-82), were analyzed. Microscopic damage was observed in 212 of 262 patients (81%) with normal mucosa. Mild to moderate and severe duodenitis or villi atrophy was histologically confirmed in 65%, 26% and 8% of 212 patients respectively. The negative predictive value of a normal appearing duodenal mucosa was 19%. Additional tests confirmed celiac disease in 12 patients. Lactose malabsorption was present in 42%, bacterial overgrowth in 14%, and H. pylori infection in 28%. Colonoscopy performed in 92 patients revealed non specific colitis (25%), microscopic colitis (28%), Crohn's disease (1%), and diverticulosis (15%).CONCLUSION:Duodenal biopsies revealed abnormalities in the majority of adults with chronic diarrhea and/or abdominal pain despite macroscopically normal gross findings. These results suggest that duodenal biopsies could be helpful in patients with chronic diarrhea and/or abdominal pain for the following work up.

ABSTRACTBackground. Although effective therapies are available for curing Helicobacter pylori infection, the problem persists about what to do for patients who fail two or more treatment courses despite a good compliance.Aim. To test a twice a day midday quadruple therapy as salvage therapy.Methods. Dyspeptic H. pylori‐infected patients who failed two or more courses of anti‐H. pylori therapy received omeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate caplets 240 mg twice a day (with the midday and evening meals) for 14 days. H. pylori status was evaluated by 13C‐urea breath test and histology 4–6 weeks after therapy. Eradication was defined as no positive test.Results. Seventy‐one patients were enrolled and 68 completed the full 14 days of therapy (mean age 46 years; 28 men). Thirty‐three patients had failed prior treatment twice, 19 had failed three times, and 16 had failed four or more times.The cure rates were: intention to treat = 93% (66/71); (95% CI = 84% to 98%), per protocol = 97% (66/68); (95% CI = 89%– 100%). Success was excellent irrespective of diagnosis, age, prior treatment protocols, or smoking status. Moderate side‐effects were experienced by only two patients.Conclusion. Midday bismuth subcitrate based twice a day quadruple therapy was an excellent salvage therapy. BID midday quadruple regimen should be considered as the therapy of choice.

Objective: Helicobacter pylori (H. pylori) eradication rates in northern Sardinia using standard 1-wk triple therapies (i.e., a proton pump inhibitor and two antibiotics) are typically <60%, primarily because of antibiotic resistance. The aim of this study was to test b.i.d. quadruple therapy as primary and as salvage therapy in this population.Methods: This was a prospective, single center study of consecutive dyspeptic H. pylori-infected patients. Therapy consisted of omeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate caplets 240 mg, all b.i.d. with the midday and evening meals for 14 days. H. pylori status was evaluated by 13 C-urea breath test and histology before and 4-6 wk after therapy. Eradication was defined as no positive test.Results: We enrolled 118 consecutive dyspeptic patients (mean age 46 yr; 73 men, including 15 with peptic ulcer disease). Of the patients, 42 (38%) had failed prior therapy: twice in 21 cases, three times in 12, and four or more tunes in nine. The intention-to-treat cure rate was 95% (110 of 116) (95% CI=90-98%) overall, and 98% per protocol, irrespective of diagnosis. age, prior treatment failure, or smoking status. Moderate or severe side effects were experienced by only 5% of patients.Conclusions: Bismuth subcitrate-based b.i.d. quadruple therapy was an excellent primary and salvage therapy and should be considered as first line therapy.

in the atrophic gastritis groups.Based on the endoscopic findings in EGFR a significant decrease (p

a ~BC-UBT to diagnose active H. pylori infection and then underwent EGD to establish the presence of an active ulcer.Biopsies were obtained for culture and histopathology, both pre-treatment and post-treatment, Antimicrobial susceptibility testing by agar dilution was performed on all isolates.Breakpoints used to assess resistance were >0.25 /~g/mL for amoxicillin, >l/~g/mL for clarithromycin and azithromycin.Results: 357 patients were enrolled.The male:female ratio was -2:1, Cure rates were: AAO = 56.7%(95% CI = 48% to 64%); AO = 34.7%;AA = 0%; and C0 = 0%.Macrolide resistance rates for the entire study group was 9.4%.Cross-resistance was present among clarithromycin and azithromycin.Conclusion: Three day azithromycin-PPI based triple therapy was not an efficacious therapy for the treatment of H. pylor/infection.

Background.Although combinations of antibiotics and antisecretory drugs are useful for treatment ofHelicobacter pyloriinfection, treatment failure is common. The aim of this study was to evaluate the relation between pretreatment antibiotic resistance and outcome by using six different treatment regimens forH. pyloriinfection.Patients and Methods.Three hundred sixty‐nine consecutiveH. pylori–infected patients with dyspeptic symptoms were enrolled in three consecutive randomized, controlled, single‐center clinical trials: trial A, 128 patients; trial B, 125 patients; trial C, 116 patients. Treatments consisted of (A) a 15‐day course of dual therapy (omeprazole, 20 mg bid, and amoxicillin, 1 gm bid, or clarithromycin, 500 mg tid) (OA vs OC); (B) a 7‐day triple therapy of omeprazole, 20 mg bid, plus metronidazole, 500 mg bid, and amoxicillin, 1,000 mg bid, or clarithromycin, 500 mg tid (OMA vs OMC); or (C) omeprazole, 20 mg bid, plus metronidazole, 500 mg bid, plus tetracycline, 500 mg qid, or doxycycline, 100 mg tid (OMT vs OMD). Diagnostic endoscopy was made in all patients before and 5 to 6 weeks after therapy. Six biopsies were taken from each patient for histology, rapid urease test, andH. pyloriculture; antibiotic susceptibility testing was performed using the E‐test method.Results.Overall cure rates were poor for both dual therapies OA and OC (38% and 37%, respectively) and for triple therapies OMA, OMC, and OMD (57%, 55%, and 58%, respectively). The OMT combination was successful in 91% (95% confidence interval [CI], 80.4%–97%). Metronidazole resistance was present in 29.7% (95% CI, 24%–35%), amoxicillin resistance was present in 26% (95% CI, 21%–32%), clarithromycin resistance was present in 23.1% (95% CI, 18%–29%), tetracycline resistance was present in 14% (95% CI, 10%–20%), and doxycycline resistance was present in 33.3% (95% CI, 21%–47%). Antibiotic resistance markedly reduced the cure rates and accounted for most of the poor results with the triple therapies: 89% versus 23%; 77% versus 26%; 100% versus 60%; and 67% versus 23% for OMC, OMA, OMT, and OMD, respectively. OMT appeared to be the best because of the high success rate with metronidazole‐resistantH. pylori(71%) and in low‐level tetracycline resistance.Conclusions.Pretreatment antibiotic‐resistantH. pylorican, in part, explain the low cure rate of the infection and the variability in outcome in reported trials.

Aims of the study: To evaluate Helicobacter Pylori significance in the development of intestinal metaplasia (IM) in gastric mucosa and to establish how the bacterial eradication modifies its further evolution.Subjects and methods: Ninety-nine consecutive patients affected from inflammatory and/ or ulcerative diseases of the stomach and/or of the duodenum showing IM in histologic specimen collected during upper endoscopy were studied for a two years period after first diagnosis.Every patient allowed to the study was endoscopically reinvestigated every year and underwent to six biopsies each time, three from angular and three from body mucosa of the stomach in order to evaluate IM and HP presence.The HP positive patients affected from IM underwent eradication by triple therapy with omeprazole 40 mg once daily for 4 weeks, amoxycillin 1 g twice daily for one week and clarithrom~cin 500 mg twice daily for one week.Statistical analysis was performed by % method.Results: Eighty-two (82,8%) out of 99 IM positive patients resulted also lip positive and seventeen (17,2%) HP negative at histology.All 82 IM and HP positive patients underwent eradication therapy and 69 (84,1%) of them resulted eradicated two months after the end of treatment by urea-breath test.Twelve and twenty-four months later 98 patients out of 99 underwent endoscopic control; one IM positive HP negative patient dropped out.In control group (16 IM positive HP negative) 14 patients (87,5%) at first year and 15 patients (93,7%) at second year control showed again IM.All of them resulted HP negative at histology in both occasions.In the treated patients group (82 IM positive-HP positive) only 53 (64,5%) at first year control and 49 (59,7%) at second year control were found positive for IM at histology.In both cases 40 patients, out of 53 at first year control and out of 49 at second year control, were histologically negative for HP detection.29 (35,5%) initially IM positive patients resulted negative after one year and 33 (40,2%) after two years.Moreover 27(93,1%) out of 29 IM negative patients at first year and 31 (93.9%)out of 33 IM negative patients at second year resulted Helicobacter Pylori negative at histology.Statistical analysis by Z z method between IM positive-HP negative patients and IM positive-HP positive one and two years after eradication showed P < 0.001.Conclusions: Helicobacter Pylori eradication allows regression of histological intestinal metaplasia in the stomach in more than 30% cases after two years from eradication.According to Correa's gastric carcinogenesis model, Helicobacter Pylori positive patients with proven intestinal metaplasia have to be eradicated.

Aims of the study: To evaluate Helicobacter Pylori significance in the development of intestinal metaplasia (IM) in gastric mucosa and to establish how the bacterial eradication modifies its further evolution.Subjects and methods: Ninety-nine consecutive patients affected from inflammatory and/ or ulcerative diseases of the stomach and/or of the duodenum showing IM in histologic specimen collected during upper endoscopy were studied for a two years period after first diagnosis.Every patient allowed to the study was endoscopically reinvestigated every year and underwent to six biopsies each time, three from angular and three from body mucosa of the stomach in order to evaluate IM and HP presence.The HP positive patients affected from IM underwent eradication by triple therapy with omeprazole 40 mg once daily for 4 weeks, amoxycillin 1 g twice daily for one week and clarithrom~cin 500 mg twice daily for one week.Statistical analysis was performed by % method.Results: Eighty-two (82,8%) out of 99 IM positive patients resulted also lip positive and seventeen (17,2%) HP negative at histology.All 82 IM and HP positive patients underwent eradication therapy and 69 (84,1%) of them resulted eradicated two months after the end of treatment by urea-breath test.Twelve and twenty-four months later 98 patients out of 99 underwent endoscopic control; one IM positive HP negative patient dropped out.In control group (16 IM positive HP negative) 14 patients (87,5%) at first year and 15 patients (93,7%) at second year control showed again IM.All of them resulted HP negative at histology in both occasions.In the treated patients group (82 IM positive-HP positive) only 53 (64,5%) at first year control and 49 (59,7%) at second year control were found positive for IM at histology.In both cases 40 patients, out of 53 at first year control and out of 49 at second year control, were histologically negative for HP detection.29 (35,5%) initially IM positive patients resulted negative after one year and 33 (40,2%) after two years.Moreover 27(93,1%) out of 29 IM negative patients at first year and 31 (93.9%)out of 33 IM negative patients at second year resulted Helicobacter Pylori negative at histology.Statistical analysis by Z z method between IM positive-HP negative patients and IM positive-HP positive one and two years after eradication showed P < 0.001.Conclusions: Helicobacter Pylori eradication allows regression of histological intestinal metaplasia in the stomach in more than 30% cases after two years from eradication.According to Correa's gastric carcinogenesis model, Helicobacter Pylori positive patients with proven intestinal metaplasia have to be eradicated.