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Should we rely on rapid urease test or routine staining for the accurate diagnosis of helicobacter pylori
STOMACH AND DUODENUM 269
11271
SHOULD WE RELY ON RAPID UREASE TEST OR ROUTINE STAINING FOR THE ACCURATE DIAGNOSIS OF HELICOBACTER PYLORI RK Hsu MD M Chang MD, A Yu MD, B Yost* MD, B Ruebner* MD, JG Lee MD and JW Leung MD. Division of Gastroenterolgy and Department of Pathology*, University of California, Davis Medical Center, Sacramento CA Introduction Rapid Urease Test and histology are two common endoscopic tests for Hp detection. Discrepancies between these two tests can cause confusion in the actual diagnosis. In praetice, Genta stain is more sensitive than H&E and Giemsa stain but are not used in routine. The aim of this study is to examine the error rate of RUT and histology using routine staining as reference to the consensus results by pathologists with special interest in GI pathology. Method: Standard antral biopsy were obtained from 40 outpatients presented with ulcer and nonulcer dyspepsia using Wilson Cook Maxum biopsy forceps with cup diameter 2.5mm. The patients were not on treatment with proton pump inhibitors. The HP status was detected using Hpfast rapid urease test (RUT) and initial histology by routine H&E or Giemsa stain interpreted by general pathologists. The histology slides were then reviewed by two pathologists with special interest in GI pathology who were blinded to the initial results. Genta stain was used for the final diagnosis in doubtful cases. Using these consensus results as the gold standard, comparison of the error rate of RUT and general staining was made. The Hpfast RUT results were reevaluated independently by l0 different physicians and nurses. Results: (n = 40) Error rate with 95% Confident interval Group # error Rate SE U95 L95 RUT 16 0.4 0.l 0.9544 0.2614 H&E/Giemsa 4 0.1 0.05 0.2386 0.0307 The greatest discrepancies in the interpretation of Hpfast results were observed at the color change that were seen at the range of pH 5.8-6.5. Conclusions: 1. Inter-observational variability in the interpretation of color changes in Hpfast RUT in the marginal cases could be a factor for the discrepancies seen in routine practice. A single trained observer may avoid the problem. 2. When both tests agree with each other, the accuracy rate is 92%. 3. In doubtful cases with routine staining, Genta stain is required to confirm the diagnosis.
CURE Multicenter Randomized, Prospective Trial of Gold Probe vs. Injection & Gold Probe for Hemostasis of Bleeding Peptic Ulcers. Jensen D M Kovacs TOG, Jutabha R, Machicado GA, Savides T J, Smith J, Cheng S, Jensen ME, Gornbein J, King J. Los Angeles, New Orleans, and San Diego. This is an initial report of a blinded, prospective, multicanter trial of endoscopic therapies for ulcer hemostasis. Specific aims are 1) to determine whether combination therapy (epinephrine injection+Gold probe-INJ-GP) stops active ulcer bleeding (AB) or prevents rebleeding from non-bleeding visible vessels ( N B W ) more often than single therapy (GP alone) and 2) to report on results with a new device, the injector GP. 50 patients were stratified by AB (18 pts) or N B W (32 pts) and randomized to GP vs. INJ-GP, Results. Background variables of the groups were similar. See Table 1 (Means or %). Hypo=hypotension at admission; Prog. Score=prognosis score which increases with comorbid disease from 0 (excellent) to 6 (very poor). Table 1. # ~ Hvpo Proa Score Ulcer Dia Hct GP 25 59 48% 2.0 11.8 mm 23.5 INJ-GP 25 63 47% 2.2 13.1 mm 25.0 Other variables for GP vs. INJ-GP were: smokers (28% vs 18%), drinkers (32% vs 21%), recent NSAID &/or ASA ingestion (64% vs 65%) and H.pylori prevalence (28% vs 52%). A new INJ-GP was utilized in the last 10 pts and compared with separate injection and GP. Routine outcomes are in Table 2 (Means or %). URBC is units of red cells transfused; Hosp=days hospitalized after randomization; Rate dc is the rating (1 excellent to 4 death) at discharge. Table 2. Results at 30 Davs After Randomization Rx Rebld Fail Sura Death uRBc Hoso Rate dc GP 12% 20% 12% 8% 0,6• 7.0_+1.6 1.4+0.2 INJGP 18% 9% 9% 0% 1.0_+0.5 8.2+1.8 1.1+0.1 Conclusions: For patients with major stigmata of hemorrhage: 1) To date none of these results are significantly different. However, there are arithmetically lower rates of failure, surgery, and death for the combination treated patients. 2) The new INJ-GP was easier and faster to use than separate injection plus GP, especially for active bleeding, 3) no major complications occurred, and 4) there was a low prevalence of H,pylori infection for GU's (58%) and DU's (33%) but a high prevalence of NSAID or ASA ingestion (64-70%).
$270
$272
DIAGNOSTIC YIELD OF ENDOSCOPY IN ANTICOAGULATED PATIENTS WITH GASTROINTESTINAL BLEEDING [GIB]. G Isenboro. A Chak, GS Cooper. University Hospitalsof Cleveland,CaseWesternReserveUniversity,Cleveland,OH. Sacknrnund Previousinvestigations of GIB in patients receiving anticoagulant therapy report identifiable etiologies in only 30-40% of cases, but diagnostic evaluation included radiographic studiesand incomplete endoscopicevaluationof the gastrointestinal tract. To date, there are no adequate prospectiveendoscopicstudies of frank and occult GIB n patients on anticoagulanttherapy. Methods We prospectivelyassessedthe diagnosticyield of endoscopyin patients > 18 yrs old on heparinor Coumadinfor > 48 hourswho presentedwith overtsignsof GIB or guaiacpositive stool associatedwith a 2 g/dL decreasein hemoglobin.Patients initially underwent esophagogestroduodenoscopy[EGD] if they had hematemesis, a positive NG aspirate, or melena associated with upper GI symptoms. All other pts underwent colonescopyand if nondiagnostic, an EGDwas performed. If no etiology was identified after EGD/colonoscopy, an enteroscopy was performed. Significant upper GI tract lesions were defined as esophagitis (grade 2 or more), gastric ~icer [GU], duodenal ulcer [DU], malignancy, or esophageal varices, hemorrhagic gastritis or duodenitis, or arteriovenous malformations [AVMs] (if no other source identified). Significant lower GI tract lesions were definedas malignancy, polyps > lcm, diverticula or AVMs (if associated with active bleedingor a positive ongiogram/nuclearmedicine study), or hemorrhoids(if active bleedingseen). All pts were followedfor 6 monthsafter evaluation. Results 69 pts (mean age 82.5, 48 men, 20 women, mean INR 2.23 on admit] were enrolled. 36/38 pts with overtUGIBhad an etiologyfound on EGD,including 19 (56%] with gastritis/gastric erosions/benignGU, 10 (30%) with DU, 7 (18%) with esophagitis, and 1 (3%) with gastric cancer.Enteroscopywas performed on 2 pts with normal EGDswith 1 pt revealing a bleedingduodenalAVM. 19/31 pts who underwent initial colonoscopyrevealed 12 (63%) pts with large colon polyps, 3 (16%) pts with colon cancer, 3 (16%) pts with diverticula, and 1 (5%) pt with hemorrhoids, The remaining 12 pts with nondiagnostic colonoscopiesunderwentEGD: 5 (42%) had gastritis/gastric erosions/benignGU, 3 (25%) had DU, 2 (17%) hod esophagitis. 3 pts with normal colon/EGDunderwententoroscopy(the other pt declined)with no etiology found. At 6 month follow-up, there was no evidenceof recurrentbleedingfollowingtreatmentof the abovelesions. Conclusions [1] Contraryto previousstudies, endoscopicevaluationidentified 91% of the etiologies of GIB in anticoagulatedpatients, [2] malignancy was found in 6% of patients evaluated, [3] most lesions found are remediablewith no recurrent bleeding at 6 month follow-up, and [4] enterescopyhas a limited yield in identifying a potential sourcefor GIB in anticoagulatodpatients.
Gastrointestinal Bleeding (GIB) of Obscure Origin in an Era of Managed Care and Push Enteroscopy. Jensen DM. Kovaca TOG, Jutabha R, Cheng S, Jensen ME, King J, Fontana L, Stone LJ. CURE, West L A V A Med. Ctr. and UCLA, Los Angeles. CA. In our managed care area, ~)atients with recurrent GIB of obscure origin often have multiple tests and hospitalizations before referral for tertiary care evaluation and enteroscopy. Our purposes in this study were: 1) to delineate the diagnosis and treatments before vs. after our GI consultation and enteroscopy, 2) to evaluate the possible reasons that diagnoses were not made previously by gastroenterologists, and 3) to describe the patients' and referral physicians' initial responses to our diagnosis and treatment plans. Methods: 71 consecutive patients with recurrent GIB of obscure etiology who were referred had prospective evaluation and push entemscopies (Pentax 3400 L video). Prior GIB, hospitalizations, transfusions, and tests were verified with medical and blood bank records by study nurses. Standard forms and SAS were utilized for data management. Diagnoses and management after entemscopy were discussed with patients and referring physicians and their responses were rated as favorable, incredulous, or neutral. Results: 1~ diagnoses at enteroscopy were: angioma 47.9% (jejunalo JJ-19.7%, duodenum-duo-21.2Vo, gastdc 7%), Cameron ulcers 9.9%, ulcer-erosions 7%, Watermelon Stomach-WMS-5.6%, JJ Ca-polyp 5.6%, JJ ulcer 2.8%, Dieulafoy's 1.4%, other 2.9% and no diagnosis 16.9%. Reasons for referral MD's not making the dx in 58 pts who had a dx during enterescopy were: 1) location in post-bulbar duo (25.8%), 2) JJ location (34.5%), or 3) UGI lesion not recognized on EGD &/or bx (39.6%). Based upon our findings, a change in specific therapy was made in 83% of patients (endoscopic treatments 64.9%, surgery or angiography 8.5% and medical 19.7%). The response of pts (& referral MD's) was favorable 85% (vs. 65%), neutral 15% (25%), or incredulous 0% (15%). Conclusions: 1) GI angiomas were the most prevalent cause of obscure GIB, accounting for 47.9 o%. 2) Lesions within reach of EGD were not diagnosed in 39.6% of referrals, because these were not recognized (WMS, Cameron ulcers) or missed (ulcers, Dieulafoy's, angiomas). 3) Specific management changed in 83% of patients based upon our diagnoses. 4) 85% of patients had favorable responses but 40% of referral physicians had neutral or incredulous responses to our diagnoses & recommendations.
AB92
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997
11271
SHOULD WE RELY ON RAPID UREASE TEST OR ROUTINE STAINING FOR THE ACCURATE DIAGNOSIS OF HELICOBACTER PYLORI RK Hsu MD M Chang MD, A Yu MD, B Yost* MD, B Ruebner* MD, JG Lee MD and JW Leung MD. Division of Gastroenterolgy and Department of Pathology*, University of California, Davis Medical Center, Sacramento CA Introduction Rapid Urease Test and histology are two common endoscopic tests for Hp detection. Discrepancies between these two tests can cause confusion in the actual diagnosis. In praetice, Genta stain is more sensitive than H&E and Giemsa stain but are not used in routine. The aim of this study is to examine the error rate of RUT and histology using routine staining as reference to the consensus results by pathologists with special interest in GI pathology. Method: Standard antral biopsy were obtained from 40 outpatients presented with ulcer and nonulcer dyspepsia using Wilson Cook Maxum biopsy forceps with cup diameter 2.5mm. The patients were not on treatment with proton pump inhibitors. The HP status was detected using Hpfast rapid urease test (RUT) and initial histology by routine H&E or Giemsa stain interpreted by general pathologists. The histology slides were then reviewed by two pathologists with special interest in GI pathology who were blinded to the initial results. Genta stain was used for the final diagnosis in doubtful cases. Using these consensus results as the gold standard, comparison of the error rate of RUT and general staining was made. The Hpfast RUT results were reevaluated independently by l0 different physicians and nurses. Results: (n = 40) Error rate with 95% Confident interval Group # error Rate SE U95 L95 RUT 16 0.4 0.l 0.9544 0.2614 H&E/Giemsa 4 0.1 0.05 0.2386 0.0307 The greatest discrepancies in the interpretation of Hpfast results were observed at the color change that were seen at the range of pH 5.8-6.5. Conclusions: 1. Inter-observational variability in the interpretation of color changes in Hpfast RUT in the marginal cases could be a factor for the discrepancies seen in routine practice. A single trained observer may avoid the problem. 2. When both tests agree with each other, the accuracy rate is 92%. 3. In doubtful cases with routine staining, Genta stain is required to confirm the diagnosis.
CURE Multicenter Randomized, Prospective Trial of Gold Probe vs. Injection & Gold Probe for Hemostasis of Bleeding Peptic Ulcers. Jensen D M Kovacs TOG, Jutabha R, Machicado GA, Savides T J, Smith J, Cheng S, Jensen ME, Gornbein J, King J. Los Angeles, New Orleans, and San Diego. This is an initial report of a blinded, prospective, multicanter trial of endoscopic therapies for ulcer hemostasis. Specific aims are 1) to determine whether combination therapy (epinephrine injection+Gold probe-INJ-GP) stops active ulcer bleeding (AB) or prevents rebleeding from non-bleeding visible vessels ( N B W ) more often than single therapy (GP alone) and 2) to report on results with a new device, the injector GP. 50 patients were stratified by AB (18 pts) or N B W (32 pts) and randomized to GP vs. INJ-GP, Results. Background variables of the groups were similar. See Table 1 (Means or %). Hypo=hypotension at admission; Prog. Score=prognosis score which increases with comorbid disease from 0 (excellent) to 6 (very poor). Table 1. # ~ Hvpo Proa Score Ulcer Dia Hct GP 25 59 48% 2.0 11.8 mm 23.5 INJ-GP 25 63 47% 2.2 13.1 mm 25.0 Other variables for GP vs. INJ-GP were: smokers (28% vs 18%), drinkers (32% vs 21%), recent NSAID &/or ASA ingestion (64% vs 65%) and H.pylori prevalence (28% vs 52%). A new INJ-GP was utilized in the last 10 pts and compared with separate injection and GP. Routine outcomes are in Table 2 (Means or %). URBC is units of red cells transfused; Hosp=days hospitalized after randomization; Rate dc is the rating (1 excellent to 4 death) at discharge. Table 2. Results at 30 Davs After Randomization Rx Rebld Fail Sura Death uRBc Hoso Rate dc GP 12% 20% 12% 8% 0,6• 7.0_+1.6 1.4+0.2 INJGP 18% 9% 9% 0% 1.0_+0.5 8.2+1.8 1.1+0.1 Conclusions: For patients with major stigmata of hemorrhage: 1) To date none of these results are significantly different. However, there are arithmetically lower rates of failure, surgery, and death for the combination treated patients. 2) The new INJ-GP was easier and faster to use than separate injection plus GP, especially for active bleeding, 3) no major complications occurred, and 4) there was a low prevalence of H,pylori infection for GU's (58%) and DU's (33%) but a high prevalence of NSAID or ASA ingestion (64-70%).
$270
$272
DIAGNOSTIC YIELD OF ENDOSCOPY IN ANTICOAGULATED PATIENTS WITH GASTROINTESTINAL BLEEDING [GIB]. G Isenboro. A Chak, GS Cooper. University Hospitalsof Cleveland,CaseWesternReserveUniversity,Cleveland,OH. Sacknrnund Previousinvestigations of GIB in patients receiving anticoagulant therapy report identifiable etiologies in only 30-40% of cases, but diagnostic evaluation included radiographic studiesand incomplete endoscopicevaluationof the gastrointestinal tract. To date, there are no adequate prospectiveendoscopicstudies of frank and occult GIB n patients on anticoagulanttherapy. Methods We prospectivelyassessedthe diagnosticyield of endoscopyin patients > 18 yrs old on heparinor Coumadinfor > 48 hourswho presentedwith overtsignsof GIB or guaiacpositive stool associatedwith a 2 g/dL decreasein hemoglobin.Patients initially underwent esophagogestroduodenoscopy[EGD] if they had hematemesis, a positive NG aspirate, or melena associated with upper GI symptoms. All other pts underwent colonescopyand if nondiagnostic, an EGDwas performed. If no etiology was identified after EGD/colonoscopy, an enteroscopy was performed. Significant upper GI tract lesions were defined as esophagitis (grade 2 or more), gastric ~icer [GU], duodenal ulcer [DU], malignancy, or esophageal varices, hemorrhagic gastritis or duodenitis, or arteriovenous malformations [AVMs] (if no other source identified). Significant lower GI tract lesions were definedas malignancy, polyps > lcm, diverticula or AVMs (if associated with active bleedingor a positive ongiogram/nuclearmedicine study), or hemorrhoids(if active bleedingseen). All pts were followedfor 6 monthsafter evaluation. Results 69 pts (mean age 82.5, 48 men, 20 women, mean INR 2.23 on admit] were enrolled. 36/38 pts with overtUGIBhad an etiologyfound on EGD,including 19 (56%] with gastritis/gastric erosions/benignGU, 10 (30%) with DU, 7 (18%) with esophagitis, and 1 (3%) with gastric cancer.Enteroscopywas performed on 2 pts with normal EGDswith 1 pt revealing a bleedingduodenalAVM. 19/31 pts who underwent initial colonoscopyrevealed 12 (63%) pts with large colon polyps, 3 (16%) pts with colon cancer, 3 (16%) pts with diverticula, and 1 (5%) pt with hemorrhoids, The remaining 12 pts with nondiagnostic colonoscopiesunderwentEGD: 5 (42%) had gastritis/gastric erosions/benignGU, 3 (25%) had DU, 2 (17%) hod esophagitis. 3 pts with normal colon/EGDunderwententoroscopy(the other pt declined)with no etiology found. At 6 month follow-up, there was no evidenceof recurrentbleedingfollowingtreatmentof the abovelesions. Conclusions [1] Contraryto previousstudies, endoscopicevaluationidentified 91% of the etiologies of GIB in anticoagulatedpatients, [2] malignancy was found in 6% of patients evaluated, [3] most lesions found are remediablewith no recurrent bleeding at 6 month follow-up, and [4] enterescopyhas a limited yield in identifying a potential sourcefor GIB in anticoagulatodpatients.
Gastrointestinal Bleeding (GIB) of Obscure Origin in an Era of Managed Care and Push Enteroscopy. Jensen DM. Kovaca TOG, Jutabha R, Cheng S, Jensen ME, King J, Fontana L, Stone LJ. CURE, West L A V A Med. Ctr. and UCLA, Los Angeles. CA. In our managed care area, ~)atients with recurrent GIB of obscure origin often have multiple tests and hospitalizations before referral for tertiary care evaluation and enteroscopy. Our purposes in this study were: 1) to delineate the diagnosis and treatments before vs. after our GI consultation and enteroscopy, 2) to evaluate the possible reasons that diagnoses were not made previously by gastroenterologists, and 3) to describe the patients' and referral physicians' initial responses to our diagnosis and treatment plans. Methods: 71 consecutive patients with recurrent GIB of obscure etiology who were referred had prospective evaluation and push entemscopies (Pentax 3400 L video). Prior GIB, hospitalizations, transfusions, and tests were verified with medical and blood bank records by study nurses. Standard forms and SAS were utilized for data management. Diagnoses and management after entemscopy were discussed with patients and referring physicians and their responses were rated as favorable, incredulous, or neutral. Results: 1~ diagnoses at enteroscopy were: angioma 47.9% (jejunalo JJ-19.7%, duodenum-duo-21.2Vo, gastdc 7%), Cameron ulcers 9.9%, ulcer-erosions 7%, Watermelon Stomach-WMS-5.6%, JJ Ca-polyp 5.6%, JJ ulcer 2.8%, Dieulafoy's 1.4%, other 2.9% and no diagnosis 16.9%. Reasons for referral MD's not making the dx in 58 pts who had a dx during enterescopy were: 1) location in post-bulbar duo (25.8%), 2) JJ location (34.5%), or 3) UGI lesion not recognized on EGD &/or bx (39.6%). Based upon our findings, a change in specific therapy was made in 83% of patients (endoscopic treatments 64.9%, surgery or angiography 8.5% and medical 19.7%). The response of pts (& referral MD's) was favorable 85% (vs. 65%), neutral 15% (25%), or incredulous 0% (15%). Conclusions: 1) GI angiomas were the most prevalent cause of obscure GIB, accounting for 47.9 o%. 2) Lesions within reach of EGD were not diagnosed in 39.6% of referrals, because these were not recognized (WMS, Cameron ulcers) or missed (ulcers, Dieulafoy's, angiomas). 3) Specific management changed in 83% of patients based upon our diagnoses. 4) 85% of patients had favorable responses but 40% of referral physicians had neutral or incredulous responses to our diagnoses & recommendations.
AB92
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997