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Association between subjects with dyspeptic sumptoms and Helicobacter pylori infection: Epidemilogic study conducted at 16 centers in Argentina
A248 AGA ABSTRACTS
GASTROENTEROLOGYVol. 114, No. 4
• G1016 ASSOCIATION BETWEEN SUBJECTS WITH DYSPEPTIC SYMPTOMS AND HELICOBACTER PYLORI INFECTION: EPIDEMIOLOGIC STUDY CONDUCTED AT 16 CENTERS IN ARGENTINA. J.A. Olmos; R. Higa; H. Rfos; L. O. Soifer; J: A. De Paula; R. Pedrana; N. Chopita; O. Gadea, J. Katz; J. Adami; E. Varela. Hospital Italiano, Buenos Aires, Argentina Background: It has been suggested that Helicobacter pylori (Hp) causes the symptoms of dyspepsia. However, the prevalence of Hp infection in dyspeptic patients is still discussed. At present, there are no trials matching patients with controls in relation to epidemiological variables. Aim: To determine the strength of the association between dyspepsia and its symptomatic subgroups with Hp infection. Methods: The study comprised 270 patients from both genders with dyspeptic symptoms consecutively recruited from health centers across 16 geographic areas. These subjects were referred by general practitioners, 182 were women (67.4%) and 88 were men (32.%) (age: 42.3 +_.16.5 years). Dyspepsia was defined by clinical Rome (1989) criteria. Patients were divided into 3 subgroups of symptoms: ulcer like, dismotility like and non specific. The patients with dyspeptic symptoms were matched with controls by age, gender, socioeconomic status and education level. The control group was formed by 264 subjects with no upper abdominal digestive symptoms; 159 women (60.2%) and 105 men (39.8%) (age: 40.8 _+17.8). Hp infection status was assessed with quick serological test (Flex-pack Hp test). Odds ratio (OR), 95% confidence interval (95% CI) and multiple logistic regression tests were applied to validate the results. Results:
Group Controls Dyspeptic subjects
N 264 270
Hp+ 116 (44.3%) 137 (51.8%)
OR
95%CI
p
1.27
0.89-1.83
0.18
Ulcer like Dismotility like Non specific
37 139 94
15 (40.5%) 72 (51.8%) 53 (56.4%)
1.21 1.69
0.55-2.69 0.74-3.88
0.63 0.22
Conclusions: The rate of Hp infection in subjects with dyspeptic symptoms was higher than in controls, but the difference was not statistically significant. Besides, no difference was found in Hp infection rates according to symptomatic subgroups. G1017 HIGHER SEROPREVALENCE OF HELICOBACTER PYLORI INFECTION (HE) IN PROCTOLOGISTS THAN IN ENT SPECIALISTS: ONE EVIDENCE SUPPORTING THE FECAL-ORAL ROUTE OF TRANSMISSION. J. O!mos; H. Rios; R. Higa; N. Chopita; O. Gadea; R. Pedrana; A. Podio; V. Pigatto; L. Soifer. Hospital Italiano, Buenos Aires, ARGENTINA Background: Person to person transmission is currently considered the main via of acquiring Hp infection, and the proposed routes are oral-oral and the fecal-oral. However, the relative importance of both infection routes is still unclear. Some physicians are more exposed than others to Hp acquisition due to their professional activity. Aim: To assess Hp prevalence among ENT specialists and proctologists, who are exposed to oral-oral and fecal-oral routes of infection, respectively. Subjects and methods: Forty male ENT specialists age ~ 44.4 _+ 11.0 and 40 male proctologists, age $ 47.2-+ 10.9 were evaluated. Both groups were matched with a control group by age, gender, education level and socioeconomic status. The control group was formed by 80 male subjects, age 44.9 -+ 10.6. The infection status was assessed with a quick serological test (Flex-pack Hp test). Odds ratio (OR), 95% confidence interval (95%CI) and Fisher's test were used to validate the results. Results: Hp prevalence among ENT specialists was 47.5% (19/40), 60% (24/40) among proctologists, and 36.25% in the control group (29/80). When the data of the controls were matched with those of the proctologists, the results were: OR=2.64 (95% CI=1.13-6.21) p=0.02; and when matched with the E.N.T. specialists group the results were: OR=1.59 (95% CI=0.68-3.68) p=0.24, (NS). When both groups of professionals were compared between each other, the results were: OR=l.66 (95% CI=0.62-4.44) p=0.37, (NS). Conclusions: Although HP prevalence among ENT specialists and proctologists is higher than in the control group the difference was only statistically significant for the proctologists. On the other hand, Hp prevalence among these professionals is higher than among ENT specialists, but the difference was not significant probably due to the sample size. These findings support the evidence of the fecal-oral route. • G1018 COMBINED EMPIRIC TREATMENT AND SPECIFIC H. PYLORI SCREENING AND TREATMENT DECREASE THE COST OF EVALUATING EPIGASTRIC ABDOMINAL PAIN. AD Olson, D Deutsch. Univ. of Michigan, Ann Arbor, MI; Univ. of Illinois, Rockford, Illinosis
We used a decision analysis program to evaluate the cost effectiveness of common strategies applied to patients with abdominal pain suggestive of peptic ulcer disease. H. pylori serology and treatment (HP-SER&Rx),
H. pylori C13 breath test and treatment (HP-BT&Rx), and an empiric trial of H2 blocking agent (empiric H2 trial) were utilized in our diagnostic strategies. The diagnostic strategies evaluated included: EGD; HP-SER&Rx, an empiric H2 trial, HP-BT&Rx, and the combination of HP-SER&Rx and HP-BT&Rx with an empiric H2 trial. The decision analysis program evaluated the preferred diagnostic treatment utilizing cost as a negative utility for each workup. Baseline cost assumptions included: EGD, $1180; H. pylori serology, $80; treatment ofH. pylori infection of $180; and cost of an empiric H2 trial with Zantac, $160. Baseline assumptions included a response to empiric H2 trial of 70% in patients who are H. pylori negative and an incidence of H. pylori .40. All patients with residual or recurrent pain following their treatment strategy underwent EGD. An empiric H2 trial combined with either HP-SER&Rx or HP-BT&Rx were the preferred strategies with a cost of $576. The combination of an empiric H2 trial with eithei: HP-SER&Rx or HP-BT&Rx as specific tests for H. pylori were each significantly less expensive than either an empiric H2 trial ($797), HP-SER&Rx ($958) or HP-BT&Rx ($1032) alone. The costs of each strategy was directly dependent on the number of patients requiring EGD. When an empiric H2 trial, HP-SER&Rx or HP-BT&Rx were done alone 54%, 67% or 73% of patients underwent endoscopy. When an empiric H2 trial was combined with either HP-SER&Rx or HP-BT&Rx the number of patients undergoing EGD decreased to less than 27%. The decision analysis was sensitive to the percent of patients responding to an empiric H2 trial, the incidence of H. pylori and to the cost of EGD. When compared to the strategies of EGDs HP-SER&Rx, or HP/BT&Rx alone, the combination of an empiric H2 trial, and specific screening and treatment for H. pylori avoid 75% and 40% of EGDs and reduced the cost of diagnosis and treatment by 50% and 40% respectively. A combined empiric H2 trial with specific screening and treatment for H. pylori is the most cost effective evaluation of patients with abdominal pain examined. G1019 THE SPECTRUM OF EOSINOPHILIC ESOPHAGITIS IN CHILDREN. SR Orenstein. H Mousa, C Di Lorenzo, SA Kocoshis, PE Putnam, JF del Rosario, L Sigurdsson, TM Shalaby. Pediatric Gastroenterology, Univ Pittsburgh School of Medicine & Children's Hospital of Pittsburgh, PA. Defining eosinophilic esophagitis as > 5 eosinophils per high power field (hpf), we identified 32 children (evaluated between 1 and 19 years of age) who had had eosinophilic esophagitis on biopsies of the distal esophageal epithelium performed during the years 1993-7. Data were obtained by chart review, follow-up telephone interview, review of endoscopic and radiographic images, and dual-observer (SRO, TMS) blinded scoring of biopsies of esophagus, antrum, and duodenum. RESULTS: The 32 children (28 male) developed symptoms at a median age of 4 years (0-19 years), and were evaluated at a median age of 7 years (1-19 years). The most common presenting symptoms were vomiting (23) and abdominal or chest pain (14). An impressive number had strictures (3), food impactions in the absence of strictures (5), and dysphagia in the absence of strictures or manometric abnormalities (2). Asthma or other chronic respiratory symptoms (17), food allergies by history (13) and/or testing (17 of 25 tested), peripheral eosinophilia (25% of those tested), or elevated serum lgE (50% of those tested) were common, but not universally identified. A distinctive endoscopic manifestation, identifiable reliably without knowledge of the histology, was a granular, furrowed, occasionally ringed appearance of the esophageal mucosa, without erosions or other mucosal breaks. The distal esophagus demonstrated a median of 25 eosinophils/hpf (range 5-150). Association with eosinophilic infiltration of antrum (median 3 eosinophils/hpf, range 0-150) or duodenum (median 20/hpf, range 0-200) was variable. Of the 32 children, 2 had a history of "pyloric stenosis." There was little evidence for pathogenic gastroesophageal reflux: 2/2 nuclear scans showed postprandial reflux, but 4/4 pH probe studies were normal and 24/26 upper gastrointestinal fluoroscopies were negative for excessive reflux. Therapeutic benefit was found for dietary elimination (11/15), cromolyn sodium(6/8), or steroids (9/10), when they were tried. CONCLUSION: Eosinophilic esophagitis is in the continuum of eosinophilic gastroenteropathy, and may produce severe symptoms treatable as manifestations of food allergy in some, predominantly male, children. It is identifiable grossly at endoscopy by a characteristic granular, furrowed, ringed appearance, not previously ascribed to it. Recognition of this entity as distinct from gastroesophageal reflux disease will likely improve our diagnosis and therapy of these children. G1020 DIFFERENTIAL EXPRESSION OF CYTOKERATIN SUBSETS IN BARRETT'S ESOPHAGUS VERSUS INTESTINAL METAPLASIA OF THE STOMACH. AH Ormsbv. JR Goldblum, TW Rice, TL Gramlich, The Cleveland Clinic Foundation, Cleveland, OH Cytokeratins are a group of structural proteins present in epithelial ceils that are expressed in different profiles based on tissue differentiation. The columnar-lined esophagus with intestinal metaplasia (Barrett's esophagus) and intestinal metaplasia of the gastric mucosa are two histologicallY indistinguishable abnormalities that are associated with the development of
GASTROENTEROLOGYVol. 114, No. 4
• G1016 ASSOCIATION BETWEEN SUBJECTS WITH DYSPEPTIC SYMPTOMS AND HELICOBACTER PYLORI INFECTION: EPIDEMIOLOGIC STUDY CONDUCTED AT 16 CENTERS IN ARGENTINA. J.A. Olmos; R. Higa; H. Rfos; L. O. Soifer; J: A. De Paula; R. Pedrana; N. Chopita; O. Gadea, J. Katz; J. Adami; E. Varela. Hospital Italiano, Buenos Aires, Argentina Background: It has been suggested that Helicobacter pylori (Hp) causes the symptoms of dyspepsia. However, the prevalence of Hp infection in dyspeptic patients is still discussed. At present, there are no trials matching patients with controls in relation to epidemiological variables. Aim: To determine the strength of the association between dyspepsia and its symptomatic subgroups with Hp infection. Methods: The study comprised 270 patients from both genders with dyspeptic symptoms consecutively recruited from health centers across 16 geographic areas. These subjects were referred by general practitioners, 182 were women (67.4%) and 88 were men (32.%) (age: 42.3 +_.16.5 years). Dyspepsia was defined by clinical Rome (1989) criteria. Patients were divided into 3 subgroups of symptoms: ulcer like, dismotility like and non specific. The patients with dyspeptic symptoms were matched with controls by age, gender, socioeconomic status and education level. The control group was formed by 264 subjects with no upper abdominal digestive symptoms; 159 women (60.2%) and 105 men (39.8%) (age: 40.8 _+17.8). Hp infection status was assessed with quick serological test (Flex-pack Hp test). Odds ratio (OR), 95% confidence interval (95% CI) and multiple logistic regression tests were applied to validate the results. Results:
Group Controls Dyspeptic subjects
N 264 270
Hp+ 116 (44.3%) 137 (51.8%)
OR
95%CI
p
1.27
0.89-1.83
0.18
Ulcer like Dismotility like Non specific
37 139 94
15 (40.5%) 72 (51.8%) 53 (56.4%)
1.21 1.69
0.55-2.69 0.74-3.88
0.63 0.22
Conclusions: The rate of Hp infection in subjects with dyspeptic symptoms was higher than in controls, but the difference was not statistically significant. Besides, no difference was found in Hp infection rates according to symptomatic subgroups. G1017 HIGHER SEROPREVALENCE OF HELICOBACTER PYLORI INFECTION (HE) IN PROCTOLOGISTS THAN IN ENT SPECIALISTS: ONE EVIDENCE SUPPORTING THE FECAL-ORAL ROUTE OF TRANSMISSION. J. O!mos; H. Rios; R. Higa; N. Chopita; O. Gadea; R. Pedrana; A. Podio; V. Pigatto; L. Soifer. Hospital Italiano, Buenos Aires, ARGENTINA Background: Person to person transmission is currently considered the main via of acquiring Hp infection, and the proposed routes are oral-oral and the fecal-oral. However, the relative importance of both infection routes is still unclear. Some physicians are more exposed than others to Hp acquisition due to their professional activity. Aim: To assess Hp prevalence among ENT specialists and proctologists, who are exposed to oral-oral and fecal-oral routes of infection, respectively. Subjects and methods: Forty male ENT specialists age ~ 44.4 _+ 11.0 and 40 male proctologists, age $ 47.2-+ 10.9 were evaluated. Both groups were matched with a control group by age, gender, education level and socioeconomic status. The control group was formed by 80 male subjects, age 44.9 -+ 10.6. The infection status was assessed with a quick serological test (Flex-pack Hp test). Odds ratio (OR), 95% confidence interval (95%CI) and Fisher's test were used to validate the results. Results: Hp prevalence among ENT specialists was 47.5% (19/40), 60% (24/40) among proctologists, and 36.25% in the control group (29/80). When the data of the controls were matched with those of the proctologists, the results were: OR=2.64 (95% CI=1.13-6.21) p=0.02; and when matched with the E.N.T. specialists group the results were: OR=1.59 (95% CI=0.68-3.68) p=0.24, (NS). When both groups of professionals were compared between each other, the results were: OR=l.66 (95% CI=0.62-4.44) p=0.37, (NS). Conclusions: Although HP prevalence among ENT specialists and proctologists is higher than in the control group the difference was only statistically significant for the proctologists. On the other hand, Hp prevalence among these professionals is higher than among ENT specialists, but the difference was not significant probably due to the sample size. These findings support the evidence of the fecal-oral route. • G1018 COMBINED EMPIRIC TREATMENT AND SPECIFIC H. PYLORI SCREENING AND TREATMENT DECREASE THE COST OF EVALUATING EPIGASTRIC ABDOMINAL PAIN. AD Olson, D Deutsch. Univ. of Michigan, Ann Arbor, MI; Univ. of Illinois, Rockford, Illinosis
We used a decision analysis program to evaluate the cost effectiveness of common strategies applied to patients with abdominal pain suggestive of peptic ulcer disease. H. pylori serology and treatment (HP-SER&Rx),
H. pylori C13 breath test and treatment (HP-BT&Rx), and an empiric trial of H2 blocking agent (empiric H2 trial) were utilized in our diagnostic strategies. The diagnostic strategies evaluated included: EGD; HP-SER&Rx, an empiric H2 trial, HP-BT&Rx, and the combination of HP-SER&Rx and HP-BT&Rx with an empiric H2 trial. The decision analysis program evaluated the preferred diagnostic treatment utilizing cost as a negative utility for each workup. Baseline cost assumptions included: EGD, $1180; H. pylori serology, $80; treatment ofH. pylori infection of $180; and cost of an empiric H2 trial with Zantac, $160. Baseline assumptions included a response to empiric H2 trial of 70% in patients who are H. pylori negative and an incidence of H. pylori .40. All patients with residual or recurrent pain following their treatment strategy underwent EGD. An empiric H2 trial combined with either HP-SER&Rx or HP-BT&Rx were the preferred strategies with a cost of $576. The combination of an empiric H2 trial with eithei: HP-SER&Rx or HP-BT&Rx as specific tests for H. pylori were each significantly less expensive than either an empiric H2 trial ($797), HP-SER&Rx ($958) or HP-BT&Rx ($1032) alone. The costs of each strategy was directly dependent on the number of patients requiring EGD. When an empiric H2 trial, HP-SER&Rx or HP-BT&Rx were done alone 54%, 67% or 73% of patients underwent endoscopy. When an empiric H2 trial was combined with either HP-SER&Rx or HP-BT&Rx the number of patients undergoing EGD decreased to less than 27%. The decision analysis was sensitive to the percent of patients responding to an empiric H2 trial, the incidence of H. pylori and to the cost of EGD. When compared to the strategies of EGDs HP-SER&Rx, or HP/BT&Rx alone, the combination of an empiric H2 trial, and specific screening and treatment for H. pylori avoid 75% and 40% of EGDs and reduced the cost of diagnosis and treatment by 50% and 40% respectively. A combined empiric H2 trial with specific screening and treatment for H. pylori is the most cost effective evaluation of patients with abdominal pain examined. G1019 THE SPECTRUM OF EOSINOPHILIC ESOPHAGITIS IN CHILDREN. SR Orenstein. H Mousa, C Di Lorenzo, SA Kocoshis, PE Putnam, JF del Rosario, L Sigurdsson, TM Shalaby. Pediatric Gastroenterology, Univ Pittsburgh School of Medicine & Children's Hospital of Pittsburgh, PA. Defining eosinophilic esophagitis as > 5 eosinophils per high power field (hpf), we identified 32 children (evaluated between 1 and 19 years of age) who had had eosinophilic esophagitis on biopsies of the distal esophageal epithelium performed during the years 1993-7. Data were obtained by chart review, follow-up telephone interview, review of endoscopic and radiographic images, and dual-observer (SRO, TMS) blinded scoring of biopsies of esophagus, antrum, and duodenum. RESULTS: The 32 children (28 male) developed symptoms at a median age of 4 years (0-19 years), and were evaluated at a median age of 7 years (1-19 years). The most common presenting symptoms were vomiting (23) and abdominal or chest pain (14). An impressive number had strictures (3), food impactions in the absence of strictures (5), and dysphagia in the absence of strictures or manometric abnormalities (2). Asthma or other chronic respiratory symptoms (17), food allergies by history (13) and/or testing (17 of 25 tested), peripheral eosinophilia (25% of those tested), or elevated serum lgE (50% of those tested) were common, but not universally identified. A distinctive endoscopic manifestation, identifiable reliably without knowledge of the histology, was a granular, furrowed, occasionally ringed appearance of the esophageal mucosa, without erosions or other mucosal breaks. The distal esophagus demonstrated a median of 25 eosinophils/hpf (range 5-150). Association with eosinophilic infiltration of antrum (median 3 eosinophils/hpf, range 0-150) or duodenum (median 20/hpf, range 0-200) was variable. Of the 32 children, 2 had a history of "pyloric stenosis." There was little evidence for pathogenic gastroesophageal reflux: 2/2 nuclear scans showed postprandial reflux, but 4/4 pH probe studies were normal and 24/26 upper gastrointestinal fluoroscopies were negative for excessive reflux. Therapeutic benefit was found for dietary elimination (11/15), cromolyn sodium(6/8), or steroids (9/10), when they were tried. CONCLUSION: Eosinophilic esophagitis is in the continuum of eosinophilic gastroenteropathy, and may produce severe symptoms treatable as manifestations of food allergy in some, predominantly male, children. It is identifiable grossly at endoscopy by a characteristic granular, furrowed, ringed appearance, not previously ascribed to it. Recognition of this entity as distinct from gastroesophageal reflux disease will likely improve our diagnosis and therapy of these children. G1020 DIFFERENTIAL EXPRESSION OF CYTOKERATIN SUBSETS IN BARRETT'S ESOPHAGUS VERSUS INTESTINAL METAPLASIA OF THE STOMACH. AH Ormsbv. JR Goldblum, TW Rice, TL Gramlich, The Cleveland Clinic Foundation, Cleveland, OH Cytokeratins are a group of structural proteins present in epithelial ceils that are expressed in different profiles based on tissue differentiation. The columnar-lined esophagus with intestinal metaplasia (Barrett's esophagus) and intestinal metaplasia of the gastric mucosa are two histologicallY indistinguishable abnormalities that are associated with the development of