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Journal of Gastroenterology Apr 2021The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an...
The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an English version. The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs). Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers. Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence.
Topics: Humans; Anti-Bacterial Agents; Evidence-Based Practice; Japan; Peptic Ulcer; Proton Pump Inhibitors
PubMed: 33620586
DOI: 10.1007/s00535-021-01769-0 -
Clinical Therapeutics Nov 2017While corticosteroids are relatively inexpensive and commonly used as treatment for a variety of conditions, long-term use is known to be associated with certain... (Review)
Review
PURPOSE
While corticosteroids are relatively inexpensive and commonly used as treatment for a variety of conditions, long-term use is known to be associated with certain toxicities. Prior systematic reviews have revealed an increased risk for costly adverse events (AEs), including bone fracture, infection, and gastrointestinal bleeding. The objective of this study was to conduct a systematic literature review of recent publications on the burden of long-term corticosteroid exposure, specifically, to summarize the AEs and economic impact of long-term corticosteroid use and to reveal data gaps for additional research.
METHODS
The Ovid search platform was used to access scientific literature databases. The search strategy targeted the use of corticosteroids and economic outcomes research. Articles were restricted to those published between 2007 and 2016 to cover publications since prior reviews; conference abstracts and articles assessing pediatrics were excluded. Titles and abstracts resulting from inclusion criteria were screened, and reviewers independently extracted relevant information from the relevant full-text articles.
FINDINGS
The literature review included 32 articles, with 75% focusing on autoimmune diseases, asthma, or lung diseases. Included articles were 14 database analyses, 6 simulations, 6 clinical trials, 3 systematic literature reviews, 2 patient surveys, and 1 chart review. Commonly-cited AEs associated with long-term corticosteroid exposure included hypertension (prevalence >30%); bone fracture (21%-30%); cataract (1%-3%); nausea, vomiting, and other gastrointestinal conditions (1%-5%); and metabolic issues (eg, weight gain, hyperglycemia, and type 2 diabetes; cases had 4-fold the risk of controls). Association of dose and duration with increased AE risk is not well-quantified. AEs like peptic ulcer and myocardial infarction are particularly costly to payers (1-year cost of $21,825 and $26,472, respectively, in year-2009 USD). The few articles assessing the economic impact of corticosteroid use have found dose-related increases in health care resource utilization and costs, with per-annum incremental costs relative to nonusers ranging from $5700 in low-dose users (<7.5 mg/d) to $29,000 in high-dose users (>15 mg/d). Adherence to treatment guidelines on avoiding AEs (eg, prescribing of oral bisphosphonates, calcium, and vitamin D) remains low.
IMPLICATIONS
Although doses of long-term corticosteroids have fallen over the past several decades in response to AEs, dose reduction may not be a sufficient solution. Numerous AEs, some very costly, persist among long-term corticosteroid users, suggesting a need for further research to fill current data gaps, as well as a potential need for alternative treatment options.
Topics: Adrenal Cortex Hormones; Asthma; Costs and Cost Analysis; Diabetes Mellitus, Type 2; Gastrointestinal Diseases; Humans; Outcome Assessment, Health Care; Time Factors
PubMed: 29055500
DOI: 10.1016/j.clinthera.2017.09.011 -
Gastroenterologia Y Hepatologia May 2022Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last...
Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last iteration of Spanish consensus guidelines on H. pylori infection was conducted in 2016. Recent changes in therapeutic schemes along with increasing supporting evidence were key for developing the V Spanish Consensus Conference (May 2021). Fourteen experts performed a systematic review of the scientific evidence and developed a series of recommendations that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. An eradication therapy, when prescribed empirically, is considered acceptable when it reliably achieves, or preferably surpass, 90% cure rates. Currently, only quadruple therapies (with or without bismuth) and generally lasting 14 days, accomplish this goal in first- and second-line therapies. A non-bismuth quadruple concomitant regimen (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole) or a quadruple bismuth-based combination (proton pump inhibitor, bismuth, tetracycline, and metronidazole), are recommended as first-line regimens. Rescue therapies after eradication failure and management of H. pylori infection in peptic ulcer disease were also reviewed.
Topics: Amoxicillin; Anti-Bacterial Agents; Bismuth; Clarithromycin; Drug Therapy, Combination; Helicobacter Infections; Helicobacter pylori; Humans; Metronidazole; Peptic Ulcer; Proton Pump Inhibitors
PubMed: 34629204
DOI: 10.1016/j.gastrohep.2021.07.011 -
BMJ Open May 2014To assess whether corticosteroids are associated with increased risk of gastrointestinal bleeding or perforation. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To assess whether corticosteroids are associated with increased risk of gastrointestinal bleeding or perforation.
DESIGN
Systematic review and meta-analysis of randomised, double-blind, controlled trials comparing a corticosteroid to placebo for any medical condition or in healthy participants. Studies with steroids given either locally, as a single dose, or in crossover studies were excluded.
DATA SOURCES
Literature search using MEDLINE, EMBASE and Cochrane Database of Systematic Reviews between 1983 and 22 May 2013.
OUTCOME MEASURE
Outcome measures were the occurrence of gastrointestinal bleeding or perforation. Predefined subgroup analyses were carried out for disease severity, use of non-steroidal anti-inflammatory drugs (NSAIDs) or gastroprotective drugs, and history of peptic ulcer.
RESULTS
159 studies (N=33 253) were included. In total, 804 (2.4%) patients had a gastrointestinal bleeding or perforation (2.9% and 2.0% for corticosteroids and placebo). Corticosteroids increased the risk of gastrointestinal bleeding or perforation by 40% (OR 1.43, 95% CI 1.22 to 1.66). The risk was increased for hospitalised patients (OR 1.42, 95% CI 1.22 to 1.66). For patients in ambulatory care, the increased risk was not statistically significant (OR 1.63, 95% CI 0.42 to 6.34). Only 11 gastrointestinal bleeds or perforations occurred among 8651 patients in ambulatory care (0.13%). Increased risk was still present in subgroup analyses (studies with NSAID use excluded; OR 1.44, 95% CI 1.20 to 1.71, peptic ulcer as an exclusion criterion excluded; OR 1.47, 95% CI 1.21 to 1.78, and use of gastroprotective drugs excluded; OR 1.42, 95% CI 1.21 to 1.67).
CONCLUSIONS
Corticosteroid use was associated with increased risk of gastrointestinal bleeding and perforation. The increased risk was statistically significant for hospitalised patients only. For patients in ambulatory care, the total occurrence of bleeding or perforation was very low, and the increased risk was not statistically significant.
Topics: Adrenal Cortex Hormones; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Randomized Controlled Trials as Topic; Risk Assessment; Stomach Rupture
PubMed: 24833682
DOI: 10.1136/bmjopen-2013-004587 -
Critical Care (London, England) Jan 2018Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding. However, as to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pharmacologic stress ulcer prophylaxis (SUP) is recommended in critically ill patients with high risk of stress-related gastrointestinal (GI) bleeding. However, as to patients receiving enteral feeding, the preventive effect of SUP is not well-known. Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of pharmacologic SUP in enterally fed patients on stress-related GI bleeding and other clinical outcomes.
METHODS
We searched PubMed, Embase, and the Cochrane database from inception through 30 Sep 2017. Eligible trials were RCTs comparing pharmacologic SUP to either placebo or no prophylaxis in enterally fed patients in the ICU. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were explored.
RESULTS
Seven studies (n = 889 patients) were included. There was no statistically significant difference in GI bleeding (RR 0.80; 95% CI, 0.49 to 1.31, p = 0.37) between groups. This finding was confirmed by further subgroup analyses and sensitivity analysis. In addition, SUP had no effect on overall mortality (RR 1.21; 95% CI, 0.94 to 1.56, p = 0.14), Clostridium difficile infection (RR 0.89; 95% CI, 0.25 to 3.19, p = 0.86), length of stay in the ICU (MD 0.04 days; 95% CI, -0.79 to 0.87, p = 0.92), duration of mechanical ventilation (MD -0.38 days; 95% CI, -1.48 to 0.72, p = 0.50), but was associated with an increased risk of hospital-acquired pneumonia (RR 1.53; 95% CI, 1.04 to 2.27; p = 0.03).
CONCLUSIONS
Our results suggested that in patients receiving enteral feeding, pharmacologic SUP is not beneficial and combined interventions may even increase the risk of nosocomial pneumonia.
Topics: Clostridium Infections; Critical Care; Duodenal Ulcer; Enteral Nutrition; Gastrointestinal Hemorrhage; Histamine H2 Antagonists; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Peptic Ulcer; Respiration, Artificial; Risk Management; Time Factors
PubMed: 29374489
DOI: 10.1186/s13054-017-1937-1 -
Antibiotics (Basel, Switzerland) Jan 2023Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We... (Review)
Review
Ventilator-associated pneumonia (VAP) remains a common risk in mechanically ventilated patients. Different care bundles have been proposed to succeed VAP reduction. We aimed to identify the combined interventions that have been used to by ICUs worldwide from the implementation of "Institute for Healthcare Improvement Ventilator Bundle", i.e., from December 2004. A search was performed on the PubMed, Scopus and Science Direct databases. Finally, 38 studies met our inclusion criteria. The most common interventions monitored in the care bundles were sedation and weaning protocols, semi-recumbent positioning, oral and hand hygiene, peptic ulcer disease and deep venus thrombosis prophylaxis, subglottic suctioning, and cuff pressure control. Head-of-bed elevation was implemented by almost all studies, followed by oral hygiene, which was the second extensively used intervention. Four studies indicated a low VAP reduction, while 22 studies found an over 36% VAP decline, and in ten of them, the decrease was over 65%. Four of these studies indicated zero or nearly zero after intervention VAP rates. The studies with the highest VAP reduction adopted the "IHI Ventilator Bundle" combined with adequate endotracheal tube cuff pressure and subglottic suctioning. Multifaced techniques can lead to VAP reduction at a great extent. Multidisciplinary measures combined with long-lasting education programs and measurement of bundle's compliance should be the gold standard combination.
PubMed: 36830138
DOI: 10.3390/antibiotics12020227 -
The Journal of Trauma and Acute Care... Oct 2021There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and...
BACKGROUND
There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and inadequate repair is associated with high morbidity and mortality. The aim of this study was to carry out a systematic literature review of different surgical techniques used to treat large duodenal perforations, provide a narrative description of these techniques, and propose a framework for approaching this pathology.
METHODS
PubMed/MEDLINE database was searched for articles published in English between January 1, 1970, and December 1, 2020. Studies describing surgical techniques used to treat giant duodenal ulcer perforation and their outcomes in adult patients were included. No quantitative analysis was planned because of the heterogeneity across studies.
RESULTS
Out of 960 identified records, 25 studies were eligible for inclusion. Two randomized controlled trials, one case-control trial, three cohort studies, 14 case series, and 5 case reports were included. Eight main surgical approaches are described, ranging from simple damage-control operations, such as the omental plug and triple-tube techniques, all the way to complex resections, such as gastrectomy.
CONCLUSION
Evidence on surgical treatment of large duodenal defects is of poor quality, with the majority of studies corresponding to Oxford levels 3b-4. Current evidence does not support any single surgical technique as superior in terms of morbidity or mortality, but choice of technique should be guided by several factors including location of the perforation, degree of duodenal tissue loss, hemodynamic stability of the patient, as well as expertise of the operating surgeon.
LEVEL OF EVIDENCE
SR with more than two negative criteria, Level IV.
Topics: Duodenal Ulcer; Duodenum; Humans; Peptic Ulcer Perforation; Risk Factors
PubMed: 34254960
DOI: 10.1097/TA.0000000000003357 -
JAMA Internal Medicine Nov 2014Current guidelines recommend an intravenous bolus dose of a proton pump inhibitor (PPI) followed by continuous PPI infusion after endoscopic therapy in patients with... (Comparative Study)
Comparative Study Meta-Analysis Review
IMPORTANCE
Current guidelines recommend an intravenous bolus dose of a proton pump inhibitor (PPI) followed by continuous PPI infusion after endoscopic therapy in patients with high-risk bleeding ulcers. Substitution of intermittent PPI therapy, if similarly effective as bolus plus continuous-infusion PPI therapy, would decrease the PPI dose, costs, and resource use.
OBJECTIVE
To compare intermittent PPI therapy with the currently recommended bolus plus continuous-infusion PPI regimen for reduction of ulcer rebleeding.
DATA SOURCES
Searches included MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases through December 2013; US and European gastroenterology meeting abstracts from 2009 to 2013; and bibliographies of systematic reviews.
STUDY SELECTION
Randomized trials of patients with endoscopically treated high-risk bleeding ulcers (active bleeding, nonbleeding visible vessels, and adherent clots) comparing intermittent doses of PPIs and the currently recommended regimen (80-mg intravenous bolus dose of a PPI followed by an infusion of 8 mg/h for 72 hours).
DATA EXTRACTION AND SYNTHESIS
Duplicate independent data extraction and risk-of-bias assessment were performed. Data were pooled using a fixed-effects model or a random effects model if statistical heterogeneity was present.
MAIN OUTCOMES AND MEASURES
The primary outcome was rebleeding within 7 days; additional predefined outcomes included rebleeding within 3 and 30 days, need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay. The primary hypothesis, defined before initiation of the literature review, was that intermittent use of PPIs was noninferior to bolus plus continuous infusion of PPIs, with the noninferiority margin predefined as an absolute risk difference of 3%.
RESULTS
The risk ratio of rebleeding within 7 days for intermittent vs bolus plus continuous infusion of PPIs was 0.72 (upper boundary of 1-sided 95% CI, 0.97) and the absolute risk difference was -2.64% (upper boundary of 1-sided 95% CI, -0.28%, which is well below the predefined noninferiority margin of 3%). Risk ratios for rebleeding within 30 days and 3 days, mortality, and urgent interventions were less than 1 and mean differences for blood transfusion and hospital length of stay were less than 0, indicating that no summary estimate showed an increased risk with intermittent therapy. The upper boundaries of 95% CIs for absolute risk differences were less than 1.50% for all predefined rebleeding outcomes.
CONCLUSIONS AND RELEVANCE
Intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. Guidelines should be revised to recommend intermittent PPI therapy.
Topics: Humans; Infusions, Intravenous; Peptic Ulcer; Peptic Ulcer Hemorrhage; Proton Pump Inhibitors
PubMed: 25201154
DOI: 10.1001/jamainternmed.2014.4056 -
Journal of Gastrointestinal Surgery :... Jun 2023Marginal ulcer (MU) is a common complication following Roux-en-Y gastric bypass (RYGB) with an incidence rate of up to 25%. Several studies have evaluated different risk... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Marginal ulcer (MU) is a common complication following Roux-en-Y gastric bypass (RYGB) with an incidence rate of up to 25%. Several studies have evaluated different risk factors associated with MU with inconsistent findings. In this meta-analysis, we aimed to identify the predictors of MU after RYGB.
METHODS
A comprehensive literature search of PubMed, Embase, and Web of Science databases was conducted through April 2022. All studies that used a multivariate model to assess risk factors for MU after RYGB were included. Pooled odds ratios (OR) with 95% confidence intervals (CI) for risk factors reported in ≥ 3 studies were obtained within a random-effects model.
RESULTS
Fourteen studies with 344,829 patients who underwent RYGB were included. Eleven different risk factors were analyzed. Meta-analysis demonstrated that Helicobacter pylori (HP) infection (OR 4.97 [2.24-10.99]), smoking (OR 2.50 [1.76-3.54]), and diabetes mellitus (OR 1.80 [1.15-2.80]), were significant predictors of MU. Increased age, body mass index, female gender, obstructive sleep apnea, hypertension, and alcohol use were not predictors of MU. There was a trend of an increased risk of MU associated with nonsteroidal anti-inflammatory drugs (OR 2.43 [0.72-8.21]) and a lower risk of MU with proton pump inhibitors use (OR 0.44 [0.11-2.11]).
CONCLUSIONS
Smoking cessation, optimizing glycemic control, and eradication of HP infection reduce the risk of MU following RYGB. Recognition of predictors of MU after RYGB will allow physicians to identify high-risk patients, improve surgical outcomes, and reduce the risk of MU.
Topics: Humans; Female; Gastric Bypass; Peptic Ulcer; Risk Factors; Proton Pump Inhibitors; Hypertension; Obesity, Morbid; Retrospective Studies
PubMed: 36795250
DOI: 10.1007/s11605-023-05619-7 -
World Journal of Gastroenterology Mar 2016To evaluate whether Helicobacter pylori (H. pylori) eradication therapy benefits patients with functional dyspepsia (FD). (Meta-Analysis)
Meta-Analysis Review
AIM
To evaluate whether Helicobacter pylori (H. pylori) eradication therapy benefits patients with functional dyspepsia (FD).
METHODS
Randomized controlled trials (RCTs) investigating the efficacy and safety of H. pylori eradication therapy for patients with functional dyspepsia published in English (up to May 2015) were identified by searching PubMed, EMBASE, and The Cochrane Library. Pooled estimates were measured using the fixed or random effect model. Overall effect was expressed as a pooled risk ratio (RR) or a standard mean difference (SMD). All data were analyzed with Review Manager 5.3 and Stata 12.0.
RESULTS
This systematic review included 25 RCTs with a total of 5555 patients with FD. Twenty-three of these studies were used to evaluate the benefits of H. pylori eradication therapy for symptom improvement; the pooled RR was 1.23 (95%CI: 1.12-1.36, P < 0.0001). H. pylori eradication therapy demonstrated symptom improvement during long-term follow-up at ≥ 1 year (RR = 1.24; 95%CI: 1.12-1.37, P < 0.0001) but not during short-term follow-up at < 1 year (RR = 1.26; 95%CI: 0.83-1.92, P = 0.27). Seven studies showed no benefit of H. pylori eradication therapy on quality of life with an SMD of -0.01 (95%CI: -0.11 to 0.08, P = 0.80). Six studies demonstrated that H. pylori eradication therapy reduced the development of peptic ulcer disease compared to no eradication therapy (RR = 0.35; 95%CI: 0.18-0.68, P = 0.002). Eight studies showed that H. pylori eradication therapy increased the likelihood of treatment-related side effects compared to no eradication therapy (RR = 2.02; 95%CI: 1.12-3.65, P = 0.02). Ten studies demonstrated that patients who received H. pylori eradication therapy were more likely to obtain histologic resolution of chronic gastritis compared to those who did not receive eradication therapy (RR = 7.13; 95%CI: 3.68-13.81, P < 0.00001).
CONCLUSION
The decision to eradicate H. pylori in patients with functional dyspepsia requires individual assessment.
Topics: Adult; Anti-Bacterial Agents; Chi-Square Distribution; Drug Therapy, Combination; Dyspepsia; Female; Helicobacter Infections; Helicobacter pylori; Humans; Male; Middle Aged; Odds Ratio; Proton Pump Inhibitors; Remission Induction; Risk Factors; Treatment Outcome
PubMed: 27022230
DOI: 10.3748/wjg.v22.i12.3486