A cost-utility analysis comparing omeprazole with ranitidine in the maintenance therapy of peptic esophageal stricture.
Stal JM. Gregor JC. Preiksaitis HG. Reynolds RP.
Department of Medicine, University of Western Ontario, London.
BACKGROUND: Recent studies have suggested that patients receiving omeprazole for prophylaxis against peptic esophageal stricture recurrence have less dysphagia and require fewer repeat dilations than patients receiving ranitidine. OBJECTIVE: To estimate the incremental utility gain and associated incremental cost of omeprazole compared with those of ranitidine for the maintenance therapy of patients with peptic stricture who required esophageal dilation. METHODS: Decision analysis using SMLTREE software was used to compare the incremental cost-utility of omeprazole 20 mg once daily with that of ranitidine 150 mg bid for one year. Variables were estimated from the literature, hospital data, and utility analyses involving patients with peptic stricture and health professionals. The primary outcome measure was cost per quality-adjusted life-years (QALYs) gained. RESULTS: The incremental cost of omeprazole compared with that of ranitidine was $556 per patient treated. The incremental utility gain of omeprazole was 0.0112 QALYs. Overall, the incremental cost:utility ratio of omeprazole in the maintenance therapy of patients with peptic stricture was $49,600 per QALY gained. A sensitivity analysis revealed that the estimates with the greatest impact on the cost:utility ratio were disutility associated with dysphagia and dilation, the probability of requiring redilation and the cost of medications. CONCLUSIONS: Omeprazole 20 mg once daily is associated with greater utility and higher cost than ranitidine 150 mg bid when used as prophylaxis against stricture recurrence. Omeprazole may be considered clinically and economically sufficient enough to warrant widespread use in this setting.
Combination ciprofloxacin and metronidazole for active Crohns disease.
Greenbloom SL. Steinhart AH. Greenberg GR.
Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario.
Recent experimental evidence underscores the contribution of intestinal bacteria to the inflammatory process of Crohn's disease. This open study examined the efficacy and safety of combination ciprofloxacin and metronidazole for patients with active Crohn's disease of the ileum and/or colon. Seventy-two patients with active Crohn's disease of the ileum (n = 27), ileocolon (n = 22) or colon (n = 23) were treated with ciprofloxacin 500 mg bid and metronidazole 250 mg tid for a mean of 10 weeks. Clinical remission was defined as a Harvey-Bradshaw index of three points or less; an index reduction of at least three points indicated a clinical response. Clinical remission was observed in 49 patients (68%), and 55 patients (76%) showed a clinical response. A clinical response was noted in 29 of 43 patients (67%) who were not taking concurrent prednisone treatment and in 26 of 29 patients (90%) receiving prednisone (mean dose of 15 mg/day). A clinical response also occurred in a greater proportion of patients with colonic disease, with or without ileal involvement (84%), compared with patients with ileal disease alone (64%), and in patients without resection (86%) compared with those with previous resection (61%). Five patients discontinued antibiotics because of adverse events. After a mean follow-up of nine months, clinical remission was maintained in 26 patients off treatment and in 12 patients who continued antibiotic therapy. Ciprofloxacin in combination with metronidazole is well tolerated and appears to play a beneficial role in achieving clinical remission for patients with active Crohn's disease, particularly when there is involvement of the colon.
Antibody levels in Ethiopian children five years after vaccination with two different doses of hepatitis B vaccine: is there a need for booster vaccine?
Tsega E. Horton J. Nordenfelt E. Hansson BJ. Tafesse B. Wolde-Hawariat G. Lindberg J.
Department of Internal Medicine, Faculty of Medicine, Memorial University, St John's, Newfoundland. email@example.com
It was hypothesized that, following effective initial vaccination, a booster dose of hepatitis B vaccine will not be necessary in areas of hyperendemicity for hepatitis B virus (HBV) infection. A total of 314 Ethiopian children, ranging from two to 14 years old, were alternatively vaccinated with 10 and 20 micrograms hepatitis B vaccine doses, using the initial, one- and six-month schedule. Five years later, 210 of the vaccinees were retested for anti-HBV surface antibody titres. Both 10 and 20 micrograms doses of hepatitis B rDNA yeast vaccine were equally immunogenic and protective against HBV infection for at least five years despite marked reduction of mean antibody levels and geometric mean titres, with 11% of the vaccinees showing antibodies below the protective level. For firm further recommendations a longer follow-up period of vaccinees is suggested.
Liver transplantation for neuropsychiatric Wilson disease.
Kassam N. Witt N. Kneteman N. Bain VG.
Department of Medicine, University of Alberta, Edmonton.
Although neuropsychiatric manifestations are prominent in some patients with Wilson disease, there is little published information regarding the efficacy of liver transplantation for these patients. A 22-year-old male with advanced neurological impairment and prominent psychiatric manifestations due to Wilson disease who underwent liver transplantation is presented. After transplantation, the ceruloplasmin and copper studies normalized and eventually the Kayser-Fleischer rings disappeared. Neurological recovery was very slow and incomplete, and his behavioural and personality disorder was entirely unaffected. He committed suicide 43 months post-transplantation. A review of the small number of related published cases in the English language literature shows variable neurological recovery post-transplantation, but the course of psychiatric manifestations is virtually never described. This case suggests that one must be cautious regarding liver transplantation for Wilson disease in patients with prior psychiatric manifestations. Aggressive medical management is likely to be preferable in most cases.
Hemorrhagic intestinal Henoch-Schonlein purpura complicated by cytomegalovirus infection.
Nguyen-Ho P. Jewell LD. Thomson AB.
Department of Medicine (Gastroenterology), University of Alberta Hospitals, Edmonton.
A 54-year-old man on hemodialysis for acute chronic renal failure and on corticosteroids for Henoch-Schonlein purpura developed massive hematochezia. After extensive clinical investigation, an ileal bleeding site was identified and surgically removed. Pathological examination of the diseased bowel segment revealed an extensive vasculitis with mucosal ulceration attributable to Henoch-Schonlein purpura as well as florid cytomegalovirus infection.
Obscure gastrointestinal bleeding from an ampullary tumour in a patient with a remote history of renal cell carcinoma: a diagnostic conundrum.
Janzen RM. Ramj AS. Flint JD. Scudamore CH. Yoshida EM.
Department of Medicine, University of British Columbia, Vancouver.
Metastasis of renal cell carcinoma to the ampulla of Vater is a rare occurrence. The outlined case, which presented as an upper gastrointestinal bleed, is only the eighth such reported case in the English-language literature. This case is the longest reported time interval between surgical nephrectomy to presentation with ampullary metastasis at 17.5 years. The ampullary source of bleeding in this case was initially obscure and missed by conventional gastroscopy. Diagnosis was made with a side-viewing endoscope, emphasizing the usefulness of this instrument in the investigation of active bleeding from a small bowel source.
Gastroesophageal reflux disease.
Chronic GERD is an unremitting, incurable disorder that recurs rapidly upon discontinuation of therapy. Primary complications of GERD include esophagitis, esophageal stricture and Barrett esophagus. Current therapy focuses on modifying risk factors, inhibiting the production of acid and enhancing esophageal gastric motility. In patients with uncomplicated heartburn, nondrug therapy should be the initial therapeutic approach, with patient education a major step in promoting lifestyle changes and improving the outcome. Maintenance therapy is central to the management of GERD. If symptoms persist to suggest complicated disease, further diagnostic tests (endoscopy) are indicated. H2 receptor antagonists usually resolve symptoms in 50% to 70% of patients, and PPIs in 74% to 96% of patients. Agents that improve esophageal motility, such as cisapride, may provide symptomatic relief of heartburn, but healing effects are inconsistent. In refractory disease, therapy is individualized to the patient, and may include combination therapy, more aggressive single line therapy or an appropriate surgical approach.
Utility of serology in determining Helicobacter pylori eradication after therapy.
Fallone CA. Loo VG. Barkun AN.
Division of Gastroenterology, Royal Victoria Hospital, Montreal, Quebec. firstname.lastname@example.org
OBJECTIVE: To determine the usefulness of four serological tests in confirming cure of H pylori infection before the previously reported six-month post-treatment delay. PATIENTS AND METHODS: As part of a prospective, blinded, controlled trial, in which patients with duodenal ulcers were randomized to receive different combinations of antibiotics, serum samples were obtained in 89 patients before treatment, as well as on several occasions after treatment. Antibody titres were determined by ELISA with Bio-Rad immunoglobulin (Ig) A, Bio-Rad IgG, Pyloriset EIA-A for IgA and Pyloriset EIA-G for IgG. Eradication was confirmed with antral biopsy three months after therapy. RESULTS: The percentage drop in titre following treatment was significantly larger for the group of patients who were treated successfully with all four kits. Optimal cut-offs for identifying successful therapy were determined, and accuracy improved as the interval between testing and therapy was prolonged. Six months after therapy, the IgG test from Bio-Rad achieved 100% sensitivity and 80% specificity, and that from Pyloriset achieved 88% sensitivity and 100% specificity. At three months, however, test performance was quite good, with 90% sensitivity and 80% specificity when using a Pyloriset IgA titre drop of 20% or greater to predict successful eradication. CONCLUSION: Serology is a simple, easily available, noninvasive method that exhibits good positive predictive value in the confirmation of successful cure of H pylori infection three or six months after treatment.
Postliver transplant allograft reinfection with a lamivudine-resistant strain of hepatitis B virus: long-term follow-up.
Yoshida EM. Ma MM. Davis JE. Fischer KP. Kneteman NM. Erb SR. Tyrrell DL. Bain VG.
Department of Medicine, University of British Columbia.
Lamivudine is a nucleoside analogue with efficacy in the suppression of hepatitis B viral (HBV) replication. In a previously reported study, lamivudine was administered to patients with chronic, actively replicating HBV infection who subsequently underwent liver transplantation. Patients became serum HBV DNA-negative in response to lamivudine before transplantation, which was continued in the post-transplant period. Two of four patients surviving the immediate postoperative period developed allograft reinfection 240 and 409 days post-transplant. The strain of the reinfecting virus was analyzed, and a mutation in the YMDD region of the viral polymerase conferring resistance to lamivudine was discovered. The long term follow-up of these two patients is reported. The first patient developed ascites 16.5 months after allograft reinfection. A transjugular liver biopsy performed 18 months after the emergence of the lamivudine-resistant strain revealed cirrhosis and lobular hepatitis without rejection. The gradient between hepatic vein wedged and free pressures was 13 mmHg, consistent with portal hypertension. The second patient, 16 months after allograft reinfection with the lamivudine-resistant strain, is without clinical evidence of portal hypertension, although liver enzymes remain elevated. Both patients were given a trial of famciclovir, which did not significantly suppress HBV viremia. In conclusion, lamivudine-resistant HBV strains with the YMDD mutation may have an aggressive clinical course with rapid progression to cirrhosis. Famciclovir did not appear to be an effective rescue agent in these two patients.
Altered colonic environment, a possible predisposition to colorectal cancer and colonic inflammatory bowel disease: rationale of dietary manipulation with emphasis on disaccharides.
Department of Medicine, Sir Mortimer B Davis Jewish General Hospital, Faculty of Medicine, McGill University, Montreal, Quebec.
A recurrent theme in the schema of pathogenetic mechanisms attributed to colorectal cancer (CRC) and inflammatory bowel disease (IBD) is the interaction between genes and environment. Dietary and other environmental factors, and lower intestinal flora and their chemical interactions occur in the pathogenesis of both. Events at the mucosal surface may be influenced by factors in the luminal environment and by contributions of the host. In addition, both forms of IBD--Crohn's disease (CD) and ulcerative colitis (UC)--have distinctive associated host events. Even within CD and UC, different clinical patterns and prognoses may have different specific host mechanisms. Some of the current putative pathogenetic processes in CRC and IBD are reviewed. Particular attention is given to hypotheses relating to the role of dietetic substances, mainly fibre and dairy products, and how they may affect disease formation. It is argued that within the context of hypotheses proposed for possible beneficial effects of these two dietetic factors, CRC and IBD may be considered together. Further support is lent to arguments that similar and additional hypothetical features ascribed to beneficial effects of fibre may be attributed to disaccharides, lactose and its derivatives, lactulose and lactitol.
Survey of gastroenterologists on the diagnosis and treatment of adult patients with celiac disease in British Columbia.
Department of Medicine (Gastroenterology), University of British Columbia, Vancouver.
A recent survey of physician specialists from New York City suggested that few patients with celiac disease are seen and that management experience is limited. The present study, using a survey similar to that of the New York City investigation, evaluated the diagnostic and management experience of specialists for adult celiac disease patients in British Columbia. Four hundred and four patients were reported in the combined clinical practice experience of the responding physicians. Of these, 59, or 15%, were diagnosed in the prior year. Although each physician diagnosed an average of 2.4 new celiac disease patients per year in their entire practice experience, an average of over 4.0 new celiac disease patients were detected in the past year. Most patients presented with diarrhea, weight loss, anemia or nutrient deficiency, but about 14% were asymptomatic or diagnosed by an incidental small intestinal biopsy done at upper gastrointestinal endoscopy. Specialist physicians in British Columbia usually refer patients to their family physicians, dietitians and patient support groups for continued care and appear to rarely rely on serological assays, including antibody tests, for detection of celiac disease in adults. An associated or complicating lymphoma was detected in 16 of 404 patients (4%). Recognition of biopsy-defined celiac disease appears to be increasing in British Columbia.
The evolving role of endoscopic retrograde cholangiography before and after cholecystectomy.
Ganguli SC. Pasha TM. Petersen BT.
Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Laparoscopy is the preferred approach for cholecystectomy; however the indications for pre- versus postoperative endoscopic retrograde cholangiography (ERC) are still evolving. The records of patients who had ERC performed one month before (n = 119) or after (n = 35) laparoscopic or open cholecystectomy from January 1990 to August 1992 (period 1), and 66 patients who had preoperative ERC from November 1995 to October 1996 (period 2) are reviewed, ERC indications, findings and outcomes were reviewed, and trends in the use of preoperative ERC from 1990 to 1996 were sought. Between periods 1 and 2 the yield of preoperative ERC increased from 36% to 58% (P < 0.01). The use of preoperative ERC for the indication of abnormal liver enzymes declined (P < 0.05), while the yield increased (25% versus 61%, P < 0.01). Both the use of ERC and the yield remained stable for other indications. ERC was felt to have changed the surgical approach in 5% of patients. Primary indications for postoperative ERC (n = 35) included abnormal intraoperative cholangiography (43%), liver function test abnormalities (23%) and recurrence of preoperative symptoms (14%); stones were found in 60%, 50% and 20% of patients with these indications, respectively. Overall, 46% of postoperative studies revealed duct stones. The roles for pre- and postoperative ERC are changing and depend greatly on the relative laparoscopic and endoscopic expertise at a given institution.
Nutrition and chronic liver disease.
Siriboonkoom W. Gramlich L.
Department of Medicine, University of Alberta, Edmonton.
Malnutrition frequently occurs in patients with chronic liver disease, and may influence both short and long term clinical outcome in these patients. Therefore, nutritional intervention may play an important role in the management of chronic liver disease patients. Recent progress in nutritional assessment, principles of nutrition management and the impact of malnutrition upon the clinical outcome of chronic liver disease are reviewed and summarized. Recommendations on how to manage/prevent malnutrition in these patients will be presented.
Churg-Strauss syndrome leading to small bowel infarction: an unusual case of abdominal pain in a young patient.
Sookram S. Hancock-Friesen C. Ferguson JP. Sosnowski T. Russell LJ.
Division of Emergency Medicine, University of Alberta, Edmonton.
A 33-year-old man with a history of severe asthma presented to the emergency department with a week-long history of severe unrelenting abdominal pain, nausea and decreased appetite. He was admitted to hospital, and routine gastrointestinal investigations were performed, which did not elucidate the cause of his abdominal pain. Exploratory laparotomy demonstrated patchy infarction of the entire small bowel, characteristic of Churg-Strauss syndrome. The patient subsequently underwent 12 separate laparotomies to salvage surviving small bowel. The patient is maintained on total parenteral nutrition.
Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation.
Marshall JK. Thompson AB. Armstrong D.
Division of Gastroenterology, McMaster University, Hamilton, Ontario.
Symptomatic gastroesophageal reflux is a common complication of pregnancy and lactation. However, the safety of many effective medical therapies, including oral proton pump inhibitors, has not been well defined. The administration of oral omeprazole to a 41-year-old female during the third trimester of pregnancy, after ranitidine and cisapride failed to control her refractory gastroesophageal reflux, is reported. No adverse fetal effects were apparent, and the patient elected to continue omeprazole therapy (20 mg/day) while breastfeeding. Peak omeprazole concentrations in breast milk (58 nM, 3 h after ingestion) were less than 7% of the peak serum concentration (950 nM at 4 h), indicating minimal secretion. Although omeprazole is a potentially useful therapy for refractory gastroesophageal reflux during pregnancy and lactation, further data are needed to define better its safety and efficacy.