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N Vakil

Publications and source records attributed to N Vakil.

At least 19 recordsLinked to original sources
PubMed2006

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report.

BACKGROUND: Guidelines on the management of Helicobacter pylori, which cover indications for management and treatment strategies, were produced in 2000. AIMS: To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer. RESULTS: Eradication of H pylori infection is recommended in (a) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; (b) patients with atrophic gastritis; (c) first degree relatives of patients with gastric cancer; (d) patients with unexplained iron deficiency anaemia; and (e) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a "test and treat" strategy if other causes are excluded. Eradication of H pylori infection (a) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and (b) may prevent peptic ulcer in patients who are naïve users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility. CONCLUSION: The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.

Adult↗
PubMed2006

Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro-oesophageal reflux disease in Western patients with non-ulcer dyspepsia.

BACKGROUND: The effect of Helicobacter pylori eradication on the development of gastro-oesophageal reflux disease is controversial. Aim To determine the incidence of symptoms of reflux disease and of erosive oesophagitis, and the relationship to changes in histological gastritis, in patients with non-ulcer dyspepsia over 12 months. METHODS: Six hundred and ninety-three patients in two similar randomized placebo controlled trials of H. pylori eradication in non-ulcer dyspepsia were studied. Symptoms were assessed using the validated Gastrointestinal Symptom Rating Scale during a 1-week run-in period, at 6 months and 12 months. Endoscopy was performed at baseline to exclude patients with pathology and at 3 months and 12 months to determine if oesophagitis was present. Gastric biopsies were scored using the modified Sydney Classification. RESULTS: Patients without predominant heartburn, oesophagitis or ulcers at endoscopy were randomized to active (n = 297, omeprazole, amoxicillin and clarithromycin) treatment or to placebo/omeprazole (n = 306) for 1 week. The eradication rate was 82% in the active treatment group. Antrum-predominant gastritis (55%) was more frequently found than corpus-predominant gastritis (6%). In patients with antrum-predominant gastritis, heartburn and regurgitation scores improved significantly 12 months after eradication. Erosive oesophagitis developed in 15/232 patients in the eradication group (7%) compared with 2/227 (2%) in the control group, but there was no significant difference when adjusted for oesophagitis present at baseline. CONCLUSIONS: Antrum-predominant gastritis is the most common pattern of gastritis seen in non-ulcer dyspepsia in Western populations. Heartburn and regurgitation improve after eradication therapy or placebo in patients with non-ulcer dyspepsia; the development of oesophagitis is uncommon.

Adolescent↗
PubMed2006

Emergent management of ruptured pericallosal-callosomarginal artery aneurysm using stent-assisted coil embolization.

We present a case of a ruptured bilobed pericallosal aneurysm successfully treated with coil embolization through a Neuroform stent. A 48-year-old male presented with subarachnoid hemorrhage (SAH) following rupture of a previously clipped aneurysm at the bifurcation of the pericallosal and callosomarginal arteries, primarily along the pericallosal artery, Hunt and Hess grade 5. After an initial unsuccessful attempt to embolize the wide-neck aneurysm with a detachable coil, a 4x15 Neuroform stent was uneventfully deployed across the aneurysm neck followed by successful coil embolization using detachable coils. We believe this case describes the first successful use of the Neuroform stent to assist in coiling of a wide-neck pericallosal-callosomarginal aneurysm. This case highlights the expanding role of emergency endovascular therapies to manage severe SAH.

Aneurysm, Ruptured↗
PubMed2006

The effect of over-the-counter ranitidine 75 mg on night-time heartburn in patients with erosive oesophagitis on daily proton pump inhibitor maintenance therapy.

BACKGROUND: H2-receptor antagonists are widely used with proton pump inhibitors. AIM: To determine if H2-receptor antagonists used in conjunction with proton pump inhibitors were effective for nocturnal heartburn in patients taking proton pump inhibitors. METHODS: We evaluated 386 patients with erosive oesophagitis documented at endoscopy who were receiving single daily maintenance proton pump inhibitor therapy to determine if they had symptoms of nocturnal heartburn. Patients with two or more episodes of night-time a week were invited to participate in the study. Patients were randomly assigned to a single dose of an over-the-counter preparation of ranitidine 75 mg at bedtime or matching placebo for 14 days. RESULTS: The prevalence of nocturnal symptoms was 10.6%. Mean symptom scores on the first day of the trial (baseline) were similar between the treatment group (1.1 +/- 0.9) and the placebo group (1.1 +/- 1.1). On day 3, symptom scores were significantly lower in the ranitidine group (0.71 +/- 0.69) compared with the control group (1.4 +/- 1.2; P = 0.045). On day 14, mean symptom scores were similar in the ranitidine group (0.82 +/- 0.95) and the control group (1 +/- 0.84). CONCLUSIONS: Nocturnal heartburn is uncommon on proton pump inhibitor therapy; the addition of ranitidine at bedtime resulted in a decrease in symptom scores on day 3 but there were no differences on day 14.

Esophagitis, Peptic↗
PubMed2006

Pretreatment endoscopy--pro & contra: is endoscopy needed before treatment in all patients with gastroesophageal reflux disease?

The role of endoscopy in reflux disease has changed from being primarily diagnostic to one of risk management. Objective studies of routine endoscopy have shown little change in outcomes after the examination. Screening and surveillance for Barrett's esophagus is still an unconfirmed strategy. In most developed countries, including western Europe and North America, middle-aged patients (over the age of 50) with gastroesophageal reflux disease would benefit more from colonoscopy than upper endoscopy.

Barrett Esophagus↗
PubMed2005

The cost-effectiveness of biomarkers for predicting the development of oesophageal adenocarcinoma.

BACKGROUND: The recommended surveillance strategy for oesophageal adenocarcinoma may prevent as few as 50% of cancer deaths. Tissue biomarkers have been proposed to identify high-risk patients. AIM: To determine performance characteristics of an ideal biomarker, or panel of biomarkers, that would make its use more cost-effective than the current surveillance strategy. METHODS: We created a Markov model using data from published literature, and performed a cost-utility analysis. The population consisted of 50-year-old Caucasian men with gastro-oesophageal reflux, who were monitored until age 80. We examined strategies of observation only, current practice (dysplasia-guided surveillance), surveillance every 3 months for patients with a positive biomarker (biomarker-guided surveillance), and oesophagectomy immediately for a positive biomarker (biomarker-guided oesophagectomy). The primary outcome was the threshold cost and performance characteristics needed for a biomarker to be more cost-effective than current practice. RESULTS: Regardless of the cost, the biomarker needs to be at least 95% specific for biomarker-guided oesophagectomy to be cost-effective. For biomarker-guided surveillance to be cost-effective, a $100 biomarker could be 80% sensitive and specific. CONCLUSIONS: Biomarkers predicting the development of oesophageal adenocarcinoma would need to be fairly accurate and inexpensive to be cost-effective. These results should guide the development of biomarkers for oesophageal adenocarcinoma.

Adenocarcinoma↗
PubMed2005

Review article: how valuable are proton-pump inhibitors in establishing a diagnosis of gastro-oesophageal reflux disease?

Diagnostic studies for gastro-oesophageal reflux disease (endoscopy, pH testing) have significant limitations. A short trial of acid suppression with a proton-pump inhibitor is often used in clinical practice as a diagnostic test for gastro-oesophageal reflux disease. If there is a significant improvement in symptoms, the patient is considered to have gastro-oesophageal reflux disease. Several studies have evaluated the administration of proton-pump inhibitors as a diagnostic test for gastro-oesophageal reflux disease. A recent meta-analysis found that response to a proton-pump inhibitor had limited value as a diagnostic test. Likelihood ratios for a positive test ranged from 0.45 to 1.86. The positive predictive value of the test ranged from 0.17 to 0.90 and the negative predictive value from 0.17 to 1, depending on the gold standard against which comparisons were made. These results may be explained by the inadequacy of the gold standard against which the proton-pump inhibitor test is compared or by the inability of acid suppression to differentiate between gastro-oesophageal reflux disease, peptic ulcer disease or dyspepsia. Although a trial of acid suppression may have pragmatic value in clinical practice, the proton-pump inhibitor test is not an accurate test for the diagnosis of gastro-oesophageal reflux disease.

Diagnosis, Differential↗
PubMed2005

Comprehension and awareness of symptoms in women with dyspepsia.

BACKGROUND: Overlapping symptoms of gastro-oesophageal reflux disease and dyspepsia are a problem for physicians and patients. AIM: This study explored comprehension of dyspepsia symptoms and associated medical terminology among women with symptoms of dyspepsia. METHODS: The US women aged > or = 18 years with dyspepsia (defined by Rome II criteria) were recruited in two phases, via direct mail, the Internet, clinical investigators and/or gastroenterologists. In phase I, subjects took part in an hour-long telephonic interview comprising open-ended questions relating to symptom frequency/duration, triggers/patterns and severity. During phase II, subjects took part in a 45-min telephonic interview, which explored their understanding of dyspepsia symptoms and their predominant or most bothersome symptom. RESULTS: Subjects with 'pure' dyspepsia (without overlapping symptoms of gastro-oesophageal reflux disease or irritable bowel syndrome) were sought, but of 777 subjects screened, most were excluded because of gastrointestinal comorbidities (irritable bowel syndrome, gastro-oesophageal reflux disease). Only 85 (11%) subjects had 'pure' dyspepsia of whom 11 withdrew. Of the 74 subjects interviewed, 70% were unfamiliar with the term 'dyspepsia'. Subjects reported several symptoms, including bloating (65%), gas (50%), nausea (41%) and discomfort (36%). Most subjects could distinguish between symptom bothersomeness and severity, and between pain and discomfort. Terms such as 'satisfactory relief', 'central upper abdominal discomfort', 'early satiety' and 'postmeal fullness' were often misunderstood. CONCLUSIONS: Subjects with 'pure' dyspepsia are rare, because of comorbidities. Dyspepsia-related terminology is often misunderstood by subjects.

Adult↗
PubMed2004

Symptomatic gastro-oesophageal reflux, arousals and sleep quality in patients undergoing polysomnography for possible obstructive sleep apnoea.

INTRODUCTION: Nocturnal acid reflux is common and could disturb sleep by causing arousals that fragment sleep. AIM: To determine the prevalence of gastro-oesophageal reflux symptoms and their association with arousals, stages of sleep and quality of life in patients undergoing evaluation for excessive daytime sleepiness and obstructive sleep apnoea. METHODS: Ninety-four consecutive patients with excessive daytime sleepiness were prospectively studied. Patients completed the gastrointestinal symptom rating scale, a validated symptom questionnaire for reflux disease and a disease-specific quality of life questionnaire, the sleep apnoea quality of life index and then underwent overnight polysomnography, which was read in a blinded manner. RESULTS: There were 40 males and 54 females with a mean age of 47 +/- 13 years. Reflux symptoms were present in 63 of the 94 (67%) patients. Patients with reflux symptoms had significantly more arousals from sleep 43 +/- 70/h than those without (20 +/- 24/h; P = 0.03). The sleep duration during the second stage of sleep was shorter (44 +/- 21%) for those with reflux symptoms than those without (52 +/- 12%; P = 0.03). Patients with reflux spent significantly shorter periods in stage II sleep (44 +/- 21%) than those without (52 +/- 12%; P = 0.03). The sleep-related quality of life score in patients with gastro-oesophageal reflux (3.1 +/- 1.1) was significantly lower than in patients without reflux (3.7 +/- 1.0; P = 0.02). Regression analysis demonstrated a significant inverse correlation between quality of life and reflux symptom score (P =0.002) and total spontaneous arousals (P = 0.04). CONCLUSIONS: Gastro-oesophageal reflux is common in patients with sleep disorders, is associated with increased arousal, decreased durations spent in the deeper stages of sleep and poorer sleep-related quality of life.

Arousal↗
PubMed2004

Seven-day therapy for Helicobacter pylori in the United States.

BACKGROUND: The ideal duration of Helicobacter pylori treatment in the United States and whether eradication therapy is as successful in nonulcer dyspepsia as in peptic ulcer disease are controversial topics. AIM: This study compared the efficacy of 3-, 7- and 10-day triple therapies with rabeprazole to a 10-day omeprazole control triple therapy for the eradication of Helicobacter pylori in patients with and without peptic ulcer disease in the United States. METHODS: This was a multicentre, double-blind, randomized, parallel-group trial. A total of 803 patients with H. pylori infection (determined by [13C]urea breath test and rapid urease test or culture) received either rabeprazole 20 mg b.d., amoxicillin 1000 mg b.d., and clarithromycin 500 mg b.d. for 3, 7, or 10 days, or 10 days of omeprazole 20 mg b.d. with the same antibiotic regimen (control). H. pylori status was assessed by [13C]urea breath test > or =6 weeks after completing treatment. RESULTS: In intent-to-treat patients, the eradication percentages achieved for the rabeprazole-based treatments were: 3-day, 27% (95% confidence interval: 21%-34%); 7-day, 77% (95% confidence interval: 71%-83%); and 10-day, 78% (95% confidence interval: 72%-84%). The eradication percentage with the 10-day omeprazole-based treatment was 73% (95% confidence interval: 67%-79%). There was no statistically significant difference between the 7-day rabeprazole-based regimen and the 10-day rabeprazole- and omeprazole-based regimens. CONCLUSIONS: Seven-day therapy with rabeprazole, clarithromycin, and amoxicillin is similar in efficacy to 10-day therapies and had similar efficacy in patients with and without ulcer disease.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2004

Review article: new pharmacological agents for the treatment of gastro-oesophageal reflux disease.

Proton pump inhibitors, which act at the terminal point of acid secretion--the H+, K+-ATPase--are currently the most effective pharmacological treatments available for reflux disease. Despite the efficacy of the proton pump inhibitors, there is still potential for clinical improvement in gastro-oesophageal reflux disease pharmacotherapy. Faster onset of complete acid inhibition and improved duration of efficacy are two potential areas for improvement A number of novel pharmaceutical agents are currently undergoing clinical evaluation for the treatment of gastro-oesophageal reflux disease. These include transient lower oesophageal sphincter relaxation-reducing agents, serotonergic agents/prokinetics, potassium-competitive acid blockers, mucosal protectants, histamine H3 agonists and anti-gastrin agents. One or more of these drug groups may represent the future medical therapy for gastro-oesophageal reflux disease, should they prove effective in the clinical setting. This review summarizes the state of the art with these agents.

Gastric Mucosa↗
PubMed2004

Symptom evaluation in reflux disease: workshop background, processes, terminology, recommendations, and discussion outputs.

There has been no published indepth systematic evaluation of the best approaches to symptom evaluation in gastro-oesophageal reflux disease (GORD). A two day international multidisciplinary workshop was therefore held in Marrakech, Morocco, in September 2002 to address these issues. The aim of the workshop was to critically review the data regarding the reliability, processes, and priorities for symptom evaluation in GORD patients. The workshop was designed to give outputs that could be readily reported and to arrive at specific recommendations on best practice in symptom evaluation in reflux disease.

Adenocarcinoma↗
PubMed2003

Direct comparative trials of the efficacy of proton pump inhibitors in the management of gastro-oesophageal reflux disease and peptic ulcer disease.

BACKGROUND: Five proton pump inhibitors are now available for use in North America. Claims of differences in the clinical efficacy of different strengths and/or agents have been made. AIM: To identify any consistent evidence of differences in outcomes between agents or doses within this class of drugs. METHODS: A search of the medical literature was performed in two electronic databases, and randomized controlled trials of higher quality were included in the assessment. RESULTS AND CONCLUSIONS: Thirty-two trials met our criteria. No convincing data were found to indicate that low doses of proton pump inhibitors are as effective as standard doses of proton pump inhibitors in the healing of erosive oesophagitis or in the relief of symptoms of gastro-oesophageal reflux disease; however, they may be as effective as maintenance therapy for gastro-oesophageal reflux disease and peptic ulcer disease. Differences were found between the standard doses of proton pump inhibitors with regard to the onset of symptom relief in gastro-oesophageal reflux disease (lansoprazole was faster than omeprazole, and esomeprazole was faster than both lansoprazole and omeprazole) and the healing of oesophagitis (esomeprazole was superior to both omeprazole and lansoprazole). Despite these differences, there are as yet insufficient data to establish the superiority of any one agent over all others across all disease states treated with these agents.

Anti-Ulcer Agents↗
PubMed2003

Review article: endoscopic treatments for gastro-oesophageal reflux disease.

A number of endoscopic techniques have been described for the treatment of reflux disease. These include endoscopic plicators, which place submucosal or transmural sutures around the lower oesophageal sphincter, the Stretta procedure, which places minute areas of thermal injury in the muscle of the lower oesophageal sphincter and cardia, and injection techniques, in which inert substances are injected into the mucosa or the muscle of the lower oesophagus. The mechanism of action of these procedures has been studied to varying degrees. The Stretta procedure is the only endoscopic technique that has been shown to be effective in a sham-controlled trial. Complication rates are generally low, but serious complications have been reported in some cases. The results with some of these techniques are promising, but all procedures described to date are limited by the absence of large, rigorously controlled trials against a form of treatment that has been proven to be both safe and effective (medical therapy). Future studies will need to use controls, validated outcome measures and pre-determined end-points and to provide comparative and long-term data.

Biomarkers↗
PubMed2003

A rapid, low-dose, 13C-urea tablet for the detection of Helicobacter pylori infection before and after treatment.

BACKGROUND: A new urea breath test (UBT) has been described which uses a tablet formulation of 13C-urea with citric acid and allows breath sampling to be performed as early as 10 min after ingestion of the tablet. AIM: To assess the diagnostic accuracy of tablet-based 13C-UBTs (50 and 100 mg 13C-urea) before and after Helicobacter pylori eradication treatment, compared with an endoscopy gold standard and a conventional 13C-UBT (75 mg 13C-urea). METHODS: Two hundred dyspeptic patients underwent endoscopy, followed by tablet-based 13C-UBTs (50 and 100 mg 13C-urea) and a conventional 13C-UBT (75 mg 13C-urea). H. pylori-infected patients were prescribed treatment and asked to return 4-6 weeks after the end of therapy for repeat endoscopy and 13C-UBTs. RESULTS: One hundred and thirteen patients were infected with H. pylori. The sensitivity and specificity of the conventional 13C-UBT were both 100%; the sensitivity and specificity of the 100-mg tablet-based 13C-UBT were 100% and 98.85%, respectively. For the 50-mg tablet-based 13C-UBT, cut-off values of the difference over baseline of between 1.65 and 3.15 provided a sensitivity and specificity of 100%. At follow-up, the sensitivity and specificity of the conventional and 100-mg tablet-based 13C-UBTs were both 100%. For the 50-mg tablet-based 13C-UBT, cut-off values of the difference over baseline of between 1.49 and 1.56 gave a sensitivity and specificity of 100%. CONCLUSIONS: New 10-min 13C-UBTs using tablet formulations of 13C-urea with citric acid are reliable for the assessment of H. pylori status pre- and post-treatment.

Biopsy↗
PubMed2003

Health-related anxiety and the effect of open-access endoscopy in US patients with dyspepsia.

BACKGROUND: The role of endoscopy in dyspepsia is the subject of debate. The detection of lesions is infrequent, but patients may benefit from the knowledge that the examination is normal. We sought to determine the prevalence of health-related anxiety in dyspeptic patients referred for open-access endoscopy and to investigate the effect of endoscopy on health-related anxiety. METHODS: Consecutive patients referred for open-access endoscopy from primary care were studied using a validated questionnaire for health-related anxiety before and after endoscopy, at 1 month and 6 months. Symptoms were assessed using a validated questionnaire at 1 and 6 months. RESULTS: One hundred and nine patients were studied (69 women and 40 men; mean age, 49 +/- 15 years). Thirty-six of the 109 patients (33%) had high anxiety scores at baseline (mean score, 41 +/- 1), which decreased after endoscopy to 35 +/- 1 (P < 0.05). The changes persisted at 1 month (33 +/- 1) and 6 months (33 +/- 1). Endoscopic findings were as follows: normal examination, 120; erosive oesophagitis, 11 (Grade A); erosive duodenitis (all Helicobacter pylori-negative), 6. Scales for preoccupation with health and fear of illness and death showed significant improvement after endoscopy, and the effects were preserved for 6 months. Anxiety scores in our population were substantially higher than in a corresponding UK population. CONCLUSIONS: Health-related anxiety is common in dyspeptic patients referred for endoscopy. Endoscopy decreases the preoccupation with health and fear of illness and death in patients with severe anxiety, and the effects persist for 6 months.

Anxiety↗
PubMed2003

High eradication rates of Helicobacter pylori with a new sequential treatment.

BACKGROUND: Eradication rates of Helicobacter pylori with standard triple therapy are disappointing, and studies from several countries confirm this poor performance. AIM: To assess the eradication rate of a new sequential treatment regimen compared with conventional triple therapy for the eradication of H. pylori infection. METHODS: One thousand and forty-nine dyspeptic patients were studied prospectively. H. pylori-infected patients were randomized to receive 10-day sequential therapy [rabeprazole (40 mg daily) plus amoxicillin (1 g twice daily) for the first 5 days, followed by rabeprazole (20 mg), clarithromycin (500 mg) and tinidazole (500 mg) twice daily for the remaining 5 days] or standard 7-day therapy [corrected] [rabeprazole (20 mg), clarithromycin (500 mg) and amoxicillin (1 g) twice daily]. H. pylori status was assessed by histology, rapid urease test and 13C-urea breath test at baseline and 6 weeks or more after completion of treatment. RESULTS: Higher eradication rates were found with the sequential regimen compared to the standard regimen (intention-to-treat: 92% vs. 74%, P < 0.0001; per protocol: 95% vs. 77%, P < 0.0001). Higher eradication rates were also seen in patients with peptic ulcer disease and non-ulcer dyspepsia. In both treatments, compliance was similar (> 90%), as was the rate of side-effects, which were mild. CONCLUSIONS: This 10-day sequential treatment regimen achieves high eradication rates in peptic ulcer disease and non-ulcer dyspepsia.

2-Pyridinylmethylsulfinylbenzimidazoles↗