BACKGROUND:Helicobacter pylori infection is usually treated with a proton pump inhibitor (PPI), amoxicillin and clarithromycin, but it fails in ≥ 20% of patients.AIM: To estimate, by a systematic review and meta-analyses, the most effective rescue treatments after the failure of a first-line therapy with PPI, amoxicillin and clarithromycin in H. pylori eradication.METHODS: Selection of studies: Meta-analyses were performed with randomized clinical trials (RCT) that assessed the efficacy of second-line regimens; the generic inverse variance was applied on prospective and retrospective studies.Inclusion criteria: studies treating H. pylori-positive patients after clarithromycin-amoxicillin-PPI failure.Exclusion criteria: Secondline treatment based on the antibiotic sensitivity, or if the confirmation of eradication were made only by serology, PCR or polyclonal stool antigen test.Search strategy: Bibliographical searches were performed in PubMed, CINAHL, Cochrane Library, ClinicalTrials.gov,DDW y EHSG, up to April 2013.Data synthesis: Intention to treat eradication rate.RESULTS: The efficacies of the second-line treatments are shown on the table attached.A metaanalysis comparing the triple therapy with levofloxacin-amoxicillin-PPI against the quadruple bismuth-metronidazole-tetracycline-PPI regimen showed a non-statistically significant tendency towards better results levofloxacin (OR = 1.74; 95% C.I. = 0.83-3.67;p = 0.14; I2 = 79%; 6 studies; 1,057 patients).CONCLUSION: The most effective second-line treatments, after a clarithromycin-amoxicillin-PPI failure, are the metronidazole-amoxicillin-PPI or a 10 days levofloxacin-amoxicillin-PPI therapy.More high quality trials, performed outside Japan, are needed to verify the efficacy of the 14 days dual therapy with amoxicillin-PPI.

Background: Second-line bismuth-containing quadruple therapy is complex and frequently induces adverse effects. A triple rescue regimen containing levofloxacin is a potential alternative; however, resistance to quinolones is rapidly increasing. Aim: To evaluate the efficacy and tolerability of a second-line triple-regimen–containing levofloxacin in patients whose Helicobacter pylori eradication treatment failed and to assess whether the efficacy of the regimen decreases with time. Methods: Design: Prospective multicenter study. Patients: In whom treatment with a regimen comprising a proton-pump inhibitor, clarithromycin, and amoxicillin had failed. Intervention: Levofloxacin (500 mg bid), amoxicillin (1 g bid), and omeprazole (20 mg bid) for 10 days. Outcome: Eradication was confirmed using the 13C-urea breath test 4 to 8 weeks after therapy. Compliance/tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by means of a questionnaire. Results: The study sample comprised 1000 consecutive patients (mean age, 49±15 y, 42% men, 33% peptic ulcer) of whom 97% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 75.1% (95% confidence interval, 72%-78%) and 73.8% (95% confidence interval, 71%-77%). Efficacy (intention-to-treat) was 76% in the year 2006, 68% in 2007, 70% in 2008, 76% in 2009, 74% in 2010, and 81% in 2011. In the multivariate analysis, none of the studied variables (including diagnosis and year of treatment) were associated with success of eradication. Adverse effects were reported in 20% of patients, most commonly nausea (7.9%), metallic taste (3.9%), myalgia (3.1%), and abdominal pain (2.9%). Conclusions: Ten-day levofloxacin-containing therapy is an encouraging second-line strategy, providing a safe and simple alternative to quadruple therapy in patients whose previous standard triple therapy has failed. The efficacy of this regimen remains stable with time.

Background: Second-line bismuth-containing quadruple therapy is complex and frequently induces adverse effects. A triple rescue regimen containing levofloxacin is a potential alternative; however, resistance to quinolones is rapidly increasing. Aim: To evaluate the efficacy and tolerability of a second-line triple-regimen–containing levofloxacin in patients whose Helicobacter pylori eradication treatment failed and to assess whether the efficacy of the regimen decreases with time. Methods: Design: Prospective multicenter study. Patients: In whom treatment with a regimen comprising a proton-pump inhibitor, clarithromycin, and amoxicillin had failed. Intervention: Levofloxacin (500 mg bid), amoxicillin (1 g bid), and omeprazole (20 mg bid) for 10 days. Outcome: Eradication was confirmed using the 13C-urea breath test 4 to 8 weeks after therapy. Compliance/tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by means of a questionnaire. Results: The study sample comprised 1000 consecutive patients (mean age, 49±15 y, 42% men, 33% peptic ulcer) of whom 97% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 75.1% (95% confidence interval, 72%-78%) and 73.8% (95% confidence interval, 71%-77%). Efficacy (intention-to-treat) was 76% in the year 2006, 68% in 2007, 70% in 2008, 76% in 2009, 74% in 2010, and 81% in 2011. In the multivariate analysis, none of the studied variables (including diagnosis and year of treatment) were associated with success of eradication. Adverse effects were reported in 20% of patients, most commonly nausea (7.9%), metallic taste (3.9%), myalgia (3.1%), and abdominal pain (2.9%). Conclusions: Ten-day levofloxacin-containing therapy is an encouraging second-line strategy, providing a safe and simple alternative to quadruple therapy in patients whose previous standard triple therapy has failed. The efficacy of this regimen remains stable with time.

Background: Helicobacter pylori infection induces chronic inflammation in gastric mucosa and promotes the occurrence of gastric cancer.Although the relationship between Helicobacter pylori infection and gastric cancer has been evaluated in many studies, the effect of Helicobacter pylori treatment on recurrence after endoscopic mucosal resection (EMR) of gastric cancer remain uncertain because of contradictory opinions.Methods: A total of 2089 adult patients aged between 28 and 88 years had undergone EMR of gastric adenoma and early gastric cancer from November 1, 2004 to December 31, 2008 were investigated retrospectively.Among them, the 521 patients had been excluded from the study because of short follow up duration (<1 year) (n=377) and short recurrence interval (<3 months) (n=4) and no tests of urea breath test or rapid urease test or histology for diagnostic test of H. pylori (n= 140).We investigated group without H. pylori infection (n=555.35.4%) and group with H. pylori infection (n=1013, 64.4%) for recurrence rate, recurrence interval, recurrence location.Results: Among group with H. pylori infection (n=1013), group without H. pylori treatment were 25.8% (n=262) and group with H. pylori treatment were 74.2% (n=751).Among group with H. pylori treatment, group with successful treatment were 96.6% (n=727) and group failed treatment of H. pylori were 3.4% (n=25).Among total enrolled patients, male was 70%, mean age was 61.6 ± 9 years old, mean follow up durations were 43 months and mean recurrence interval was 22 months.The baseline parameters of age, sex, depth of invasion, alcohol, smoking, proportion of early gastric cancer, mean follow up duration were homogenously distributed in the group without H. pylori infection and group with H. pylori infection.There was no significant difference in recurrence interval, recurrence location, proportions of local recurrence in the both groups.Recurrence rate of group without H. pylori infection and group with H. pylori infection was 4.1% (n=23) and 13.6% (n=138).(p<0.01,odds ratio 3.6) In a subgroup of patients with H. pylori infection, recurrence rate of group without H. pylori treatment and group with H. pylori treatment was 24.0% (n=6) and 8.1% (n=57) (p<0.01,odds ratio 2.7).In a subgroup of patients with H. pylori treatment, recurrence rate of group with successful treatment and group failed treatment of H. pylori was 9.2% (n=67) and 24.8% (n=65) (p<0.01,odds ratio 2.9).Conclusions: A retrospective study showed that H. pylori eradication may reduce the recurrence in the patients received EMR of adenoma and early gastric cancer.Group failed treatment of H. pylori showed as high recurrence rate as group without H. pylori treatment , therefore H. pylori test after H. pylori eradication treatment is needed and salvage therapy must be considered if treatment of H. pylori is failed.

OBJECTIVE:The purpose of this study is to determine useful parameters for the early diagnosis of colonoscopic perforation and to select those who would require surgical treatment.METHODS:We retrospectively reviewed the demographics, clinical and colonoscopic data, diagnostic-surgical interval, operative findings, complications, and hospital stay of patients who developed postcolonoscopy iatrogenic colonic perforation between January 2002 and December 2008.RESULTS:A retrospective multicentric study of patients diagnosed of colonoscopic perforation was performed. Fifty-four patients were found for final analysis (mean age, 71 years (26-91 years). Thirty-four were diagnostic and 20 were therapeutic colonoscopies. Most patients in whom the perforation was noticed during colonoscopy were treated surgically (p = 0.032) within 24 h (p = 0.004) and had a lesser degree of surgical peritonitis (p = 0.033). Those with deficient bowel preparation had more interventions (p < 0.05), ostomies (p = 0.015), and complications (p = 0.023) as well as major clinical (p < 0.001) and surgical peritonitis (p = 0.031). Patients with nonoperative management had fewer complications (p = 0.011) and lower hospital stay (p < 0.048). Surgical treatment within 24 h resulted in a lesser degree of surgical peritonitis (p < 0.001), fewer intestinal resections (p < 0.001), ostomies (p = 0.002) and complications (p < 0.047), and shorter hospital stay (p < 0.05).CONCLUSIONS:We recommend a conservative treatment for patients with the following conditions: good general health, unnoticed perforation during endoscopy, early diagnosis, no signs of diffuse peritonitis, proper colonic preparation, and a different injury mechanism to traction. Patients treated surgically after the first 24 h are likely to have a greater degree of peritonitis and more intestinal resections, ostomies, and complications.

were males, and 38% were previous NSAID users.70% had duodenal ulcer, 26% gastric ulcer, and 4% pyloric ulcer.Recurrence of bleeding was demonstrated in 2 patients at 1 year (which occurred after NSAID use in both cases), and in 2 more patients at 2 years (one occurred after NSAID use and another after H. pylori reinfection).Rebleeding incidence was 0.17% per patient-year of follow up.CONCLUSION: Peptic ulcer rebleeding does not occur in patients with complicated ulcers after H. pylori eradication.Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved.However, NSAID intake or H. pylori reinfection may cause rebleeding in H. pylori-eradicated patients.