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227 MANAGEMENT OF PEPTIC ULCER DISEASE IN PRIMARY CARE
A.J. Morris, C. Craig, C. Morran, H. Burns, A. Power, K. Harden, D. Walsh, R. C. Stuart.ACID 1 Study group, Digestive Disease Directorate, Glasgow Royal Infirmary, Glasgow, UK
Aim: Eradication of H. pylori infection in patients with peptic ulcer disease patients reduces the need for long term acid suppression therapy and the risk of complications such as bleeding and perforation yet patients with this diagnosis continue to be treated with acid suppression therapy in primary care. We aimed to assess the extent to which these patients had been investigated for H. pylori infection and identify a population who might benefit from H. pylori testing and eradication.
Methods: From 11,149 patients who had received acid suppression in the preceding year (Total GP population 176,268) we undertook case note review and identified 3071 (27.5%) patients who had previously diagnosed peptic ulcer disease (77.2% DU, 13.1% GU, 6.1% both, 3.5% unspecified ulcer type). 2063 patients were receiving maintenance therapy (Defined as ≥ 3 prescriptions/year). Of these, 1275 who had no contraindication to H. pylori eradication were invited to nurse led clinics for H. pylori testing: 705 attended and underwent 13C urea breath testing to establish H. pylori status.
Results: Only 36.4% of patients identified with known peptic ulcer disease had previously received eradication therapy. 26.9% were taking NSAIDs concomitantly (53.6% aspirin, 37.7% other NSAIDs and 8.7% both). H. pylori prevalence was 65.6% in patients who had never had documented eradication therapy and, although lower if patients had prior eradication therapy. 23.0% of previously treated ulcer patients remained infected at the time of testing.
Conclusions: A substantial proportion of ulcer patients receiving acid suppression therapy in general practice have never received H. pylori eradication and almost a quarter of those previously treated remain infected with the organism. There is considerable potential for improvement in the management of this easily identifiable patient group but post treatment testing is important to establish eradication of infection.
228 SERVICE IMPLICATIONS AND SUCCESS OF THE IMPLEMENTATION OF THE TWO-WEEK REFERRAL CRITERIA FOR UPPER GASTROINTESTINAL CANCERS IN A DISTRICT GENERAL HOSPITAL
D.J. Lassman, J. Elliott, A. Taylor, A.T. Green, C.E. Grimley.Gastroenterology Unit, Burnley General Hospital, Casterton Avenue, Burnley, UK
Introduction: The introduction of 2-week criteria in July 2000 has added a significant burden to the provision of gastroenterology services. The targets are not proven to improve outcomes for patients found to have cancer and it is unclear how effectively they are applied by primary care physicians. This study addresses the appropriateness of referrals, the success in meeting the criteria and the pick-up rate for upper GI tumours.
Methods: Data were collected prospectively by a specialist nurse. Patients referred from primary care within `2 week criteria' and those who were thought to meet the criteria but were not referred through that route were included. Time to first consultation (clinic or gastroscopy) was recorded. The final diagnosis and outcomes when available are also reported.
Results: 149 patients are included in the study. Their average age (range) is 67(19–92). 79 were referred by `two week criteria' and the others were reprioritised by the consultant reading the referral. Gastroscopy was performed in all cases. This was achieved in an average of 9 days (range 1–14) for those referred by 2-week criteria and 15 (range 7–35) days in those thought to meet the criteria but not referred by that route. There were 25 extra cases per month when the system was established. 14 malignancies were identified (9.4%). 12 cases were identified correctly by GP application of 2-week criteria (15.2%). 2/70 further malignancies were identified by consultant interpretation of routine referrals (2.9%).
Conclusion: The application of the 2-week criteria for upper GI cancers has led to an additional 25 procedures/month. Primary care physicians achieved a cancer pickup rate of 15.2%. Additional case finding by assessment of other referrals seems to have little additional benefit.
229 RABEPRAZOLE 20 MG COMPARED WITH ESOMEPRAZOLE 40 MG IN THE CONTROL OF INTRAGASTRIC PH IN HEALTHY VOLUNTEERS
K. Baisley1, S. Warrington1, B. Tejura1, A. Morocutti2, N. Miller2 (introduced by Val Heatley).1Hammersmith Medicines Research, Central Middlesex Hospital, London, UK;2Eisai Ltd, London, UK
Purpose: To compare the effects of single doses of rabeprazole (RAB) 20 mg and esomeprazole (ESO) 40 mg on intragastric pH in healthy H. pylori-negative volunteers.
Methods: 27 H. pylori-negative subjects underwent two 24-hour treatment periods, separated by a 14-day washout, in a 2-way crossover single-dose study comparing RAB 20 mg with ESO 40 mg. Intragastric pH was recorded over 24 h on Days 0 and 1 of each period. Percentage of time that intragastric pH >3 and >4 during each 24 h interval, and area under the intragastric pH-time curve (AUC0–24 h), were calculated, and compared using ANOVA.
Results: There were no statistically significant differences in mean AUC0–24 h, mean percent time pH >4 and mean percent time pH >3 between RAB and ESO treatments on Day 0 (pre-dose) or Day 1. On Day 1, mean percent time pH >4 after RAB 20 mg was 43.1 (SD=18.3) and after ESO 40 mg was 45.2 (SD=17.1); mean percent time pH >3 after RAB 20 mg was 54.8 (SD = 18.3) and after ESO 40 mg was 54.9 (SD = 15.1). For intragastric pH control during the nighttime hours (14–24h post dose), mean percent time pH >3 and pH >4 was significantly higher on RAB 20 mg than ESO 40 mg (pH >3: 42.1%, SD=25.3 and 25.1%, SD=18.0, respectively; pH >4: 32.4%, SD=24.1 and 17.0%, SD=14.9, respectively; p=0.001). During daytime hours, mean percent time pH >3 and pH >4 was significantly higher on ESO 40 mg than RAB 20 mg (pH >3: 76.2%, SD=15.7 and 63.8%, SD=20.7, respectively; pH >4: 65.4%, SD=21.5 and 50.7%, SD=21.3, respectively; p=0.02).
Conclusion: Over a 24 h period, there was no difference between RAB 20 mg and ESO 40 mg with respect to effects on intragastric pH. In the morning, the effects of ESO were greater than those of RAB, whilst during the nighttime hours, the effects of RAB were greater than those of ESO. These results concur with published data on the effects of RAB and ESO on intragastric pH.
This research was supported by Eisai Ltd, London, UK.
230 “TEST AND TREAT” A PILOT STUDY OF A COMMUNITY BASED C13 UREA BREATH TEST SERVICE (C13UBT)
V. Edge, C. Macdonald, S. Raimes, A. Edgar, J. Honeyman, I. Keyes, D. Burke.Cumberland Infirmary, Carlisle and Primary Care, North Cumbria, UK
H pylori (HP) “test and treat” strategies have been shown to be effective and safe in the management of uncomplicated dyspepsia in under 45 year olds and may reduce endoscopy demands. Non-invasive HP tests include serology, breath tests and recently a faecal antigen test. Near patient tests have been shown to be unreliable, serology does not allow early follow up assessment. UBT allow non-invasive pre and post treatment assessment of HP. C14 based tests cannot easily be used in the community.
Aims: To assess the practicality, accessibility, appropriate use and effectiveness of a C13UBT service in the community of North Cumbria.
Methods: Two practices were recruited to act as local C13UBT sites and clinics led by a single nurse specialist for 6 months. Criteria for referral; age >18, <45, new onset uncomplicated dyspepsia, no NSAID, no PPI. After a 4 hour fast, CO2 samples were taken at baseline and 30 minutes post ingestion of C13 labelled urea with orange juice. CO2 samples were analysed (Cumberland Infirmary, Carlisle, PDZ Europa C13 analyser) and result returned to GP within 24 hours. Subsequent management and outcome was monitored and nurse recorded any problems encountered during the process from referral to treatment.
Results: 55 referrals (34F, 21M), 17 HP +ve, 38 –ve. 78.2% were tested within 1 week of referral (10 deferred at patient request) 6 tests deferred because not fasted, 3 taken medication. 2 patients were > 45, 36 patients had had symptoms for >6 months, 2 previous eradication. 1 patient travelled 12 miles to his GPs surgery for a C13UBT when he was working adjacent to a clinic site. All HP positive patients received eradication therapy. Post C13UBT, 9.1% (3 HP +ve and 2 –ve) were referred for gastroscopy, 16 (29%, 3HP +ve) received H2 antagonists and 13 (24%, 5 HP +ve) a PPI.
Conclusions: Rapid HP testing was achieved with a low endoscopy rate. Changes to information sheets avoided further problems with pre test preparation. Central booking would allow patient choice of test site. These figures translate to ∼1850 C13UBT but only 166 endoscopies per year for this age group if extended to the whole of North Cumbria.
231 EFFECTS OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS ON ENDOTHELIAL CELL PROLIFERATION AND MIGRATION IN VITRO
H.R. Pearce1, N.J. Brown1, K.D. Bardhan2, N. Kalia1.1Surgical & Anaesthetic Sciences, Royal Hallamshire Hospital, University of Sheffield;2District General Hospital, Rotherham, UK
Background/Aims: Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with delayed healing of peptic ulcers which in turn is dependent upon angiogenesis or new blood vessel formation. Proliferation and migration of endothelial cells (ECs) are crucial stages in angiogenesis. This study aimed to determine whether NSAIDs inhibited these two processes in vitro.
Methods: The effects of indomethacin and aspirin (0.01μM-1mM) were assessed on human umbilical vein ECs. To determine proliferation, ECs were exposed individually to the two NSAIDs for 24, 48, 72 and 96 hrs. An MTT proliferation assay quantified EC viability and Hoescht/Propidium Iodide staining identified apoptotic, necrotic and viable ECs. Cell cycle changes were analysed using flow cytometry. Migration in response to vascular endothelial growth factor (VEGF) was assayed over 4.5 hrs using a microchemotaxis chamber following 24 hr pre-incubation with the drugs. Relevant controls were performed in all cases.
Results: Control ECs significantly proliferated at 48, 72, and 96 hrs (<0.05). No significant proliferation was observed with 1mM indomethacin or 1mM aspirin. 1mM indomethacin induced significant necrosis, (p<0.05), and inhibited the transition of cells from G1 to S phase. VEGF significantly increased control EC migration (P<0.01) which was significantly inhibited by 0.1mM and 1mM aspirin, and 1mM indomethacin, (P<0.01).
Conclusion: High concentrations of NSAIDs inhibit EC proliferation in vitro by cytotoxic, (indomethacin), or cytostatic (aspirin), mechanisms. Similar concentrations of NSAIDs inhibit the migration of ECs in vitro. Inhibition of EC proliferation and migration may decrease angiogenesis at the ulcer site which in turn may explain the delay in ulcer healing associated with the administration of NSAIDs.
232 ALOE VERA GEL STIMULATES PGE2 PRODUCTION AND COX2 EXPRESSION IN GASTRIC CARCINOMA CELL LINES
G.V. Smith, L. Langmead, D.S. Rampton.Dept of Adult and Paediatric Gastroenterology, Barts and the London School of Medicine and Dentistry, London, UK
Background: Aloe vera gel (AV) is the mucilaginous aqueous extract from the leaf of Aloe barbadensis miller. It is a widely used herbal remedy for inflammatory conditions and digestive disorders. It is claimed to have anti-ulcer effects. Gastric epithelial cells produce COX2 and prostaglandins in response to ulceration as part of mucosal healing.
Aims: To determine the effects of AV on production of PGE2 and expression of COX2 by gastric epithelial cells in culture.
Methods: MKN7 and MKN 45 gastric cell lines were cultured in vitro in RPMI medium containing increasing concentrations of AV gel for 24 hrs. PGE2 production was measured in the culture supernatant by ELISA. Western blotting was used to detect COX2 expression by cells. Results were corrected for cell numbers estimated by MTT assay.
Results: Incubation of both MKN7 and MKN 45 cell cultures with AV gel at 1:10 dilution produced significant increases in PGE2 production compared with control incubations. Higher dilutions of AV had no effect. Control experiments showed the effects of AV were not mediated solely by its low pH (6.8 at 1:10 dilution). PGE2 concentrations (pg/ml, median and range, n>5) for each cell line (*p<0.005 versus controls) are shown in the table.
Conclusion: The stimulatory effect of aloe vera gel (in a concentration likely to be to found in the stomach after an oral dose) on PGE2 production and COX2 expression by gastric cell lines suggest that this herbal remedy is worth assessing for the treatment and prevention of peptic and NSAID-induced gastroduodenal ulceration.
233 PEPTIC ULCER IN GENERAL PRACTICE IN ENGLAND AND WALES 1994–1998: A DISEASE IN DECLINE
S. Subramanian1, A. Tinto2, J. Higham2, A. Majeed3, J.Y. Kang1.1Dept of Gastroenterology, St George's Hospital;2Office for National Statistics;3University College, London, UK
Background: While hospital admission rates in England and Wales for complicated peptic ulcer has increased among older people, little is known about its prevalence in the community.
Aims: To analyse recent time trends in England and Wales in the prevalence of peptic ulcer, based on the proportion of the population who had been seen either by the general practitioner or a hospital doctor, during each one-year period. The drug treatment for peptic ulcer was also studied.
Methods: For each year between 1994–98, information on the age, sex and drug treatment for patients with peptic ulcer was extracted from the General Practice Research Database. Age-sex specific prevalence and treatment rates were then calculated.
Results: See table. The decline in age-standardised prevalence was more evident among people aged less than 65 (60% for males, 50% for males) compared to people aged 65 and over (29% for females, 33% for males). The decline was also greater among males registered with practices located in the most deprived electoral wards (63%) compared to those located in the least deprived (30%).
Conclusions: Over a 5-year period, there has been a marked decrease in the prevalence of peptic ulcer, especially among younger people and those from deprived areas. This decrease is too rapid to be accounted for by a reduction in the prevalence of H pylori infection, but would be consistent with widespread use of H pylori eradication therapy in the community.
234 A PROSPECTIVE STUDY OF GASTROENTEROLOGY CONSULTATIONS IN AN URBAN TEACHING HOSPITAL
S. Bohra, M.F. Byrne, D. Manning, C. Smyth, S.E. Patchett, F.E. Murray.Dept of Gastroenterology, Beaumont Hospital, Dublin, Ireland
Consultation between individual specialities is common and little studied. Gastroenterology consultations account for a substantial workload for the GI team. The aim of this study was to prospectively analyse the referral patterns and outcome for Gastroenterology in-patient consultations in a teaching hospital over a five month period.
242 consecutive in-patients consultation to the GI service were analysed. All patients were initially evaluated by a GI registrar prior to being seen by one of the two consultants. The patients were referred by 32 consultants from various specialities. Average delay before consultations were seen was less than one working day. The referral sources were predominantly from respiratory medicine, general surgery, nephrology and neurosciences. The commonest reasons for referral were abdominal pain (15.8%), PEG tube insertion (13.6%), diarrhoea (12.8%), and abnormal liver blood tests (10%). Ongoing care was subsequently assumed by GI services in 23 patients (9.5%). 132 (54.5%) patients required some form of endoscopic procedure while 55 patients (22.7%) required follow-up at GI outpatients clinic after discharge. Iatrogenic diseases (drug-induced hepatitis, diarrhoea/colitis, peptic ulceration, pancreatitis etc) accounted for 6.2% of consultations. Among referral for PEG tube insertion, over a quarter were considered better managed without a PEG.
The provision of the GI inpatient consultation services constitutes a significant and increasing proportion of the workload in Gastroenterology. Most clinical problems assessed were dealt with satisfactorily in a consultation setting, with only a minority requiring transfer to a Gastroenterology team during inpatient stay but a significant percentage required endoscopic procedures and follow up at a GI clinic after discharge. Consultations for PEG tube insertion were especially worthwhile.
235 GASTRODUODENAL MUCOSAL DAMAGE IN MAJOR BURNS:HOW SIGNIFICANT IS IT?
S. Kumarage, P.A.H.A. Gunawardena, J. Hewavisenthi1, K.I. Deen.University Departments of Surgery and1Pathology, North Colombo General Hospital Ragama, SriLanka
Introduction: Acute gastroduodenal mucosal injury has been known to be associated with major burns. The aim of this study was to assess the incidence and rationale of giving prophylactic acid suppression treatment to all patients with major burn injury.
Patients and Methods: 18 patients (13 females, median age 23 years-range 14–42)with major burn injury (Burn surface area >20%) admitted over 20 months were analysed. The aetiology was flame burns-10,hot water burnsd-5,and acid burns-3.All patients were received within 6 hours of injury. Initial fluid resuscitation was performed using Parkland regime. Non steroidal analgesics and acid suppression was not employed. All patients were subjected to upper gastrointestinal endoscopy(UGIE) between 24–72 hours after admission and antral mucosal biopsy was obtained. UGIE was repeated a week later. Histology samples were evaluated by a single blinded pathologist. Dyspeptic symptoms were sought on a daily basis.
Results: 2(11.1%)Patients had mild upper abdominal pain. 2(11.1%)Patients had abnormal UGIE findings during the first endoscopy.(1-superficial gastritis,1-errosive gastritis).3(16.7%) Patients had abnormal endoscopic findings during subsequent endoscopy(2-superficial gastritis,1-erosivegastritis). No peptic ulcers were detected in any of the patients.8(44.4%) Patients had mild histological changes(7-mild acute inflammatory changes,1-chronic inflammatory changes).
Conclusion: This study shows that there was no endoscopic evidence of serious gastroduodenal mucosal injury in patients with major burns. Furthermore antral mucosal histology revealed only mild inflammatory changes. The use of prophylactic acid suppression in major burns as a blanket policy may require re-evaluation.
236 NSAID AND PEPTIC ULCER DISEASE: A RANDOMISED TRIAL OF OMEPRAZOLE 20 MG VERSUS 10 MG FOR MAINTENANCE OF REMISSION AFTER PEPTIC ULCER HEALING AND HELICOBACTER PYLORI ERADICATION
A. Dajani, R. Dham, H. Mardini, C.O. Record.Julphar Pharmaceuticals, UAE; Royal Victoria Infirmary, Newcastle NE1 4LP, UK
Background: The role of H. pylori eradication in NSAID users with peptic ulcer disease is controversial especially in countries with a high prevalence of the infection. Also the value of low dose Omeprazole for maintenance of remission is not yet known.
Patients and methods: 138 symptomatic out-patients receiving continuous Cox 1 NSAID therapy, were treated with Omeprazole 40mg/day upon endoscopic confirmation of gastro-duodenal ulceration or erosions while those infected with H. pylori received in addition Clarithromycin 500 mg and Amoxycillin 1000 mg twice daily during the first week of treatment. After endoscopic confirmation of healing at the end of week 5 (n=116), the patients were randomised to receive Omeprazole 10 mg (n=50) or 20 mg once daily (n=66) and endoscopy repeated after 20 weeks. No patients discontinued treatment because of adverse effects of the drugs and efficacy results are for patients completing the trial protocol.
Results: The overall healing rate at five weeks (n=130) was 89.1% (95% confidence limits 84.7–93.5) while in 86.3% (81.2–89.1) eradication was successful. The healing rate for the H. pylori eradicated patients (n=65) was 89.2%, for those who failed eradication (n=11) it was 72.7% (NS), while for patients not infected with H. pylori at entry to the study (n=54) it was 96.1% (NS). After 20 weeks of Omeprazole prophylaxis with the 10mg dose (N=45), 91.1% (86.1–95.8%) had maintained healing while for the 20mg dose (N=60) a similar figure was observed (96.7%; 91.1–99.9%; NS). Only five of these patients had persistent H pylori infection.
Conclusion: In a Middle Eastern population with NSAID induced gastro/duodenal lesions, H pylori eradication and high dose Omeprazole treatment were not associated with impaired ulcer healing. After eradication, Omeprazole 10 or 20 mg per day were highly and equally effective for maintenance of gastroduodenal mucosal integrity during continued NSAID use.
237 WARFARIN ANTI-COAGULATION CONTROL IN PATIENTS TAKING PROTON PUMP INHIBITORS
C.F. Donnellan, S. Dass, F. Dunn1, M.A. Hull.Dept of Gastroenterology, St James's University Hospital;1The Anti-coagulation Clinic, Seacroft Hospital, Leeds, UK
Background: There is evidence that proton pump inhibitor (PPI) use can increase the prothrombin time in healthy volunteers taking warfarin. However, no studies have been carried out to investigate the effect of PPIs on anti-coagulation (AC) control in patients requiring warfarin therapy. Therefore we tested the hypothesis that PPI therapy worsens AC control in patients attending an AC Clinic.
Methods: The Leeds AC Clinic database was analysed retrospectively. We collected data on patient age, indication for and duration of AC, PPI use and warfarin dose. We also obtained all the INR values for each patient. INR control was expressed as the percentage of INR values above, within or below the target range for each individual.
Results: 14.8% (n=503) of patients were taking a PPI (omeprazole, n=310 [61.7%]; lansoprazole, n=167 [33.2%]; pantoprazole, n=15 [3%]; rabeprazole, n=8 [1.6%] and esomeprazole, n=3 [0.6%]) and there were 2885 (85.2%) patients not taking a PPI (non-PPI). The proportion of patients in each group who were receiving AC for AF or venous thrombo-embolic disease was similar (PPI 75.7% vs non-PPI 74.4%). For PPI patients, the mean percentage of INR values above the target range was 19.8%, in the target range 49.6% and below the target range 30.6%. Comparative values for non-PPI patients were 17.6% (p<0.001; Student's t test) 52.6% (p<0.001) and 29.8% (p=0.32). However there was no significant difference in mean INR value, warfarin dose or duration of therapy between the two groups. The two groups did differ with respect to age (PPI, mean 72.4 yrs vs non-PPI, 70.8 yrs; p=0.005) and frequency of INR testing (PPI, every 53 days vs non-PPI, 47 days; p=0.017). Logistic regression analysis confirmed that percentage of INR values in the target range, patient age and test rate were all significantly different between PPI and non-PPI patients (all p<0.01).
Conclusion: PPI therapy was associated with a small, but significant decrease in AC control although the increased age and lower testing frequency in the PPI patient group may have contributed to this. A prospective study, including data on other drug use eg anti-epileptics as well as on clinically significant bleeding episodes, is warranted.
238 ERADICATION OF HELICOBACTER PYLORI: CLINICAL PRACTICE AMONG HOSPITAL CONSULTANTS IN THE UNITED KINGDOM
S. Aroori, S.G. Jacob
Aim: To assess the clinical practice of hospital doctors across United Kingdom in eradication of Helicobacter pylori
Methods: The study was carried between October 2000 and May 2001 during which time a questionnaire was sent to 130 gastroenterologists and 130 general and upper G.I surgeons across United Kingdom inquiring the following: (1) The pathological conditions in which they chose to eradicate the organism - Gastro oesophageal reflux disease (GORD), gastritis, gastric ulcer, gastric erosions, duodenal ulcer, duodenitis, non-ulcer dyspepsia (NUD), a combination of some of the conditions and (2) the type of regimen used.
Results: Eighty (61.5%) gastroenterologists and sixty-two (47.5%) surgeons replied to the questionnaire. The over all response rate was 55%. Almost all gastroenterologists and surgeons recommended treatment for eradication in duodenal and gastric ulcer disease. However, there were wide variations in recommending eradication therapy for patients with NUD and GORD. Fifty gastroenterologists (62.5%) and thirty-two (51.6%) surgeons did not recommend eradication therapy for patients with GORD while 47.5% of gastroenterologists and 53% of surgeons did recommend eradication in patients with NUD. 24% of gastroenterologists and 18% of surgeons had not considered eradication at all in gastritis while in patients with duodenitis, 17.5% of gastroenterologists and 11.3% of surgeons did not favour eradication of the organism. Majority of surgeons and gastroenterologists favoured triple therapy using combination of Proton Pump Inhibitor, Clarithromycin and Amoxicillin.
Conclusions: In this study, we have noted wide variations in the practice of gastroenterologists and surgeons across United Kingdom in advising eradication therapy for H. pylori positive patients in various upper GI conditions. While there is a general consensus in the mode of therapy offered, there seems to be varied practice in eradication of the organism in conditions such as NUD and GORD.
239 A 5-YEAR, DOUBLE-BLIND, RANDOMISED COMPARISON OF RABEPRAZOLE AND OMEPRAZOLE IN GORD MAINTENANCE TREATMENT: GASTRIC BIOPSY RESULTS
B. Thjodleifsson1, N.M. Miller2, K.D. Bardhan3.1University Hospital, Reykjavik, Iceland;2Eisai Ltd, London, UK;3Rotherham General Hospital, Rotherham, UK
Background: Although long-term treatment with proton-pump inhibitors is generally considered safe, there is still little evidence from prospective studies about the effect of such treatment on the gastric mucosa.
Objectives: The primary objective was to assess efficacy in preventing GORD relapse. The secondary objective reported here was to assess the effect of 5 years' treatment with rabeprazole or omeprazole on the gastric mucosa.
Methods: 243 patients were randomised to double-blind treatment with rabeprazole (10 mg or 20 mg) or omeprazole (20 mg) once daily for up to 5 years. Biopsy samples were taken from the corpus and antrum after 13, 26, and 52 weeks, and annually thereafter.
Results: The percentage of patients with H pylori infection fell substantially during the study in all groups in the antrum, but only in the 10 mg rabeprazole group in the corpus. Inflammation, activity of inflammation, and mucosal atrophy were all more severe in H pylori positive patients than in H pylori negative patients. Those variables generally improved during the study, except inflammation in the corpus, which improved only in the 10 mg rabeprazole group and changed little in the other groups, and atrophy in the corpus, which became more marked in all groups. Argyrophil ECL cell hyperplasia was generally mild, with no dysplasia or neoplasia observed in any patient. However, it became less marked during the study in the rabeprazole groups, but tended to increase in the omeprazole group.
Conclusions: Treatment with 10 or 20 mg rabeprazole or 20 mg omeprazole once daily for 5 years is largely free of deleterious effects on the gastric mucosa. Features of the gastric mucosa were more affected by H pylori status than by treatment, few differences being observed among the treatments.
240 THE INFLUENCE OF SMOKING AND NSAIDs ON SYMPTOM SEVERITY IN PATIENTS TAKING ANTI SECRETORY THERAPY
A.J. Morris, C. Craig, C. Morran, K. Harden, H. Burns, A. Power, D. Walsh, R.C. Stuart.ACID 1 study group, Digestive Disease Directorate, Glasgow Royal Infirmary, Glasgow, UK
Aim: In a large general practice study (ACID1) of H. pylori eradication in patients receiving maintenance anti-secretory therapy we investigated the effects of smoking and NSAID use on dyspepsia severity scores.
Patients/Methods: 4003 patients receiving maintenance therapy (≥3 scripts/year of a H2RA or PPI drug) were invited to a nurse led community dyspepsia clinics. 2353 attended and completed a modified Glasgow Dyspepsia Severity Score (GDSS) and Digestive Disease Quality of Life Score (DDQ). Prescribing data was collected for the 12 months prior to study enrolment from computer and case note records.
Results: Mean scores are presented in the table. Aspirin use alone was associated with lower GDSS but, in combination with other NSAIDs, it resulted in higher symptom severity and lower quality of life scores. There was no correlation between smoking and GDSS or DDQ scores. See table.
Conclusions: In dyspeptic patients receiving acid suppressing agents: (1) Aspirin use, on its own, was associated with lower symptom severity scores but, when combined with other NSAIDs, it resulted in higher symptom severity and poorer quality of life scores. (2) Smoking did not affect symptom severity or quality of life scores in patients.
241 NSAID PRESCRIBING GUIDELINES: CONTINUED ULCER BLEEDING DESPITE MANAGEMENT CONSENSUS
M.M. Skelly1, B. Pick1, R.F.A. Logan2, C.J. Hawkey1.Divisions of1Gastroenterology and2Dept of Public Health and Epidemiology, University Hospital, Nottingham, UK
Introduction: Use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with peptic ulcer disease (PU) complications. Local consensus guidelines on NSAID prescribing include a preference for use of ibuprofen ≤ 1200mg if NSAID use was unavoidable, avoidance of slow release preparations, use of a COX II inhibitor or co-prescription of a proton pump inhibitor or misoprostol for patients at high risk of ulcer complications (PU history, age ≥ 65, use of NSAID other than ibuprofen, high NSAID doses, concomitant corticosteroids or anti-coagulation.
Aim: To study all patients admitted with upper gastrointestinal haemorrhage (UGH) and to determine if prescribing guidelines were being followed in those cases on NSAIDs.
Method: All patients admitted with UGH over 4 months were identified prospectively. Details were collected regarding demographics, aspirin or NSAID use, co-morbidity and features of the bleeding episode. Patients found to have bled from varices were excluded from analysis.
Results: Ninety four patients were admitted with confirmed non-variceal upper gastrointestinal haemorrhage (53 men; mean age 60+/-2.1, range 18–96). Ten patients were on non-aspirin NSAIDs (four men, mean age 52+/-8, 18–96) of whom three were on lower-risk formulations. None of these ten patients were co-prescribed gastro-protective drugs, one patient each was on aspirin and corticosteroids in addition to the NSAID. Eight patients on NSAID had significant co-morbid disease, five of whom were aged over 65years. No patient on NSAID had a history of PUD. Twenty-three patients (17 aged ≥ 65, 2 with PU history) were taking aspirin. Only one was co-prescribed a gastro-protective drug.
Summary: Patients who presented with an upper GI bleed while on NSAIDs were not prescribed NSAIDs in accordance with locally agreed guidelines. NSAID-associated ulcer complications could be reduced by better prescribing.
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