Dyspepsia: clinical aspects and current approach

Dyspepsia is a syndrome with a high prevalence in general population, but only few patients seek medical care by his symptoms. The concepts and the approaches related to syndrome, supported by Roma III Consensus, are presented in this article. Clinical cases in medical practice are proposed for self evaluation and the solutions with proper commentaries are presented also.A dispepsia é uma síndrome de alta prevalência, embora somente uma pequena parte dos pacientes que sofrem com ela procure atenção médica. Os conceitos e abordagens relacionadas à síndrome, apoiados nas sugestões do Consenso de Roma III, são apresentados neste artigo. Casos da síndrome na prática médica são propostos para auto-avaliação, e suas soluções e comentários são também apresentados

Low efficacy of an ultra-short term, once-daily dose triple therapy with omeprazole, azithromycin, and secnidazole for Helicobacter pylori eradication in peptic ulcer

PURPOSE: To determine the eradication rate of an ultra-short treatment schedule for Helicobacter pylori infection in a population with peptic ulcers, using omeprazole, secnidazole, and azithromycin in a once-daily dose for 3 days. METHODS: Thirty patients with peptic ulcer diagnosed by upper endoscopy and for Helicobacter pylori infection by rapid urease test and histologic examination received omeprazole 40 mg, secnidazole 1000 mg, and azithromycin 500 mg, administered once daily for 3 days. A follow-up exam was performed 12 weeks after the end of the treatment. Patients who were negative for Helicobacter pylori infection by rapid urease test and histologic examination were considered cured. RESULTS: Patients were predominantly female, and the mean age was 50 years. Duodenal peptic ulcer was found in 73% of the patients. Eradication was achieved in 9 of the 28 (32%) patients as determined from the follow-up endoscopic exam. The eradication rate by intention to treat was 30%. Side effects were present in 3% of the patients, and compliance to treatment was total. CONCLUSIONS: In spite of the low rate of side effects and good compliance, the eradication index was low. A possible drawback of this therapy is that it reduces the efficacy of macrolide and nitroimidazole compounds in subsequent treatments.OBJETIVO: Testar a eficácia de um esquema ultra-curto de erradicação do H. pylori em uma população de ulcerosos, usando Omeprazol, Secnidazol e Azitromicina em dose única diária por três dias. PACIENTES E MÉTODOS: Trinta doentes portadores de úlcera péptica, documentada por exame endoscópico e com infecção pelo H. pylori confirmada pelo teste da urease e exame histológico, foram tratados com Omeprazol 40mg, Secnidazol 1000 mg e Azitromicina 500mg dados em dose única diária por três dias. Em controle endoscópico realizado 12 semanas após o término do tratamento, foram considerados curados da infecção os pacientes que apresentaram o teste da urease e exame histológico negativos para a bactéria. RESULTADOS: As mulheres predominaram (63%), a idade média foi de 50 anos e a úlcera duodenal foi identificada em 73% dos pacientes. Nos 28 doentes que realizaram o exame de controle, a erradicação foi constatada em nove (32%). Por intenção de tratamento o índice foi de 30%. A adesão ao tratamento foi total e houve um baixo índice de efeitos adversos (3%). CONCLUSÃO: O esquema apesar de proporcionar alta adesão e poucos efeitos adversos, apresenta baixa taxa de erradicação, mesmo em se considerando um país em desenvolvimento e apresenta como possível agravante comprometer a eficácia de outros macrolídeos e nitroimidazólicos no uso de esquemas de erradicação subseqüentes

Omeprazole, Furazolidone, and Tetracycline: an eradication treatment for resistant H. pylori in Brazilian patients with peptic ulcer disease

OBJECTIVES: To determine the efficacy of a simple, short-term and low-cost eradication treatment for Helicobacter pylori (H. pylori) using omeprazole, tetracycline, and furazolidone in a Brazilian peptic ulcer population, divided into 2 subgroups: untreated and previously treated for the infection. PATIENTS AND METHODS: Patients with peptic ulcer disease diagnosed by endoscopic examination and infected by H. pylori diagnosed by the rapid urease test (RUT) and histological examination, untreated and previously unsuccessfully treated by macrolides and nitroimidazole, were medicated with omeprazole 20 mg daily dose and tetracycline 500 mg and furazolidone 200 mg given 3 times a day for 7 days. Another endoscopy or a breath test was performed 12 weeks after the end of treatment. Patients were considered cured of the infection if a RUT and histologic examination proved negative or a breath test was negative for the bacterium. RESULTS: Sixty-four patients were included in the study. The women were the predominant sex (58%); the mean age was 46 years. Thirty-three percent of the patients were tobacco users, and duodenal ulcer was identified in 80% of patients. For the 59 patients that underwent follow-up examinations, eradication was verified in 44 (75%). The eradication rate for the intention-to-treat group was 69%. The incidence of severe adverse effects was 15%. CONCLUSION: The treatment provides good efficacy for H. pylori eradication in patients who were previously treated without success, but it causes severe adverse effects that prevented adequate use of the medications in 15% of the patients.OBJETIVO: Testar a eficácia de um esquema simplificado e de baixo custo para erradicação do H. pylori utilizando omeprazol, tetraciclina e furazolidona, em uma população de ulcerosos do Brasil, já tratados e não tratados previamente para a infecção. PACIENTES E MÉTODOS: Pacientes portadores de úlcera péptica, documentada por exame endoscópico e infectados pelo H. pylori confirmado pelo teste da urease e exame histológico, não tratados previamente ou já tratados sem sucesso com macrolídeos e nitroimidazólicos, foram tratados com Omeprazol 20mg em dose única diária, associado à Tetraciclina 500mg e Furazolidona 200mg dadas três vezes ao dia, por três dias. Uma nova endoscopia ou um Teste Respiratório foi realizado 12 semanas após o término do tratamento e foram considerados erradicados da infecção os pacientes que apresentaram o teste da urease e exame histológico negativos ou o Teste Respiratório negativo para a bactéria. RESULTADOS: Sessenta e quatro pacientes foram incluídos no estudo, 26 deles não previamente tratados. As mulheres predominaram (58%), a idade média foi de 46 anos, 33% dos pacientes eram tabagistas e a úlcera duodenal foi identificada em 80% dos pacientes. Nos 59 doentes que realizaram o exame de controle, a erradicação foi constatada em 44 (75%). Por intenção de tratamento o índice foi de 68%. O grupo não tratado previamente não diferiu do grupo previamente tratado. A incidência de efeitos adversos intensos foi de 15%. CONCLUSÃO: O esquema proporciona boa eficácia na erradicação do H. pylori em pacientes já previamente tratados sem sucesso, porém apresenta efeitos adversos intensos, que impediu o uso adequado dos medicamentos em 15% dos pacientes

Esquema quádruplo com furazolidona para retratamento do Helicobacter pylori, em pacientes ulcerosos

PURPOSE: Many of the currently used eradication regimens against Helicobacter pylori fail to cure the infection either due to antimicrobial resistance or to poor patient compliance. The infection leads to increased risk of developing potentially severe complications, such as gastric cancer. This study was aimed at assessing the efficacy and safety of a quadruple therapy with furazolidone for H. pylori retreatment. METHODS: Patients who had failed one or more eradication regimens against H. pylori infection underwent upper gastrointestinal endoscopy. Biopsy specimens were taken from the gastric antrum and corpus for histology and for a urease test and. Patients received omeprazole 20 mg, bismuth citrate 240 mg, tetracycline 500 mg, and furazolidone 200 mg, all twice daily for 7 days. Therapeutic success was evaluated by endoscopy and biopsies 8 weeks after the end of treatment. RESULTS: Sixty two patients were enrolled, and 58 completed the study. Under this protocol, H. pylori eradication was achieved in 39/58 patients (67%). Mild adverse events were reported. CONCLUSION: The short quadruple therapy course with furazolidone is well tolerated, inexpensive, and effective in retreatment for H. pylori infection. It is a good option for developing countries.OBJETIVO: Muitos dos esquemas atualmente usados na erradicação do Helicobacter pylori não conseguem curar a infecção, pela resistência bacteriana ou pela baixa adesão do paciente. Esta condição manterá os riscos de desenvolvimento das potenciais complicações graves da infecção. Este estudo procurou determinar a eficácia e segurança de um esquema quádruplo que associou a furazolidona para o retratamento da infecção pelo H. pylori. MÉTODOS: Pacientes que não alcançaram erradicação em um ou mais tratamentos foram submetidos à endoscopia digestiva alta e dois fragmentos do antro e do corpo foram retirados para exame histológico e de urease. Receberam então 20mg de omeprazol, 240mg de sub-citrato de bismuto, 500mg de tetraciclina e 200mg de furazolidona duas vezes ao dia por 7 dias. O sucesso terapêutico foi determinado pela negativação de nova biópsia endoscópica, após 8 semanas do tratamento. RESULTADOS: Sessenta e dois pacientes foram incluídos, cinqüenta e oito completaram o estudo. Por protocolo, 67% (39/58) dos pacientes conseguiram a erradicação da bactéria. Efeitos adversos leves foram relatados. CONCLUSÃO: O tratamento de curto prazo, em esquema quádruplo com a furazolidona , é bem tolerado, barato e eficaz no re-tratamento do H. pylori. Uma boa opção de re-tratamento para países em desenvolvimento

Fatores que afetam a erradicação do Helicobacter pylori usando um tratamento triplo de sete dias com um inibidor de bomba de prótons associado ao tinidazol e a claritromicina, em pacientes brasileiros com úlcera péptica

O esquema tríplice tem sido demonstrado como sendo o melhor tratamento para a erradicação do Helicobacter pylori. Nos países industrializados o uso de um inibidor de bomba de prótons associado a claritromicina e a amoxicilina ou a um nitroimidazólico, tem proporcionado os melhores resultados. Objetivamos estudar na nossa população a taxa de erradicação do H. pylori para a associação de um inibidor de bomba de prótons com o tinidazol e a claritromicina e determinar se a resposta ao tratamento é influenciada pelo tratamento prévio, sexo, tabagismo, alcoolismo, idade e uso de anti-inflamatórios não esteroidais (AINEs). PACIENTES E PROCEDIMENTOS: Duzentos pacientes com diagnóstico endoscópico de úlcera péptica e com infecção pelo H. pylori, confirmada pelo exame histológico e pelo teste rápido da urease (TRU), foram incluídos no estudo. Um inibidor de bomba de prótons (lansoprazol 30mg ou omeprazol 20 mg), tinidazol 500mg e claritromicina 250mg foram ministrados duas vezes ao dia, por um período de 7 dias. A erradicação era determinada depois de 10 a 12 semanas após o fim do tratamento, por histologia e TRU. RESULTADOS: O percentual de erradicação do H. pylori (por protocolo) foi de 65% (128/196 pacientes). Para pacientes previamente tratados o valor foi de 53%, aumentando para 76% nos pacientes não previamente tratados com diferença estatística (pTriple therapy is accepted as the treatment of choice for H. pylori eradication. In industrialized countries, a proton pump inhibitor plus clarithromycin and amoxicillin or nitroimidazole have shown the best results. Our aims were: 1. To study the eradication rate of the association of a proton pump inhibitor plus tinidazole and clarithromycin on H. pylori infection in our population. 2. To determine if previous treatments, gender, age, tobacco, alcohol use, and non-steroidal anti-inflammatory drugs (NSAIDs) change the response to therapy. METHODS: Two hundred patients with peptic ulcer (upper endoscopy) and H. pylori infection (histology and rapid urease test - RUT) were included. A proton pump inhibitor (lansoprazole 30 mg or omeprazole 20 mg), tinidazole 500 mg, and clarithromycin 250 mg were dispensed twice a day for a seven-day period. Eradication was assessed after 10 to 12 weeks of treatment through histology and RUT. RESULTS: The eradication rate of H. pylori per protocol was 65% (128/196 patients). This rate was 53% for previously treated patients, rising to 76% for not previously treated patients, with a statistical difference

Efficacy of levofloxacin, amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers

OBJECTIVES: The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication. METHODS: Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days. RESULTS: A total of 66 patients were evaluated. The patients’ mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints. CONCLUSIONS: Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen

Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study

Abstract\ud \ud \ud \ud Background\ud \ud The treatment for the eradication of Helicobacter pylori (H. pylori) is complex; full effectiveness is rarely achieved and it has many adverse effects. In developing countries, increased resistance to antibiotics and its cost make eradication more difficult. Probiotics can reduce adverse effects and improve the infection treatment efficacy.\ud If the first-line therapy fails a second-line treatment using tetracycline, furazolidone and proton-pump inhibitors has been effective and low cost in Brazil; however it implies in a lot of adverse effects. The aim of this study was to minimize the adverse effects and increase the eradication rate applying the association of a probiotic compound to second-line therapy regimen.\ud \ud \ud \ud Methods\ud \ud Patients with peptic ulcer or functional dyspepsia infected by H. pylori were randomized to treatment with the furazolidone, tetracycline and lansoprazole regimen, twice a day for 7 days. In a double-blind study, patients received placebo or a probiotic compound (Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum and Streptococcus faecium) in capsules, twice a day for 30 days. A symptom questionnaire was administered in day zero, after completion of antibiotic therapy, after the probiotic use and eight weeks after the end of the treatment. Upper digestive endoscopy, histological assessment, rapid urease test and breath test were performed before and eight weeks after eradication treatment.\ud \ud \ud \ud Results\ud \ud One hundred and seven patients were enrolled: 21 men with active probiotic and 19 with placebo plus 34 women with active probiotic and 33 with placebo comprising a total of 55 patients with active probiotic and 52 with placebo. Fifty-one patients had peptic ulcer and 56 were diagnosed as functional dyspepsia. The per-protocol eradication rate with active probiotic was 89.8% and with placebo, 85.1% (p = 0.49); per intention to treat, 81.8% and 79.6%, respectively (p = 0.53). The rate of adverse effects at 7 days with the active probiotic was 59.3% and 71.2% with placebo (p = 0.20). At 30 days, it was 44.9% and 60.4%, respectively (p = 0.08).\ud \ud \ud \ud Conclusions\ud \ud The use of this probiotic compound compared to placebo in the proposed regimen in Brazilian patients with peptic ulcer or functional dyspepsia showed no significant difference in efficacy or adverse effects.\ud \ud \ud \ud Trial registration\ud \ud Current Controlled Trials ISRCTN04714018Drugs providing supported from Medley Indústria Farmacêutica, São Paulo, Brazil

Helicobacter pylori reinfection in brazilian patients with peptic ulcer disease, a five year follow-up

Introdução: A reinfecção pelo Helicobacter pylori em países em desenvolvimento parece ser maior do que nos países desenvolvidos. O retratamento da bactéria e o controle periódico de cura são necessários, quando elevadas taxas de reinfecção são verificadas. O objetivo do trabalho foi determinar a taxa anual de reinfecção, em pacientes brasileiros com úlcera péptica, num seguimento de cinco anos. Métodos: Pacientes com úlcera péptica, diagnosticada por endoscopia digestiva alta e infecção pelo Helicobacter pylori documentada por histologia, teste da urease, reação em cadeia da polimerase e teste respiratório, foram tratados para erradicação da bactéria. A cura da infecção foi verificada com os mesmos exames, três meses após o término do tratamento. Avaliação clínica e teste respiratório foram realizados aos seis e nove meses. Com um ano de seguimento, endoscopia, exame histológico, teste da urease, reação em cadeia da polimerase e teste respiratório foram novamente realizados. Até o quinto ano de seguimento, foram feitas consultas semestrais e testes respiratórios anuais. Na inclusão dos pacientes e nos reinfectados foram estudados 15 diferentes genes da bactéria. Resultados; Cento e quarenta e sete pacientes foram seguidos: 19 por um ano, oito por dois anos, quatro por três anos, cinco por quatro anos e 98 por cinco anos, num total de 557 pacientes/ano. Não ocorreu reinfecção no primeiro ano. No segundo ano, dois pacientes se reinfectaram, no terceiro quatro pacientes, no quarto três pacientes e no quinto um paciente, num total de 10 reinfecções. A taxa anual de reinfecção por pacientes/ano foi de 1,8%. Conclusão: O Brasil, um país em desenvolvimento com alta prevalência da infecção pelo Helicobacter pylori, apresenta uma taxa de reinfecção semelhante à dos países desenvolvidosIntroduction: The Helicobacter pylori reinfection rate seems to be higher in developing countries, than in developed ones. If a high reinfection rate is verified, periodical exams and bacterial retreatment would be necessary. The objective of this study was to determine the annual reinfection rate of Helicobacter pylori, in Brazilian patients with peptic ulcer disease, in a five year follow-up. Methods: Patients, with peptic ulcer disease diagnosed by upper digestive endoscopy and Helicobacter pylori infection verified by histological examination, rapid urease test, polymerase chain reaction and urea breath test, were treated for bacterial eradication. The infection cure was determined by the same proceedings, three months after the treatments end. Clinical evaluation and urea breath test were performed at sixth and ninth months of the follow-up. At one year of the follow-up, upper digestive endoscopy, histological examination, rapid urea test, polymerase chain reaction and urea breath test were repeated. Up to the fifth year of follow-up semester clinical evaluation and annual urea breath test were performed. All the patients included in the study and all the reinfected patients were tested for fifteen different genes of the Helicobacter pylori. Results: One hundred and forty-seven patients were followed: nineteen patients for one year, eight patients for two years, four patients for three years, five patients for four years and ninety-eight patients for five years. The total of patients/years follow-up was 557. Reinfection did not occur in the first year of the follow-up. In the second year, two patients became reinfected; in the third year, four patients; in the fourth, three and in the fifth, one patient. The total of reinfected patients was 10. The annual reinfection rate was 1,8%. Conclusion: Brazil, a developing country, presents a high prevalence of Helicobacter pylori infection. Nonetheless, the reinfection rate is similar to the developed countries