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Prophylactic aspirin and peptic ulcer bleeding
A256
•
AGA ABSTRACTS
P R O P H Y L A C T I C A S P I R I N A N D PEPTIC U L C E R BLEEDING
J Weil, D Colin Jones, M J S Langman, D Lawson, R Logan, M Murphy, M Kawlins, M P Vessey, P Wainwright. Universities of Birmingham, Newcastle, Nottingham, Oxford, Royal Infirmary Glasgow, Queen Alexandra Hospital Portsmouth. Prophylactic aspirin is being increasingly widely used in managing patients with vascular occlusive disease, or in primary prevention. The risks of different doses of aspirin are unclear and we have therefore analysed data collected during a retrospective ease-control study of 1121 patients aged 60 and over admitted with bleeding gastric or duodenal ulcers to Hospitals in Glasgow, Newcastle, Nottingham, Oxford and Portsmouth. Data were compared with those obtained in 1126 hospital and 989 community controls. 13% of cases were regular users of aspirin at least five days a week compared with 9% of hospital and 8% of community controls. Odds ratios were raised for all doses of aspirin taken [75 mg daily 2.3, 1.2-4.4, 150rag daily 3.2, 1.7-6.5 and 300 mg daily 3.9, 2.5-6.3]. Results were not explained by confounding influences and none of the conventionally used prophylactic aspirin regimes therefore appears free of risk.
BARRETT'S ESOPHAGUS: PROSPECTIVE REEVALUATION OF HISTOLOGICAL SUBTYPES AND ASSOCIATION WITH GASTRIC INTESTINAL METAPLASIA AND HELICOBACTER PYLORL A.P. Weston, P. Krmpotich, W. Makdisi, R. Cherian, A. Dixon, D. McGregor. VAMC Kansas City, MO & Univ. Kansas Medical Center, Kansas City, KS. Barrett's epithelium is classically comprised of 3 different histologie types: specialized columnar, atrophic gastric fundic and junctional epithelium. AIM: To prospectively; i) reevaluate the histologic types of Barrett's, and ii) determine the prevalence of gastric Helicobacterpylori (Hp) and gastric intestinal metaplasia (IM) in Barrett's. METHODS: All consecutive patients undergoing EGD by the authors in whom Barrett's was known to exist or suspected had 4 quadrant biopsies taken every 2 cm from pink mucosa within the tubular esophagus. In addition, 4 gastric biopsies (2 antrum, 2 greater curve, mid-body) were taken (when indicated) for detection of Hp (modified Giemsa stain) and IM. Biopsies were also obtained from the cardia in some cases. RESULTS: 42 Barrett's patients had an EGD over a 10 week period. The results are presented from the 39 patients in whom extensive 4 quadrant biopsies, every 2 cm were obtained. Characteristics of Barrett's Patients
Gender male/female 39 M/0 F Age (years) 63.5--+10.9 Barrett's Subtype specialized 38 (97.4%) junctional 1 (2.6%) Gastric IM 11/34 (32.4%) Cardia IM 1/17 (5.9%) Gastric Hp 17/34 (50.0%) Dysplasia 15 (38.5%) Adenocarcinoma 2 (5.1%) CONCLUSIONS: With extensive biopsy sampling, 97.4% of adult patients with Barrett's esophagus are found to have specialized epithelium with the other subtypes rarely found. The frequency of IM is significantly less common in the cardia (p<0.0001) and gastric biopsies (p= 0.0001) compared to Barrett's IM.
GASTROENTEROLOGY, VoI. IO8, No. 4
• THE MODULATORY IMPACT OF THE ESOPHAGO-SALIVARY REFLEX ON SALIVARY pH IN PATIENTS WITH REFLUX ESOPHAGITIS: ITS PROTECTIVE POTENTIAL IN ESOPHAGEAL DEFENSE. J.P. Weiss, M. Marcinkiewicz, C.J. Scheurich, Z. Namiot, M.C. Edmunds, J. Sarosiek, R.W. McCallum, Universityof VirginiaHealth Sciences Center, Charlottesville, VA.
We have recently demonstrated that stimulation of intraesophageal mechano- and chemoreceptorsby insertion of a catheter with intraesophagealballoons and perfusion with HC1/pepsinresults in a significant increase in salivarypH (AIG 89:581-7; 1994), mediatedby esophago-salivaryreflex, involving predominantlyparatid glands. Little is known, however, regarding the impact of intraesophagealmechanical and chemical stimulationon salivarypH in patients with reflux esophagitis0LE). Aims: 1) To measure the pH of salivary secretion during esophageal mechanical stimulation and mucosal exposure to HCI and HC1/pepsth solutions, mimicking the natural gasnoesophageal reflux, in patients with RE, and 2) To compare these results with correspondingvalues recorded in controls. Subjects & Methods: The study was conducted in 37 patients with RE (13F, 24M; mean age 49, range 26-78; 17 grade II, 6 grade III, 10 grade III& BE, and 4 grade III & stricture) and 17 controls (9F & 8M; mean age of 42, range 22-62). Salivary secretion was collected during mechanical and chemical stimulation (mimicking the natural gastro-esophageai reflux scenario) using '0uf newly developed esophageal perfusion catheter (A.IG;88:17~9,1993). Salivary pH was recorded with IonAnalyzer (Orion, MA). Results are presented as a mean ±SEM. Statistical analysis was performed using SigmaStat software. Results: The basal salivary pH in RE patients was 6.94 ±0.06. Mechanical stimulation of the esophageal mucosa in patients with RE, b y placement of intraesophagealtubing and insufflation of balloons resulted in increase of pH to 7.74 ±0.06 and 7.64 i-0.06 respectively~<0.001 vs basal). Chemical stimulationwith HC1 and HC1/pepsinmaintained pH significantly higher than basal values (7.68 ±0.07 and 7.68 ~:0.06 respectively; p<0.001). In addition, salivary pH was also significantly increased both during mechanical and chemical stimulation as compared with pH value recorded during chewing parafilm (7.37 ±0.06; P<0.001). Salivary pH in patients with RE and controls Was similar during mechanical stimulationwith tubing. However, during chemical stimulation with both HC1 arid HCl/pepsin solutions pH values were significantly lower than correspondingvalues recorded in controls ( 7.68 ±0.07 vs 7.98 ~0.08; P=0.012 and 7.68 ±0.06 vs 7.95 ±0.08; P=0.043 respectively). Conclusions: 1) Esophago-salivary reflex governing salivary pH through mechanoreceptorsis well preservedin patients with RE. 2) Stimulationof esophageal chemical receptors generating esophago-salivaryreflex, mediating changes in salivary pH is significantlyimpaired in patients with RE.
• CLOtest SENSITIVITY AND SPECIFICITY IS DEPENDENT U P O N THE LOCATION AND NUMBER OF BIOPSIES OBTAINED. A.P. Weston, D.R. Campbell, W.F. Makdisi, R. Cherian, S. Mitchell, A. Dixon, D.H. McGregor, W. Bartholomew. VAMC Kansas City, MO & Univ. Kansas Medical Center, Kansas City, KS. The published performance of the CLOtest in the detection of Helicobacter pylori varies with sensitivity ranging from 78 % to 99 % and specificity, from 83 % to 100%. A number of factors have been proven or postulated to explain this performance. AIM: Prospective study to clarify the effect of the location from which the CLOtest biopsy is obtained and whether taking more CLOtest biopsies increases sensitivity and specificity. METHODS. Subjects ineligible for this study included t h o s e with a history (hx) of recent use (within 4 weeks) of antibiotics and/or bismuth compounds, hx gastric surgery, and hx of dysphagia. A minimum of 9 endoscopic biopsies were obtained, 3 from the antrum, 3 from the greater curve (mid/distal body), and 3 from another site (variable location). From each site, 2 biopsies were sent for histology/Giemsa staining and one for CLOtest. The presence or absence of Helicobacter pylori was based on Giemsa stained gastric biopsies. Determination of the sensitivity and:specificity of the CLOtest was based upon Giemsa staining of the multiple gastric biopsies. RF~ULTS. 50 patients entered the study, 24 of whom Helicobacterpylori was found on at least one Giemsa stained gastric biopsy specimen. CLOtest Site Antrum Alone Body Alone Either Site CLOtest sensitivity 67 % 75 % 83 % specificity 100% 100% 100% One CLOtest from the antrum was positive, yet the Giernsa stained section from the antrum was negative for Helicobacter pylorL One CLOtest from the body was also positive, yet no Helicobacterpylori was detected in the Giemsa stained section from the body biopsy. CONCLUSIONS: Taking a biopsy from the antrum as well as the body for CLOtesting increases CLOtest sensitivity from 67% to 83%. Obtaining multiple biopsies from more than one site resulted in a CLOtest specificity of 100%.
•
AGA ABSTRACTS
P R O P H Y L A C T I C A S P I R I N A N D PEPTIC U L C E R BLEEDING
J Weil, D Colin Jones, M J S Langman, D Lawson, R Logan, M Murphy, M Kawlins, M P Vessey, P Wainwright. Universities of Birmingham, Newcastle, Nottingham, Oxford, Royal Infirmary Glasgow, Queen Alexandra Hospital Portsmouth. Prophylactic aspirin is being increasingly widely used in managing patients with vascular occlusive disease, or in primary prevention. The risks of different doses of aspirin are unclear and we have therefore analysed data collected during a retrospective ease-control study of 1121 patients aged 60 and over admitted with bleeding gastric or duodenal ulcers to Hospitals in Glasgow, Newcastle, Nottingham, Oxford and Portsmouth. Data were compared with those obtained in 1126 hospital and 989 community controls. 13% of cases were regular users of aspirin at least five days a week compared with 9% of hospital and 8% of community controls. Odds ratios were raised for all doses of aspirin taken [75 mg daily 2.3, 1.2-4.4, 150rag daily 3.2, 1.7-6.5 and 300 mg daily 3.9, 2.5-6.3]. Results were not explained by confounding influences and none of the conventionally used prophylactic aspirin regimes therefore appears free of risk.
BARRETT'S ESOPHAGUS: PROSPECTIVE REEVALUATION OF HISTOLOGICAL SUBTYPES AND ASSOCIATION WITH GASTRIC INTESTINAL METAPLASIA AND HELICOBACTER PYLORL A.P. Weston, P. Krmpotich, W. Makdisi, R. Cherian, A. Dixon, D. McGregor. VAMC Kansas City, MO & Univ. Kansas Medical Center, Kansas City, KS. Barrett's epithelium is classically comprised of 3 different histologie types: specialized columnar, atrophic gastric fundic and junctional epithelium. AIM: To prospectively; i) reevaluate the histologic types of Barrett's, and ii) determine the prevalence of gastric Helicobacterpylori (Hp) and gastric intestinal metaplasia (IM) in Barrett's. METHODS: All consecutive patients undergoing EGD by the authors in whom Barrett's was known to exist or suspected had 4 quadrant biopsies taken every 2 cm from pink mucosa within the tubular esophagus. In addition, 4 gastric biopsies (2 antrum, 2 greater curve, mid-body) were taken (when indicated) for detection of Hp (modified Giemsa stain) and IM. Biopsies were also obtained from the cardia in some cases. RESULTS: 42 Barrett's patients had an EGD over a 10 week period. The results are presented from the 39 patients in whom extensive 4 quadrant biopsies, every 2 cm were obtained. Characteristics of Barrett's Patients
Gender male/female 39 M/0 F Age (years) 63.5--+10.9 Barrett's Subtype specialized 38 (97.4%) junctional 1 (2.6%) Gastric IM 11/34 (32.4%) Cardia IM 1/17 (5.9%) Gastric Hp 17/34 (50.0%) Dysplasia 15 (38.5%) Adenocarcinoma 2 (5.1%) CONCLUSIONS: With extensive biopsy sampling, 97.4% of adult patients with Barrett's esophagus are found to have specialized epithelium with the other subtypes rarely found. The frequency of IM is significantly less common in the cardia (p<0.0001) and gastric biopsies (p= 0.0001) compared to Barrett's IM.
GASTROENTEROLOGY, VoI. IO8, No. 4
• THE MODULATORY IMPACT OF THE ESOPHAGO-SALIVARY REFLEX ON SALIVARY pH IN PATIENTS WITH REFLUX ESOPHAGITIS: ITS PROTECTIVE POTENTIAL IN ESOPHAGEAL DEFENSE. J.P. Weiss, M. Marcinkiewicz, C.J. Scheurich, Z. Namiot, M.C. Edmunds, J. Sarosiek, R.W. McCallum, Universityof VirginiaHealth Sciences Center, Charlottesville, VA.
We have recently demonstrated that stimulation of intraesophageal mechano- and chemoreceptorsby insertion of a catheter with intraesophagealballoons and perfusion with HC1/pepsinresults in a significant increase in salivarypH (AIG 89:581-7; 1994), mediatedby esophago-salivaryreflex, involving predominantlyparatid glands. Little is known, however, regarding the impact of intraesophagealmechanical and chemical stimulationon salivarypH in patients with reflux esophagitis0LE). Aims: 1) To measure the pH of salivary secretion during esophageal mechanical stimulation and mucosal exposure to HCI and HC1/pepsth solutions, mimicking the natural gasnoesophageal reflux, in patients with RE, and 2) To compare these results with correspondingvalues recorded in controls. Subjects & Methods: The study was conducted in 37 patients with RE (13F, 24M; mean age 49, range 26-78; 17 grade II, 6 grade III, 10 grade III& BE, and 4 grade III & stricture) and 17 controls (9F & 8M; mean age of 42, range 22-62). Salivary secretion was collected during mechanical and chemical stimulation (mimicking the natural gastro-esophageai reflux scenario) using '0uf newly developed esophageal perfusion catheter (A.IG;88:17~9,1993). Salivary pH was recorded with IonAnalyzer (Orion, MA). Results are presented as a mean ±SEM. Statistical analysis was performed using SigmaStat software. Results: The basal salivary pH in RE patients was 6.94 ±0.06. Mechanical stimulation of the esophageal mucosa in patients with RE, b y placement of intraesophagealtubing and insufflation of balloons resulted in increase of pH to 7.74 ±0.06 and 7.64 i-0.06 respectively~<0.001 vs basal). Chemical stimulationwith HC1 and HC1/pepsinmaintained pH significantly higher than basal values (7.68 ±0.07 and 7.68 ~:0.06 respectively; p<0.001). In addition, salivary pH was also significantly increased both during mechanical and chemical stimulation as compared with pH value recorded during chewing parafilm (7.37 ±0.06; P<0.001). Salivary pH in patients with RE and controls Was similar during mechanical stimulationwith tubing. However, during chemical stimulation with both HC1 arid HCl/pepsin solutions pH values were significantly lower than correspondingvalues recorded in controls ( 7.68 ±0.07 vs 7.98 ~0.08; P=0.012 and 7.68 ±0.06 vs 7.95 ±0.08; P=0.043 respectively). Conclusions: 1) Esophago-salivary reflex governing salivary pH through mechanoreceptorsis well preservedin patients with RE. 2) Stimulationof esophageal chemical receptors generating esophago-salivaryreflex, mediating changes in salivary pH is significantlyimpaired in patients with RE.
• CLOtest SENSITIVITY AND SPECIFICITY IS DEPENDENT U P O N THE LOCATION AND NUMBER OF BIOPSIES OBTAINED. A.P. Weston, D.R. Campbell, W.F. Makdisi, R. Cherian, S. Mitchell, A. Dixon, D.H. McGregor, W. Bartholomew. VAMC Kansas City, MO & Univ. Kansas Medical Center, Kansas City, KS. The published performance of the CLOtest in the detection of Helicobacter pylori varies with sensitivity ranging from 78 % to 99 % and specificity, from 83 % to 100%. A number of factors have been proven or postulated to explain this performance. AIM: Prospective study to clarify the effect of the location from which the CLOtest biopsy is obtained and whether taking more CLOtest biopsies increases sensitivity and specificity. METHODS. Subjects ineligible for this study included t h o s e with a history (hx) of recent use (within 4 weeks) of antibiotics and/or bismuth compounds, hx gastric surgery, and hx of dysphagia. A minimum of 9 endoscopic biopsies were obtained, 3 from the antrum, 3 from the greater curve (mid/distal body), and 3 from another site (variable location). From each site, 2 biopsies were sent for histology/Giemsa staining and one for CLOtest. The presence or absence of Helicobacter pylori was based on Giemsa stained gastric biopsies. Determination of the sensitivity and:specificity of the CLOtest was based upon Giemsa staining of the multiple gastric biopsies. RF~ULTS. 50 patients entered the study, 24 of whom Helicobacterpylori was found on at least one Giemsa stained gastric biopsy specimen. CLOtest Site Antrum Alone Body Alone Either Site CLOtest sensitivity 67 % 75 % 83 % specificity 100% 100% 100% One CLOtest from the antrum was positive, yet the Giernsa stained section from the antrum was negative for Helicobacter pylorL One CLOtest from the body was also positive, yet no Helicobacterpylori was detected in the Giemsa stained section from the body biopsy. CONCLUSIONS: Taking a biopsy from the antrum as well as the body for CLOtesting increases CLOtest sensitivity from 67% to 83%. Obtaining multiple biopsies from more than one site resulted in a CLOtest specificity of 100%.