A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance

A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.     

Editorial: single-tablet ibuprofen/double-dose famotidine for reduction of gastric and duodenal ulcers (REDUCE Trials): what can be reduced?

Patients using nonsteroidal anti-inflammatory drugs (NSAIDs) who are at high risk of gastroduodenal ulcer complications often do not receive gastroprotective co-therapy. Fixed-dose combination tablets of an NSAID and a proton-pump inhibitor or misoprostol are intended to improve adherence. Whether the use of these combination tablets will improve adherence and clinical outcome remains largely uninvestigated. Unlike proton-pump inhibitors and misoprostol, the efficacy of histamine-2-receptor antagonists in preventing gastroduodenal ulcers associated with NSAID use is questionable. Nonetheless, a new fixed-dose combination tablet of an NSAID and famotidine will soon be available on the market. The study by Laine et al. is a pooled analysis of two large-scale, carefully designed randomized trials (REDUCE trials) of a fixed-combination tablet of ibuprofen and famotidine on the incidence of endoscopic ulcers. How the study findings may influence clinical practice deserves further consideration.     

Proton pump inhibitors in children: a review

Proton pump inhibitors are often used to treat disorders associated with gastric hypersecretion in children, despite the lack of pediatric formulations. They are highly effective in the treatment of ulcers, gastro-esophageal reflux disorders and hypersecretory diseases. They provide a high level of gastric acid inhibition with few adverse effects. The aim of this article is to review the available studies concerning the use of proton pump inhibitors in pediatric populations and to point out: indications for use in children, optimal dosage, risk of adverse effects and consequences of the mechanism of action, and drug interactions. We performed a Medline and Embase search of publications printed from January 1980 to December 2002 concerning the use of proton pump inhibitors in children. We consider the available randomised controlled trials and several other uncontrolled studies conducted in the pediatric population, including all available information concerning the pediatric use of proton pump inhibitors. In children as well as in adults, there are clinical conditions (i.e., severe esophagitis or eradication of Helicobacter pylori) in which proton pump inhibitors offer clear advantages over histamine-2 receptor antagonists. The relatively common use of acid inhibitors (proton pump inhibitors and histamine-2 receptor antagonists) in uncomplicated gastro-esophageal reflux disorders or in the prevention of non-steroidal anti-inflammatory drugs/steroid gastropathy is often unsubstantiated and should be limited to very specific situations. Multicentre randomised controlled studies are needed to better define the efficacy profile, the optimal dosage with respect to the different indications and the safety profile for chronic therapy of proton pump inhibitors in children.     

Effect of lansoprazole versus roxatidine on prevention of bleeding and promotion of ulcer healing after endoscopic submucosal dissection for superficial gastric neoplasia

Background  

Proton pump inhibitors have been reported to be more useful than histamine-2 receptor antagonists for the prevention of bleeding after endoscopic submucosal dissection (ESD) for superficial gastric neoplasia. The aim of this study was to assess the effects of the proton pump inhibitor lansoprazole and the histamine-2 receptor antagonist roxatidine for the prevention of bleeding and the promotion of ulcer healing after ESD and to compare the cost-effectiveness of these two drugs.     

质子泵抑制剂与酸反跳

酸反跳(rebound acid hypersecretion)指停用抑酸药物后胃酸分泌增加超过治疗前水平.质子泵抑制剂(proton pump inhibitors,PPIs)作为一代抑酸药物,比H2受体阻滞剂(histamine-2receptor antagonists,H2RA)具有更强的抑酸效果,是治疗酸相关疾病的主要药物.目前研究已经证实,PPIs可致酸反跳发生.PPIs的酸反跳可以再次诱发酸相关症状出现,不仅增加医疗预算,也给PPIs治疗的终止带来问题.高胃泌素血症是导致酸反跳现象的重要机制.正确使用PPIs,严格掌握适应证,探讨在有效治疗酸相关疾病的同时减少酸反跳发生的措施.     

Large Hiatal Hernias, Anemia, and Linear Gastric Erosion: Studies of Etiology and Medical Therapy

Patients with large diaphragmatic hiatal hernias occasionally manifest severe iron deficiency anemia. The etiology is believed to be that of small erosions at the waist of the hernia which bleed slowly. Our study attempts to determine the incidence of this condition in clinical practice, and whether acid plays a role in the pathophysiology. Sixteen such patients were identified prospectively in a series of 5219 consecutive patients (0.31%) accrued over a 5-yr interval. Anemia was the presenting feature, rather than symptoms of gastroesophageal reflux disease. The erosions were endoscopically identified and biopsied. Anemia was treated and recurrence was prevented for a mean of 24.6 months with long-term iron replacement. Of eight patients treated with iron alone, four were willing to undergo follow-up endoscopy. Of these four, none demonstrated healing. Three of these nonhealers and eight additional patients were treated with both iron and H2 antagonists. Thus, 11 patients were treated with H2 antagonists and iron, whereas four patients were treated with iron alone. At 6 wk, reendoscopy showed healing of the erosions in seven of 11 patients on H2 antagonists, but in none of those treated with iron alone (p less than 0.05). The anemia was corrected in all patients with iron therapy. We conclude that 1) gastric acid appears to have some role in the pathogenesis of this lesion; 2) short-term therapy with H2-receptor antagonists promote healing of the erosions; and 3) long-term iron therapy alone is adequate for initial and maintenance therapy of the anemia.     

Treatment of functional dyspepsia

Opinion statement Functional dyspepsia is a common chronic condition. It can have a major impact on quality of life and remains a large burden on healthcare resources. Its underlying mechanisms are not fully understood and therapies are mainly empirical. In this review, we summarize the best evidence on available therapeutic interventions in functional dyspepsia. Helicobacter pylori eradication, for those infected, is likely a safe and cost-effective strategy but benefits only a minority. Antisecretory agents such as proton-pump inhibitors and histamine-2 receptor antagonists have shown some benefit and are recommended as the firstline option in the absence of H. pylori infection. There is a lack of strong evidence of benefit from prokinetic agents, and cisapride, the most studied agent, is largely unavailable. Antidepressants need to be adequately tested in functional dyspepsia, but both psychotherapy and hypnotherapy interventions have shown promising results. Herbal therapies need further study in these patients. 5-Hydroxytryptamine3 (5-HT₃) and 5-HT₄ receptor antagonists, and cholecystokinin type A and neurokinin receptor antagonists remain promising emerging therapies.     

Effect on iron deficiency anemia of laparoscopic repair of large paraesophageal hernias

Patients with iron deficiency anemia sometimes have a large paraesophageal hernia and no other explanation for their chronic blood loss. The management of these patients can be a dilemma, especially when the hernia is otherwise asymptomatic. We aimed to determine whether a laparoscopic repair of the hernia could cure the anemia. We reviewed a consecutive series of 11 cases of iron deficiency anemia associated with a large paraesophageal hernia, many without associated linear gastric erosions, managed by laparoscopic repair and fundoplication. There was one conversion in a patient with dense adhesions from previous upper abdominal surgery. Another patient required a laparoscopic reoperation for an early recurrence. Major morbidity occurred in three patients and there was no mortality. There was no recurrence of anemia after a median follow-up of more than 2 years. Iron deficiency anemia in association with a large paraesophageal hernia can be treated by laparoscopic repair with acceptable morbidity and minimal mortality. The complications of a large paraesophageal hernia are also prevented.     

Occult gastrointestinal bleeding

Occult gastrointestinal bleeding commonly manifests as iron deficiency anemia or fecal occult blood. Iron deficiency anemia results from chronic occult gastrointestinal bleeding. Evaluation of asymptomatic patients who have iron deficiency anemia or fecal occult blood usually should begin with investigation of the colon. Colonoscopy is preferred, but flexible sigmoidoscopy plus air contrast barium enema, or computed tomographic colonography may be acceptable in certain circumstances. If evaluation of the colon does not reveal a bleeding site, evaluation of the upper gastrointestinal tract is mandatory in patients who have iron deficiency anemia, and this should be considered in those who have fecal occult blood. In patients who have gastrointestinal symptoms, evaluation of the portion of the gastrointestinal tract from which the symptoms is derived should be pursued initially. The role of small intestinal investigation is controversial, and this probably should be reserved for patients who have iron deficiency anemia and persistent gastrointestinal symptoms or those who fail to respond to appropriate therapy. Celiac sprue should be considered as a potential cause of iron deficiency anemia in all patients. The treatment and prognosis of patients who have iron deficiency anemia or fecal occult blood depends on the gastrointestinal tract abnormality(ies) identified. Those without identifiable bleeding sites generally respond to conservative management and have a favorable prognosis. On the other hand, the outlook is poorer for patients with refractory occult blood loss or those who have vascular ectasias. Both groups of patients are clinically challenging and require a focused and experienced team approach to diagnosis and therapy.     

Emerging causes of iron deficiency anemia refractory to oral iron supplementation

While oral iron supplementation is commonly used throughout many clinical setting,treatment with intravenous(IV) iron has historically been reserved for specific settings,such as chronic kidney disease,gynecologic issues,and anemia associated with cancer and its treatments.However,the use of IV iron has begun to gain popularity in the treatment of iron deficiency anemia(IDA) associated with two conditions that are being seen more frequently than in years past:patients who are status post gastric bypass procedure and those with inflammatory bowel disease(IBD).The Roux-en-Y procedure involves connecting a gastric pouch to the jejunum,creating a blind loop consisting of distal stomach,duodenum,and proximal jejunum that connects to the Roux limb to form a common tract.IDA occurs in 6%-50% of patients who have undergone a gastric bypass,the etiology being multifactorial.The proximal gastric pouch,the primary site of gastric acid secretion,is bypassed,resulting in a decreased ability to metabolize molecular iron.Once metabolized,most iron is absorbed in the duodenum,which is entirely bypassed.After undergoing bypass procedures,most patients significantly limit their intake of red meat,another factor contributing to post-bypass IDA.Chronic anemia occurs in approximately 1/3 of patients who suffer from IBD,and almost half of all IBD patients are iron deficient.IBD leads to IDA through multiple mechanisms,including chronic intestinal blood loss,decreased absorption capabilities of the duodenum secondary to inflammation,and an inability of many IBD patients to tolerate the side effects of oral ferrous sulfate.In this study,we reviewed the charts of all patients who received IV iron at Sylvester Comprehensive Cancer Center/University of Miami Hospital Clinic from January 2007 to May 2012.The most common indications for IV iron were for issues related to cancer and its treatment(21.9%),IBD(20.1%),and gastric bypass(15.0%).Of the 262 patients who received IV iron,230 received iron sucrose and 36 received iron dextran.While doses of 100,200,300,and 400 mg of iron sucrose were given,100 and 200 mg were by far the most common dosages used,122 and 120 times,respectively.The number of dosages of iron sucrose given ranged from 1 to 46,with a mean of 5.5 and a median of 4 doses.The average dose of iron dextran given was 870.5 mg,with 1000 mg being the most common dosage used.Most patients(22 of 36) who received iron dextran only received one dose.While patients with traditional indications for IV iron,such as gynecologic issues and kidney disease,still were represented in this study,we expect to see a continued increase in physicians using IV iron for emerging gastrointestinal indications,especially considering the increased safety of new low-molecular formulations.     

No significant difference in neutrophil activation found among three H2RAs

BACKGROUND: Even with the most effective treatment, Helicobacter pylori eradication is difficult in some patients. Therefore, patients sometimes require acid-suppressive therapy without H. pylori eradication. It has been reported that ranitidine inhibits neutrophil activation, whereas famotidine does not. However, few studies have been published concerning the activation of neutrophils before and after treatment using clinical doses of histamine-2 receptor antagonists in patients with H. pylori infection. AIM: To examine the effects of neutrophil activation after treatment with three different histamine-2 receptor antagonists. PATIENTS: This prospective, open-label, randomised, parallel-group study was conducted. Thirty patients with H. pylori infection were enrolled. These subjects were randomly assigned to receive one of the following treatments: (a) 150 mg ranitidine, (b) 20mg famotidine, or (c) 10 mg lafutidine b.d., for 4 weeks. Before and after histamine-2 receptor antagonist treatment, histological findings, myeloperoxidase activity, and interleukin-8 in the gastric mucosa were evaluated. RESULTS: On the basis of the histological findings between before and after histamine-2 receptor antagonist treatment, no significant differences were found in any groups. Similarly, there were no significant differences in myeloperoxidase activity or interleukin-8 levels. CONCLUSION: In patients with H. pylori, when used at clinical doses, any histamine-2 receptor antagonists can be used without concerning about inhibition of neutrophil activation.     

Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and mineral deficiencies.

One hundred forty patients were followed for a mean 24.2 months after gastric bypass. Postop multivitamin (MV) prophylaxis was recommended for all patients and 90 of 140 patients (64 percent) were regularly compliant. Deficiencies in iron, vitamin B-12 or folate were recognized in 88 of 140 patients (63 percent). Thirty of 45 patients (67 percent) with iron deficiency developed anemia. Forty-three of the 52 patients who did not have deficiencies were regularly taking MV vs 47 of 88 patients who developed deficiencies (P less than 0.001). MV prophylaxis was successful in preventing folate (P less than or equal to 0.05) and vitamin B-12 deficiencies (P less than or equal to 0.02) but did not prevent development of iron deficiency or subsequent anemia. There was no correlation between taking prescribed supplements and resolution of either iron deficiency of anemia. B-12 and folate supplements corrected deficiencies in 73 percent of cases. We conclude that oral MV prophylaxis is useful in preventing folate and B-12 deficiency after gastric bypass. Additional prophylactic iron supplements should be provided for women to prevent iron deficiency and associated anemia.     

Principes thérapeutiques du reflux gastroœsophagien

Gastroesophageal reflux is a common disease. Its chronic course, even if mild, is sometimes complicated by erosive oesophagitis. Drug therapy acts against gastric acidity and motility disorders. Treatment of gastroesophageal reflux disease has three aims: improvement of symptoms and quality of life, healing erosive lesions and prevention of symptomatic and endoscopie relapses. Non-drug measures are always useful, even if their efficacy is not well established. Initial therapy of a symptomatic reflux or mild oesophagitis is most of the time effective (antacids, prokinetics, H₂ receptor antagonists). Proton-pump inhibitors are also effective in healing and preventing severe oesophagitis. Questions about long-term treatment adverse events with powerful acid inhibitors, such as hypergastrinemia and the risk of gastric carcinoid tumours seem to be resolved. Studies are requested to define the optimal long-term maintenance treatment with cisapride, H₂ receptor antagonists or proton-pump inhibitors at low doses in prevention of symptomatic and mild oesophagitis relapses.     

Is there any relationship between pernicious anemia and iron deficiency ?

INTRODUCTION: Previous studies have suggested that iron deficiency could be due to atrophic gastritis of the body/fundus. The aim of this study was to determine the prevalence of iron deficiency among patients with pernicious anemia and associated factors. PATIENTS AND METHODS: All patients with pernicious anemia diagnosed at our institution between January 1990 and February 2005 were included. Inclusion criteria were: 1- histological diagnosis of atrophic fundic gastritis and 2- criteria of gastric autoimmune involvement. Histology of gastric biopsies was performed in a blinded manner. Iron deficiency was defined as serum ferritin level<15 microg/L in women and<40 microg/L in men. RESULTS: Ninety-five patients (69 women), mean age 60 years (range: 23-90) were included. Twenty patients (21.1%) had normal blood cell counts; 12 patients (12.6%) had microcytosis with or without anemia and 53 patients (55.8%) macrocytosis with or without anemia. Serum ferritin levels were measured in 58 patients, 16 (27.6%) of whom, all women, had iron deficiency. They were significantly younger (39.2 years) than patients without iron deficiency (61.6 years, P<0.0001). Serum gastrin levels did not differ between the groups with and without iron deficiency. A significantly more severe inflammatory infiltrate of the fundus and endocrine cell hyperplasia was observed in iron deficiency patients. Multivariate analysis showed that iron deficiency was linked to female gender and age<50 years. CONCLUSION: Iron deficiency and microcytic anemia are not rare in patients with pernicious anemia and should not rule out the diagnosis. Iron deficiency does not appear to be related to the degree of atrophic fundic gastritis but is linked to female gender and young age, suggesting menstrual blood loss could play a role. Whether decreased iron absorption due to reduced acid secretion favors the expression of gynecological iron loss cannot be ascertained.     

Gastroesophageal reflux disease in pregnancy

Gastroesophageal reflux disease during pregnancy is common. Altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus explain the high incidence of this problem in pregnant women. For the majority of patients, life-style modifications are helpful, but are not sufficient to control symptoms and medication is required. The optimum management of reflux in pregnant patients requires special attention and expertise, since the safety of the mother, foetus and neonate remain the primary focus. Gastroenterologists and obstetricians should work together to optimise treatment. Typically, one utilises a step-up program that starts with life-style modifications and antacids. If those methods fail, histamine-2 receptor antagonists and proton pump inhibitors are tried. Rarely, promotility agents are used. Initiation of these medications must be undertaken after a careful discussion of risks and benefits with patients. In patients without a prior history of reflux, symptoms usually abate after delivery.     

心力衰竭与贫血相关性研究进展

贫血在心力衰竭患者中有很高的发生率,其发病机制与血液稀释、铁缺乏、营养不良、慢性肾脏疾病、炎症性免疫激活、血管紧张素转换酶抑制剂和血管紧张素受体拮抗剂的应用等因素有关。贫血与充血性心力衰竭患者的临床预后密切相关,并被认为是心力衰竭患者临床预后不良的独立因子。使用促红细胞生成素成为治疗充血性心力衰竭性贫血的新靶点,但也存在一定的风险。     

Assessment of arterial ventricular coupling changes in patients under therapy with various antihypertensive agents by a non-invasive echocardiographic method

BACKGROUND: The integration between arterial and ventricular function has been studied by mostly invasive techniques. We considered assessing the influence of various antihypertensive medications on arterial-ventricular coupling (AVC) with the use of a non-invasive echocardiographic method. METHODS: A total of 9037 patients, who had been under treatment for essential arterial hypertension were studied echocardiographically at baseline prior to therapy and after 6 months of antihypertensive monotherapy (diuretics, beta-blockers without intrinsic sympathomimetic activity (ISA), beta-blockers with ISA, a-blockers, angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (AIIRA), non-dihydropyridine calcium antagonists, and dihydropyridine calcium antagonists). The AVC was calculated by echocardiographic measurements based on the equation: AVC=ESV/SV (ESV, end systolic volume; SV, stroke volume). RESULTS: ACEI, AIIRA, and dihydropyridine calcium antagonists decreased (P<0.0001 for all) while diuretics, alpha-blockers, both beta-blocker groups, and non-dihydropyridines increased significantly the AVC values compared to baseline measurements (P<0.0001 for all, except P=0.02 for alpha-blockers). Changes in AVC were the most highly correlated with changes in EF (r=-0.979, P<0.0001). CONCLUSION: Various antihypertensive drugs have a differential effect on AVC with ACEI, AIIRA, and dihydropyridine calcium antagonists having the most favorable effect on this index. AVC provides a meaningful index of cardiovascular performance in hypertension and offers the possibility of wide employment and serial follow-up in large numbers of patients because of its completely non-invasive nature.