Eradication of Helicobacter pylori reduces gastric and duodenal ulcer recurrence.
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Bismuth↗
Biomedical subjects
L Laine
Publications and source records attributed to L Laine.
NSAID-induced gastroduodenal injury: what's the score?
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Adult↗
Endoscopic therapy for peptic ulcer hemorrhage: heater probe and alcohol injection.
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Electrocoagulation↗
Determination of the optimal technique for bipolar electrocoagulation treatment. An experimental evaluation of the BICAP and Gold probes.
The optimal technique for use of bipolar electrocoagulation has not been established despite its widespread clinical use. This study of the BICAP (Circon-ACMI, Stamford, CT) and Gold (Microvasive, Watertown, MA) probes evaluates the maximal force that can be applied through an endoscope and quantifies the depths of coagulation and sticking at varying parameters in a beef liver model. Maximal forces of application were determined with 3.2- and 2.3-mm probes extended 3 and 6 cm outside the endoscope at 90 degrees and 45 degrees. Depths of coagulation and sticking were measured at 90 combinations of varying forces of application (0, 50, and 100 g), watt settings (1, 3, 5, 7, and 9), and durations (2, 6, 10, and 14 seconds; 3 x 2 seconds, 7 x 2 seconds) for the 3.2-mm BICAP and Gold probes. Mean maximal force of application decreased with greater extension or angulation of the probe outside the scope (3.2-mm BICAP--90 degrees: 3 cm, 110 g; 6 cm, 56 g; 45 degrees: 3 cm, 50 g; 6 cm, 30 g; P less than 0.001; 3.2-mm Gold--90 degrees: 3 cm, 130 g; 6 cm, 105 g; 45 degrees: 3 cm, 62 g; 6 cm, 48 g; P less than 0.001). The maximal force was significantly greater with the Gold probe than with the BICAP in seven of eight comparisons. Significant variations among the mean depths of coagulation (in millimeters) for pooled data of each parameter were observed with force of application (BICAP: 0 g, 0.8; 50 g, 1.4; 100 g, 1.7), watt settings (BICAP: 1, 0.6; 3, 1.7; 5, 1.4; 7, 1.4; 9, 1.3), and duration of treatment (BICAP: 2 seconds, 0.8; 6 seconds, 1.1; 10 seconds, 1.4; 14 seconds, 1.5; values for the Gold probe were comparable). The greatest depths of coagulation were observed at 100 g force, watt setting 3, and 14 seconds or 7 x 2 seconds duration. Sticking paralleled depth of coagulation, increasing with force and duration of application. In conclusion, optimal treatment of bleeding gastroduodenal lesions with bipolar electrocoagulation includes (a) placing the tip of the endoscope en face as close as possible to the bleeding lesion, (b) applying the maximal force possible, (c) using a low-watt setting (approximately 3), and (d) treating with prolonged periods of coagulation.
Electrocoagulation↗
Cysteine usage increases the need for acetate in neonates who receive total parenteral nutrition.
The addition of cysteine (as cysteine HCl) to a total parenteral nutrition (TPN) solution enhances calcium and phosphate solubility because cysteine lowers the pH of the solution. To determine whether adding cysteine to TPN solutions affected the acid-base homeostasis of infants and increased their need for acetate to obviate acidosis, we studied two groups of neonates--those receiving TPN before (group C) and after (group NC) the addition of cysteine. Measurements were made before and during the first 2 wk of TPN administration. We measured the pH of our standard TPN solution with and without the addition of cysteine. Serum carbon dioxide was significantly lower in group C despite a significantly greater intake of acetate in group NC. In the in vitro study the addition of cysteine to the TPN solution lowered the pH from 5.5 to 5.1. Newborns who received TPN solutions to which cysteine was added had lower serum carbon dioxide values and a greater need to receive acetate than did newborns who received TPN solutions without cysteine.
Acetates↗
The causes of esophageal symptoms in human immunodeficiency virus infection. A prospective study of 110 patients.
STUDY OBJECTIVES: --To determine the prevalence of infectious agents in patients with human immunodeficiency virus infection and odynophagia or dysphagia; the utility of endoscopic, histologic, cytologic, and virologic testing for the diagnosis of esophagitis; and the yield of blind brushings of the esophagus in this setting. DESIGN: --Prospective clinical case study. SETTING: --Urban county hospital. PATIENTS: --One hundred ten consecutive patients with esophageal symptoms and documented human immunodeficiency virus infection. INTERVENTION: --Blind brushing of the esophagus via orogastric tube followed by endoscopy with esophageal brushing for fungal stain, Papanicolau smear, and viral cultures and esophageal biopsies for histologic examination and viral culture. MAIN RESULTS: --Seventy-two (65%) of the 110 patients had a total of 100 esophageal infections. Thirty-three (30%) had Candida alone, 22 (20%) had Candida and cytomegalovirus, two (1.8%) had Candida with cytomegalovirus and herpes simplex virus, seven (6%) had cytomegalovirus alone, six (5%) had herpes simplex virus alone, and two (1.8%) had both viruses. Fifty of 55 patients with plaques alone had Candida, and two (4%) had only viral infection. Of 19 patients with erosions or ulcers, 11 (58%) had a viral infection, two (11%) had Candida alone, and six (30%) had no etiologic agent identified. The sensitivity of endoscopic brushings (95%) was better than that of histologic examination (70%) in the diagnosis of Candida esophagitis. Likewise, viral cultures of brushings or biopsy specimens were more sensitive (67%) than histologic examination (35%) for viral esophagitis. Blind brushing of the esophagus had a sensitivity and specificity for infectious esophagitis of 84% and 75%, respectively. Oral thrush had a sensitivity of 53% and a positive predictive value of 77% for Candida esophagitis.
Bacterial Infections↗
Upper gastrointestinal tract hemorrhage.
This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.
Diagnosis, Differential↗
Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial.
This study prospectively compares multipolar electrocoagulation and injection therapy in high-risk patients with bleeding ulcers. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia and unstable vital signs, transfusion of greater than or equal to 2 U of blood in 12 hours, or a decrease in hematocrit of greater than or equal to 6% in 12 hours. Sixty patients with endoscopic evidence of an ulcer with active bleeding (n = 26) or a nonbleeding visible vessel (n = 34) were randomly assigned to receive multipolar electrocoagulation or injection with absolute ethanol. Hemostasis was achieved in 14 of 14 actively bleeding patients with multipolar electrocoagulation vs. 10 of 12 (83%) treated with injection. No significant differences were observed between electrocoagulation and injection therapy in any parameter assessed during the hospitalization: incidence of further bleeding (6% vs. 10%), units of blood transfused after treatment (1.8 +/- 0.6 vs. 1.3 +/- 0.4), incidence of surgery for bleeding (6% vs. 7%), length of hospital stay in days (5.8 +/- 0.9 vs. 7.2 +/- 2.5), cost of hospitalization (+7160 +/- +1630 vs. +8520 +/- +2960), or mortality rate (3% vs. 3%). Treatment induced bleeding in nonbleeding visible vessels in 35% of subjects in each group, but this was controlled with continued treatment in all patients. One delayed perforation occurred 9 days after multipolar electrocoagulation. Multipolar electrocoagulation and injection therapy are of comparable efficacy in the treatment of patients with clinical evidence of a major upper gastrointestinal bleed and endoscopic evidence of an ulcer with active bleeding or a nonbleeding visible vessel.
Adult↗
The response of symptomatic gastrointestinal Kaposi's sarcoma to chemotherapy: a prospective evaluation using an endoscopic method of disease quantification.
We used an endoscopic method of quantification to evaluate the response of symptomatic gastrointestinal Kaposi's sarcoma (KS) prospectively in seven patients with acquired immune deficiency syndrome (AIDS) who were participating in chemotherapy trials for extensive cutaneous KS. The sums of the diameters of KS lesions in the esophagus, stomach, duodenum, and distal colon were used as a measure of extent of disease. Intravenous therapy [adriamycin/bleomycin/vincristine (N = 5), adriamycin (N = 1), or bleomycin/vincristine (N = 1)] was given every 2 wk for a mean of six cycles. Five of seven patients (71%) had a cutaneous response, whereas 9/15 (60%) gastrointestinal sites showed a remission. Sites of complete response all had an initial sum of lesion diameters less than or equal to 30 mm. Five of five patients with duodenal KS responded (3/5 complete), whereas just two partial responses were seen in five patients with gastric KS (4/5 with duodenal KS had sums of diameters less than or equal to 20 mm, whereas 4/5 with gastric KS had sums greater than or equal to 150 mm). Symptoms (abdominal pain, nausea/vomiting, hematemesis, diarrhea) resolved in all patients within two cycles of therapy. In summary: 1) the response rate of gastrointestinal KS to chemotherapy is similar to that of cutaneous KS; 2) the best response is seen in patients with less extensive disease and duodenal involvement; and 3) symptoms of gastrointestinal KS respond to chemotherapy even if the KS lesions do not resolve.
Acquired Immunodeficiency Syndrome↗
Prospective evaluation of blind brushing of the esophagus for Candida esophagitis in patients with human immunodeficiency virus infection.
We prospectively evaluated the diagnostic value of blind brushing of the esophagus via nasogastric tube in 66 patients with human immunodeficiency virus (HIV) infection [acquired immune deficiency syndrome (AIDS) (N = 59), or AIDS-related complex (ARC), (N = 7)] complaining of odynophagia and/or dysphagia. Brushings were obtained between 20 and 35 cm from the incisors. Patients then underwent upper endoscopy with directed brushings and biopsies; esophageal lavage was also done in the first 40 patients. Candida esophagitis was defined as an abnormal appearance of the esophageal mucosa, together with microscopic evidence of pseudohyphae in the endoscopic brushings or invasive candidiasis on biopsy. The presence of oral thrush was also recorded. Candida esophagitis was present in 28 (42%) of the 66 patients. Blind brushings diagnosed candidiasis in 27/28 cases and produced five false positives (sensitivity 96%, specificity 87%). Blind brushing of the esophagus was significantly more sensitive than the presence of oral thrush for the diagnosis of esophageal candidiasis (p = 0.02). Oral thrush was found in only 20/28 cases of Candida esophagitis and in eight patients without Candida (sensitivity 71%, specificity 79%). Esophageal lavage yielded Candida in all cases (sensitivity 100%) but had a poor specificity (64%). We conclude that blind brushing of the esophagus is a rapid, safe, and economical way to diagnose Candida esophagitis in patients with AIDS. This procedure can be performed by primary care physicians with minimal loss of sensitivity and specificity as compared to endoscopy.
Acquired Immunodeficiency Syndrome↗
Multipolar electrocoagulation in the treatment of peptic ulcers with nonbleeding visible vessels. A prospective, controlled trial.
STUDY OBJECTIVE: To assess the efficacy and safety of treatment with endoscopic multipolar electrocoagulation in patients who have ulcers with nonbleeding visible vessels. DESIGN: Prospective, randomized, sham-controlled trial; patients were followed until their discharge from the hospital. SETTING: Urban, nonreferral county hospital. PATIENTS: Consecutive sample of 75 patients who had a bloody nasogastric aspirate sample, melena, or hematochezia; unstable vital signs, a transfusion of at least two units of blood in 12 hours, or a drop in the hematocrit of at least 0.06 in 12 hours; and endoscopic evidence of an ulcer with a nonbleeding visible vessel. INTERVENTION: Sham or real multipolar electrocoagulation at the time of diagnostic endoscopy. MEASUREMENTS AND MAIN RESULTS: Compared with the control group, the group receiving multipolar electrocoagulation showed marked improvement in the following variables; rebleeding (18% compared with 41%, P less than 0.05; difference, 23%; 95% CI, 3% to 43%); need for emergency surgery (8% compared with 30%, P less than 0.05; difference, 22%; CI, 5% to 39%); mean number of hospital days (4.3 +/- 0.4 compared with 6.2 +/- 0.7, P less than 0.05; difference, 1.9; CI, 0.4 to 3.4); and cost of hospitalization ($3790 +/- $410 compared with $5730 +/- $650, P less than 0.05; difference, $1940; CI, $400 to $3480). The mean transfusion requirement in the treatment group was 1.6 +/- 0.3 as compared with 3.0 +/- 0.6 units in the control group (P = 0.13; difference, 1.4; CI, 0 to 2.8). The overall mortality was extremely low: Only 1 (1%) of 75 patients died. Bleeding was induced in 7 (18%) of the 38 patients treated with electrocoagulation, and 1 patient required urgent surgery. CONCLUSIONS: Endoscopic treatment with multipolar electrocoagulation is beneficial in patients who present with major upper gastrointestinal hemorrhage and are found to have an ulcer with a nonbleeding visible vessel.
Adult↗
An educational booklet diminishes anxiety in parents whose children receive total parenteral nutrition.
A major cause of anxiety in parents of hospitalized children is insufficient information about hospital procedures. In an effort to determine the extent to which parental anxiety could be diminished and knowledge and satisfaction enhanced in regard to total parenteral nutrition (TPN), we developed a booklet that describes the mechanics of TPN administration and related procedures. When informal discussions were held between parents and members of the nutritional support team during four alternating periods (every five to six months), parents of first-time recipients of TPN either did not receive the booklet (period 1, n = 20; period 3, n = 30) or received it (period 2, n = 23; period 4, n = 27). Within one week of TPN initiation, parents in both groups completed the Spielberger State-Trait anxiety scale, an attitude questionnaire, and a quiz on TPN. No differences between groups were found in ethnic background, socioeconomic status, severity of illness, age of children, or route of TPN administration. Predisposition to anxiety was also similar between the groups. In contrast, acute situational anxiety was significantly greater in the group with no booklet than in the booklet group. Parents in the no-booklet group demonstrated less comfort in the care of their children and less knowledge about TPN than did the booklet group. Written information provided to parents decreased their anxiety and increased satisfaction with patient care more successfully than did verbal communication. Such a booklet may reduce parentally induced anxiety in the child and facilitate parent-hospital staff interactions.
Anxiety↗
Campylobacter pylori in alcoholic hemorrhagic "gastritis".
Previously we have shown that alcohol-associated subepithelial hemorrhages histologically represent localized superficial mucosal hemorrhage, with edema in the surrounding mucosa. We studied the relationship between Campylobacter pylori (CP) and histology in gastric subepithelial hemorrhages from 20 actively drinking alcoholic patients. Biopsies of the hemorrhagic lesions and adjacent mucosa 1 and 3 cm away were taken with a "jumbo" forceps. Biopsy slides were coded and randomized before histologic scoring and examination for CP. CP was present in 15/20 (75%) biopsies of subepithelial hemorrhages and in 32/40 (80%) biopsies from surrounding mucosa. The mean hemorrhage score was not significantly different in biopsies of subepithelial hemorrhages with and without CP (2.7 +/- 0.4 vs 3.2 +/- 0.4) and the edema scores in adjacent, nonhemorrhagic mucosa were similar in specimens with and without CP (2.0 +/- 0.3 vs 1.6 +/- 0.5). The inflammatory cell density was significantly greater in CP-positive biopsies than in CP-negative specimens (2.0 +/- 0.2 vs 0.5 +/- 0.2, P less than 0.05) with the mononuclear cell and neutrophil scores contributing equally to the overall inflammatory cell score. Almost a quarter of CP-positive specimens (11/47) had no inflammation. The mean score for lining epithelial abnormalities was also significantly higher in biopsy specimens positive for CP (1.7 +/- 0.2 vs 0.5 +/- 0.3, P less than 0.05). In conclusion, CP is present in 75% of alcohol-associated subepithelial hemorrhages, but its prevalence is similar in adjacent, nonhemorrhagic mucosa. No relationship exists between the presence of CP and the characteristic histologic abnormalities of these subepithelial hemorrhages.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Subepithelial hemorrhages and erosions of human stomach.
Subepithelial hemorrhages and erosions of the stomach are being studied extensively in experimental animal models but have not been well-characterized in humans. The definitions of these hemorrhagic and erosive lesions are not uniform and are often further confused by being labeled with the blanket term "gastritis." We define these lesions from an endoscopic perspective, describe the clinical settings in which they occur, and provide endoscopic-histologic correlations, where available.
Gastric Mucosa↗
Histology of alcoholic hemorrhagic "gastritis": a prospective evaluation.
The term "hemorrhagic gastritis" is frequently applied to the subepithelial hemorrhages seen at endoscopy in alcoholic patients without a clear understanding of the histologic nature of these lesions. We prospectively screened 125 actively drinking alcoholic patients undergoing upper endoscopy for gastrointestinal bleeding. Gastric subepithelial hemorrhages were found in 20 of these patients. Biopsy specimens of hemorrhagic lesions and nonhemorrhagic mucosa 1 and 3 cm away were taken with a "jumbo" forceps. Gastric biopsy specimens from 12 patients with Barrett's esophagus served as controls for biopsy-induced trauma. Biopsy slides from the patients and controls were coded before histologic scoring. Mean hemorrhage scores (range, 0-4) for the target lesions (2.9 +/- 0.3) were significantly greater than scores for the adjacent mucosa (1 cm, 1.0 +/- 0.2; 3 cm, 1.1 +/- 0.2) or control biopsy specimens (0.8 +/- 0.1). Hemorrhage was superficial, occurring primarily in the foveolar region. Mucosal edema (score range, 0-4) was a prominent feature in the adjacent, nonhemorrhagic mucosa (target lesion, 0.7 +/- 0.2; 1 cm, 1.9 +/- 0.4; 3 cm, 2.0 +/- 0.3; controls, 0.8 +/- 0.1). Edema extended into the deeper gland zones in 11 of 20 patients but in none of the 12 controls (p less than 0.05). Inflammatory cell infiltrates were mild and scores did not vary significantly among the three biopsy sites in alcoholic patients. We conclude that subepithelial hemorrhages seen at endoscopy in alcoholic patients represent localized hemorrhage of the foveolar region with edema in the surrounding mucosa but without prominent inflammatory cell infiltration. Rather than use the term "hemorrhagic gastritis," endoscopists should simply describe these lesions as subepithelial hemorrhages.
Adult↗
Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial.
The benefit of nonsurgical therapy in the treatment of active nonvariceal upper gastrointestinal tract hemorrhage is uncertain. I performed a prospective controlled trial of endoscopic multipolar electrocoagulation for active upper gastrointestinal hemorrhage. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia, and any of the following: unstable vital signs, a requirement of greater than or equal to 2 units of blood per 12 hours, or a drop in hematocrit of greater than or equal to 6 percent in 12 hours. Forty-four patients were randomly assigned to receive multipolar electrocoagulation or sham multipolar electrocoagulation if endoscopy revealed active bleeding from an ulcer (24 patients), a Mallory-Weiss tear (17), or a vascular malformation (3). The group receiving multipolar electrocoagulation did significantly better in terms of hemostasis (90 percent vs. 13 percent, P less than 0.0001), mean (+/- SE) transfusion requirements (2.4 +/- 0.9 vs. 5.4 +/- 0.9 U; P = 0.002), mean number of hospital days (4.4 +/- 0.8 vs. 7.2 +/- 1.1, P = 0.02), and percentage needing emergency surgery or another intervention (14 vs. 57 percent, P = 0.01). Although mortality was lower in the group receiving multipolar electrocoagulation (0 vs. 13 percent), this difference was not statistically significant. The mean cost of hospitalization for treated patients was less than half that for the controls ($ 3,420 +/- 750 vs. $ 7,550 +/- 1,480, P = 0.001). I conclude that multipolar electrocoagulation markedly improves the hospital course in patients with major, nonvariceal upper gastrointestinal hemorrhage.
Adult↗
Protein-losing enteropathy in acquired immunodeficiency syndrome due to intestinal Kaposi's sarcoma.
Patients with the acquired immunodeficiency syndrome (AIDS) often have hypoalbuminemia. We report the case of a patient with AIDS in whom marked hypoalbuminemia developed due to a protein-losing enteropathy caused by small intestinal Kaposi's sarcoma--an entity not previously reported in AIDS. The patient presented with ankle edema, pleural effusions, and a decrease in albumin from 3.0 g/dL (30 g/L) to 1.7 g/dL (17 g/L) over one month. Protein-losing enteropathy was confirmed by a marked elevation in fecal alpha-1 antitrypsin, and extensive evaluation of the gastrointestinal tract revealed the source to be small intestinal Kaposi's sarcoma. A protein-losing enteropathy should be considered when hypoalbuminemia is encountered in a patient with AIDS.
Acquired Immunodeficiency Syndrome↗
Predictors of outcome in massive upper gastrointestinal hemorrhage.
We reviewed 100 consecutive cases of massive upper gastrointestinal hemorrhage (UGIH). The criteria for inclusion were a decrease in hematocrit greater than or equal to 6%, unstable vital signs, and greater than or equal to units of blood transfused (16 +/- 18 units, mean +/- SD). A multiple regression analysis of 96 variables was employed to determine the most accurate predictors of outcome. The overall mortality was 35%. Hospital status (whether the patient was an inpatient or outpatient when the UGIH began) showed a striking association with mortality (70% for inpatients vs. 22% for outpatients, p less than 0.001). Nonsurvivors also had a greater number of life-threatening diseases than survivors (1.4 +/- 1.1 vs. 0.3 +/- 0.5, p less than 0.001) and greater transfusion requirements (27 +/- 20 units vs. 10 +/- 13 units, p less than 0.001). Age, the presence of cirrhosis, and recent excessive alcohol intake were not important risk factors. At presentation, the most reliable predictor of a fatal outcome was the brevity of the interval between the onset of bleeding and the initiation of a medical work-up. The primary predictor when considering the entire hospitalization was the number of life-threatening diagnoses. Our data indicate that stratification for hospital status and for other potentially predictive risk factors should be incorporated in future trials of therapy for UGIH.
Aged↗