Der diagnostische Stellenwert der bioptischen Mikrobiologie als Methode nicht neu hat in den letzten Jahren eine grundlegende Änderung erfahren. Seitdem die endoskopische Untersuchung des Dickdarms, weil am aussagekräftigsten, mehr und mehr zur diagnostischen Methode der ersten Wahl bei entzündlichen Darmerkrankungen wird, gehört die bioptisch-histologische Untersuchung sozusagen wie selbstverständlich zum Untersuchungsprogramm. An die mikrobiologische Untersuchung von Biopsie-Partikeln, wohl in alter Vertrautheit mit der mikrobiologischen Stuhluntersuchung, wurde bisher selten gedacht (3). So hat doch die endoskopische Biopsie des Dickdarms und des angrenzenden Ileums einen entscheidenden Wandel in der Diagnose und im Verständnis entzündlicher Darmerkrankungen bewirkt (8, 12, 13, 15). Warum sollte dies nicht auch für die bioptisch-mikrobiologische Untersuchung gelten? In anderen Fachgebieten der Medizin werden Gewebeproben oder Abstriche auch direkt aus entzündlich veränderter Mucosa oder Wunden entnommen, warum nicht im Darm? Man war bisher zufrieden mit der mikrobiologischen Stuhldiagno-

In a prospective study of 132 cases of gastroduodenal ulcer, proven by endoscopic biopsy, there were 59 in which fungi were cultered (44.7%). There was no significant difference in incidence between gastric ulcer (46.2%) and duodenal ulcer (42.6%), or between benign and malignant gastric ulcer (47.2 and 42.1%, respectively). Most of the fungi were yeasts of the genus Candida and Torulopsis. The mycel phase was demonstrable only in the native or histological preparation (16.7% [native] and 10.6% [histological] positive findings). In all those cases in which pseudomycels were demonstrated the culture count was especially high (more than 20 colonies). In most of these there was an additional disease which may be associated with immunological insufficiency (e.g. diabetes, chronic alcoholism, malignoma). The presence of pseudomycelia or more than 20 colonies in the culture from gastroduodenal ulcers are thus less of a pointer as to whether the local lesion is benign or malignant than to a general weakening of the organism's defence mechanisms.

Fungal cultures, unstained smears and histological assessment of endoscopically obtained particles from ulcers in rectum, colon or terminal ileum were obtained in a prospective study of possible fungal infection in 78 patients with colitis of various aetiologies (Crohn's disease - 46; ulcerative colitis - 21; infectious colitis - 5; ischaemic colitis - 2; radiation colitis - 1; non-classifiable colitis - 3). Positive fungal culture was obtained in 13 patients (16.7%). The germ count was low (2--8 colonies per biopsy piece). The demonstrated fungi were almost exclusively Candida or Torulopsis. The potentially pathogenic mycelia phase of the fungi were never seen, either histologically or in unstained preparations. Stool specimens, obtained at the same time, were examined in 54 patients: positive cultures were obtained in 14 (25.9%). Only rarely were there concordance of positive fungal findings in both ulcer particles and faeces. It is concluded that (1) there is little danger of secondary fungal infection in colitis of various aetiologies; (2) positive faecal fungal culture is apparently of no pathogenic significance if the germ count is less than 10(6) per gram stool; (3) in the lower as well as the upper gastro-intestinal tract pathogenic fungal infection can be demonstrated only by endoscopy and biopsy.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Biliary duct ascariasis is a known complication of intestinal ascaris infestation. Treatment up to now was predominantly surgically. In a 32-year-old female Turk with a history of two years of colicky upper abdominal pains and intermittent cholestasis endoscopic transpapillary extraction of Ascaris lumbricoides in the hepatocholedochal duct was successfully performed using the Dormia basket. Pre-extraction papillotomy was not necessary.

ABSTRACT We investigated whether a novel monoclonal stool antigen test for detection of Helicobacter pylori performs with the same accuracy as the 13 C-urea breath test (UBT) for adult outpatients in the setting of a private office. The two tests showed identical levels of sensitivity when used to identify H. pylori -infected patients before and after eradication therapy.

Background and study aims: Attempts to standardize Helicobacter pylori (Hp) diagnosis and therapy have led to the publication of guidelines by various national gastroenterological societies in Europe and the USA. However, little information is available either regarding the compliance of gastroenterologists and referring physicians with these guidelines, or regarding the patients' perspective.Patients and Methods: A retrospective analysis was conducted of all outpatient upper gastrointestinal endoscopy reports for a one-month period in eleven different centers (two university hospitals and nine private practice gastroenterology offices) with a total of 24 gastroenterologists. Endoscopy reports from patients with the indications of reflux, diarrhea, and tumors were excluded. Diagnoses and treatment recommendations given by gastroenterologists were recorded. Questionnaires concerning Up diagnosis, treatment indications and performance, and follow-up were sent to referring physicians and patients.Results: A total of 772 endoscopy reports were included in the study; analyzable questionnaires were returned by 287 referring physicians (47%) and by 265 patients (59%). Gastroenterologists recommended lip eradication in all ulcers and in 29% of gastritis/nonulcer dyspepsia (NUD) cases. Referring physicians thought that 94% of ulcers should be treated by Hp eradication, which was also considered to be an absolute and relative indication in NUD by 15% and 53% of the referring physicians, respectively. Among the patients who replied, 52% had received Hp eradication regimens; ulcers were found in 22% of the total patient group. Check-up examinations after Hp therapy were considered necessary by 75% of the referring physicians, but only 22% of the responding patients actually underwent some form of check-up (upper gastrointestinal endoscopy in 91%).Conclusions: Gastroenterologists and (to a somewhat lesser extent) referring physicians appear to be following the current guidelines for lip treatment. As expected, two thirds of referring physicians consider NUD to be an absolute or relative indication for Hp eradication. Check up examinations are apparently being performed less frequently than recommended.

In this randomized, multicenter trial, we evaluated the effectiveness and side effect profile of a modified omeprazole-based triple therapy to cure Helicobacter pylori infection. The control group consisted of patients treated with standard dual therapy comprising omeprazole and amoxicillin. One hundred and fifty-seven H. pylori infected patients with duodenal ulcers were randomly assigned to receive either a combination of omeprazole 10 mg, clarithromycin 250 mg and metronidazole 400 mg (OCM) given three times daily for 10 days (n = 81), or a combination of omeprazole 20 mg and amoxicillin 1 g (OA) given twice daily for 14 days (n = 76). Prior to treatment and after 2 and 6 weeks, gastric biopsies from the antrum and corpus were obtained for histology and H. pylori culture. H. pylori infection was cured in 97.4% after OCM and in 65.8% after OA in the per-protocol analysis (p < 0.001) (intention-to-treat analysis: 93.4% and 63.2%, respectively). H. pylori was successfully cultured in 122 patients (77%). The overall rate of metronidazole resistance was 19.7% (24/122), no primary resistance to clarithromycin or amoxicillin was found. In the OCM group, all patients infected with metronidazole-sensitive H. pylori strains (n = 51) and those infected with strains of unknown susceptibility to metronidazole (n = 14) were cured (100%), while 77% (10/13) of those harboring metronidazole-resistant strains were cured of the infection (p = 0.36). Side effects leading to premature termination of treatment occurred in 2.5% of the patients in the OCM group and in 1.4% of the OA group. We conclude that combined treatment with omeprazole, clarithromycin and a higher dose of metronidazole is highly effective in curing H. pylori infection, and that this regimen remains very effective in the presence of metronidazole-resistant strains.

BACKGROUND:Our aim was to investigate the efficacy of omeprazole and amoxicillin in curing Helicobacter pylori infection in gastric ulcer patients.METHODS:In a double-blind trial 185 H. pylori-positive gastric ulcer patients were prospectively randomized to receive 40 mg omeprazole twice daily and either 750 mg amoxicillin three times daily or 750 mg amoxicillin placebo three times daily on days 1-14, followed by 20 mg omeprazole daily on days 15-56.RESULTS:Twenty-seven patients were excluded because of lack of compliance or missed follow-up examinations; one patient receiving amoxicillin discontinued treatment owing to side effects. On an intention-to-treat basis, omeprazole/amoxicillin led to cure of H. pylori infection in 67.1% (47 of 70) of patients not using non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (ASA) and in 46.7% (14 of 30) of those taking NSAIDs/ASA (P < 0.05). With the omeprazole/placebo regimen, H. pylori infection was cured in 8.8% (no NSAIDs), and 0% (NSAIDs).CONCLUSIONS:The use of NSAIDs/ASA may limit the efficacy of omeprazole/amoxicillin in curing H. pylori infection in gastric ulcer patients.

BACKGROUNDHelicobacter pylori gastritis is suggested to be the underlying condition leading to duodenal ulcer disease. The aim of the study was to investigate the relationship between chronic active H. pylori gastritis and the risk of duodenal ulcer (DU) recurrence.METHODSOne hundred and eighty-eight patients were followed up with regard to the evolution of their H. pylori gastritis after they had received antibacterial or acid-suppressing treatment for their DU. Four weeks, 1 year, and 2 years after treatment and in the case of DU recurrence several morphologic indicators of gastritis were studied histologically in the antrum and corpus.RESULTSIn patients who were cured of H. pylori infection a significant and long-lasting regression of all gastritis variables were observed. patients with persistent H. pylori infection after antibacterial treatment showed only a temporary regression of all gastritis variables. In the overall group of patients who received acid-suppressive therapy there was no change in gastritis. However, in the subgroup of patients who received omeprazole monotherapy, no change in the antrum but a statistically significant increase of gastritis in the corpus was observed. The grade of antral gastritis at the end of treatment was significantly and positively correlated with the risk of DU recurrence and was independent of the kind of pretreatment (18.5% recurrences in grade-2 versus 86% in grade-4 gastritis).CONCLUSIONSThe data show that the grade of gastritis is an important risk factor for duodenal ulcer recurrence. Cure of H. pylori infection is associated with healing of chronic H. pylori-associated gastritis. These data lend considerable support to the hypothesis that H. pylori gastritis is the most important factor among those leading to duodenal ulcer disease.

Background: Helicobacter pylori infection is associated with gastric ulcer disease in about 75% of cases. Objective: The aim of this study was to determine whether H. pylori eradication reduces gastric ulcer relapse rates. Design: The study was randomized, controlled, multicentric and investigator blinded, and was conducted at three university hospitals, two teaching hospitals, and by six practising gastroenterologists. Methods: During a period of 1 year 152 patients with gastric ulcers were randomly assigned to one of two treatment regimens: omeprazole 20 mg daily in the morning for 8 weeks (74 patients), or bismuth subsalicylate 600 mg three times daily for 8 weeks combined with 500 mg amoxicillin twice daily and 1000 mg tinidazole twice daily for the first 10 days (triple therapy) (78 patients). Foliow-up examinations were performed 6,12 and 18 months after treatment and whenever ulcer symptoms occurred. Results: Of the 152 randomized patients five were excluded because of gastric cancer, 10 missed follow-up examinations and seven receiving triple therapy terminated treatment because of side effects. Of the remaining 130 patients, five of 69 (7.2%) in the omeprazole and six of 61 (9.8%) in the triple group were H. pylori negative. After 8 weeks' therapy, the gastric ulcer was healed in 85.9% (omeprazole) and in 81.8% (triple) in H. pylori-positive patients, and in 80% (omeprazole) and 16.7% (triple) in H. pylori-negatives. H. pylori was eradicated in 8.1% of the patients who received omeprazole monotherapy and in 78.2% recieving triple therapy, and in 8.1% and 69.4% in an intention-to-treat analysis. The subsequent relapse rates during a follow-up period of 12 months were 50% in the omeprazole group and 4% in the triple group. Gastric ulcer relapse was observed in 49% of patients who were H. pylori positive and in 2% who were H. pylori negative after treatment. Conclusion: The data show that the presence of H. pylori is an important predictor of gastric ulcer relapse and that eradication of H. pylori may heal gastric ulcer disease.

Background/Aims: Anti-Helicobacter pylori treatment with combinations of omeprazole and amoxicillin is a promising treatment option. The aim of this study was to investigate whether a daily omeprazole dose of 120 mg combined with amoxicillin would cure H. pylori infection at a rate comparable with that achieved with ''triple therapy.'' Methods: In a double-blind, randomized, controlled, and multicenter trial in Germany, 270 patients with an H. pylori-associated duodenal ulcer were treated with 40 mg omeprazole three times a day and 750 mg amoxicillin three times a day for the first 14 days (n = 139) followed by 20 mg omeprazole once daily until day 42 or with omeprazole plus 750 mg amoxicillin placebo three times a day for the same time period (n = 131). Results: Cure rates of H. pylori infection were 91% in the omeprazole plus amoxicillin group, 0% in the omeprazole plus placebo group, and 89% and 0%, respectively, performing an intention-to-treat analysis. Cure of H. pylori infection in patients pretreated with omeprazole was only 58% compared with 95% in patients who were not. The-cumulative 12-month relapse rates were 11.3% and 44% in the treatment groups and 1.6% in H. pylori-negative and 49% in H. pylori-positive patients. Conclusions: The combination of 120 mg omeprazole daily and 2.25 g amoxicillin daily with its H. pylori cure rate of around 90% is one of the best tolerated and most effective treatment regimens.

BACKGROUND:Chronic Helicobacter pylori-associated gastritis is now widely accepted as one of the most important pathogenic factors in duodenal ulcer disease. However, little is known about for how long patients remain free of duodenal ulcer relapses after H. pylori infection has been cured. In the present study, we investigated remission time during a 5-year follow-up period after anti-H. pylori treatment. METHODS:The patients were randomly allocated to treatment with either a combination of 3 x 600 mg bismuth subsalicylate and 2 x 1000 mg amoxycillin or 3 x 600 mg bismuth subsalicylate monotherapy. Endoscopy, including histological and microbiological examination of biopsies, was performed 4 weeks after termination of treatment and after 1 and 2 years. During the third, fourth and fifth years of the follow-up period, patients were monitored twice a year for symptoms compatible with ulcer relapse and for their use of anti-ulcer medication. Endoscopic and histological examinations were carried out whenever symptoms occurred. RESULTS:Of 56 evaluated patients, 47 showed healing of ulcers after bismuth subsalicylate plus amoxycillin compared with 44 of 57 after bismuth subsalicylate monotherapy. H. pylori infection was cured in 52% (29 of 56) of the patients after combined therapy and in 4% (2 of 57) after the monotherapy. The cumulative duodenal ulcer relapse rates after 5 years were 38% (18 of 47) after the combined therapy and 75% (33 of 44) after the monotherapy. In patients who were cured of H. pylori infection, the cumulative duodenal ulcer relapse rate after 5 years was 9.7% (3 of 31), compared with 81.7% (49 of 60) in those patients who remained H. pylori-positive after treatment (P < 0.001). In two of the three patients who suffered duodenal ulcer relapse after being cured of H. pylori infection, H. pylori was present again at the time of relapse. CONCLUSION:The data suggest that curing H. pylori infection results in long-term cure of duodenal ulcer disease and that duodenal ulcer relapses in successfully treated patients are most often associated with H. pylori reinfection.

The present study evaluated the time in remission during a 2-year follow-up after eradication of Helicobacter pylori (HP) in patients with an HP-associated duodenal ulcer (DU). HP was eradicated by combined treatment with high-dose omeprazole (2 x 40 mg) and amoxicillin (2 x 1,000 mg; n = 27) administered for 10 days (OME + AMX); alternatively, patients were treated with omeprazole monotherapy (OME) using the same dosage (n = 25). During the 2-year follow-up period endoscopy including histological examination was performed after 1 and 2 years or whenever symptoms compatible with ulcer relapse occurred. HP eradication was achieved in 82% of the OME + AMX group, but in 0% of the OME group. The cumulative DU relapse rates were 0% after 1 year and 7% after 2 years in 22 patients who became HP-negative. Both HP-negative patients who relapsed in the 2nd year of follow-up were HP-positive again at the time of relapse. Of the 5 patients who were not eradicated after OME + AMX therapy, 2 relapsed within the 1st year (40%) and another 2 within the 2nd year (80%). In the OME group the cumulative relapse rates within 1 and 2 years of follow-up were 52 and 76%, respectively. The results further confirm that eradication of HP with combined OME + AMX treatment leads to a distinct decrease in DU relapse rates and thus may cure DU disease. Long-term eradication with combined OME + AMX treatment is possible, and the rate of reinfection with HP is low (4.5%/year).