Gastritis is closely related with gastric cancer, Peptic ulcer and functional dyspepsia


 Positive H. Pylori does not mean peptic ulcer or gastric cancer

Gastritis is closely related with gastric cancer, 
Peptic ulcer and functional dyspepsia

If gastric cancer is identified in early state, it can be
taken out by endoscopic procedures-Dr. Ken Haruma

PU should be diagnosed on history, physical examination,
lab values and on endoscopy-Wasim Jafri

KARACHI: Gastritis is an important disease as it is closely related with gastric cancer, peptic ulcer and functional dyspepsia. Hence, improvement and stability of defensive factors which includes prostaglandin, mucus and blood supply are extremely important for the treatment as well as prevention for mucosal damages and gastritis. Rebamipide is an extremely useful mucoprotective agent for the treatment of gastritis and prevention of NSAIDs/Aspirin induced mucosal damages besides Proton Pump Inhibitors (PPIs) induced Gastropathy. This was stated by Dr. Ken Haruma, Chairperson Kawasaki Medical School and Kawasaki University of Medical Welfare from Japan. He was speaking at a scientific meeting organized by Otsuka Pakistan through Webinar on June 28th 2018. These meetings were simultaneously organized in major cities of Pakistan.

The seminar at Karachi was chaired by Prof. S. M. Wasim Jafri an eminent Gastroenterologist from Aga Khan University Hospital. The guest speakers and members of the expert’s panel included Prof. Bader Faiyaz Zuberi from Dow University of Health Sciences, Prof. Dr. S. M, Zahid Azam also from DUHS, Dr. Mahfouz Alam consultant rheumatologist and Prof. Saeed Minhas a noted orthopedic surgeon from JPMC Karachi.

Otsuka Pakistan organized a scientific seminar at Karachi recently in connection with their newly launched product Rebamipide. Photograph taken on the occasion shows Prof. Wasim Jafri
(3rd form left) chairing the session. Also siting on the dais from (L to R) the speakers and panel
of experts are Prof. Saeed Minhas, Prof. Bader Fiyaz Zuberi, Prof. Zahid Azam and Dr. Mahfouz Alam.

In his presentation Dr. Ken Haruma first talked about the history of this drug Rebamipide (Mucosta), described the Shay’s balance theory and also talked about the mechanism of peptic ulcer disease. Decrease of defense factors, he opined, was important. In Japan, acid is completely controlled. Prolonged use of NSAIDs can cause diarrhea, abdominal pain. He also talked about PPI induced Gastropathy. Rebamipide, he said, is being used in many countries for the treatment of gastritis. It also prevents drug induced gastritis. He also referred to the gastric acid secretion between Japan and other Western countries. Gastric Acid secretion, he said, reduces with age. One should use combination therapy adding PPIs with this agent.

He highlighted the findings from a study wherein patients suffering from Rheumatoid Arthritis and Osteoarthritis used this drug for over twelve weeks with other medications and there was no GI bleeding due to the protective effects of Rebamipide. This agent is also effective in organic dyspepsia and improves symptoms in functional dyspepsia. Its effects on PPI induced Gastropathy were also highlighted. He further stated that in Japan there is mass screening for gastric cancer with precise examination. One can find discolored lesions on mass screening. If gastric cancer is identified at early stage, it can be taken out by endoscopic procedures, he added. Continuing Dr. Ken Haruma pointed out that there are about thirty five million people with H. Pylori in Japan and the prevalence of gastric cancer is also highest in Japan. In high risk groups, early diagnosis of gastric cancer, he stated, was extremely important. Complete eradication therapy for H. Pylori decreases the risk of gastric cancer. In addition, prompt improvement of infection is also seen with H. Pylori eradication therapy, he added.

Continuing Dr. Ken Haruma said that Rebamipide (Mucosta), also improves inflammation. He then shared a few cases, elderly male suffering from gastric ulcer with bleeding. They were taking NSAIDs and Aspirin. With the use of this drug, they improved. In another study, after two years use of PPIs, multiple polyps were found. In another patient PPIs were used to treat Aspirin induced mucosal damage. The patient had black spots, pigmentation which is seen if the patient are taking PPIs for more than six months. He concluded his presentation by stating that Gastritis was an important disease and Rebamipide (Mucosta) is quite safe and effective mucoprotective agent.

Prof. Bader Fiyaz Zuberi in his presentation on prevalence of peptic acid diseases in Pakistan said that in the past it was highly prevalence but now its prevalence has reduced. The use of Omeprazole has also reduced peptic ulcer surgery to a great extent. It is an ulcer of gastrointestinal tract mostly acidic with erosions. The patients have typical burning and pain. Its incidence has changed a lot. About two decades ago it used to be said that once an ulcer, always an ulcer but it was no more the case. The precipitating factors include H. Pylori infection, increasing use of NSAIDs. It accounts for 0.83% of total deaths in Pakistan. A study conducted at JPMC in 2014 had showed silent perforation of 77%. NSAIDs associated with ulcer disease is common. It is associated with gastric and duodenal ulcer. H.Pylori is the common infection. Duodenal ulcer is also quite common. Often there are co-morbid Non H. Pylori infection. We need to revise drug therapy for this disease though the current practices are also successful. We may be able to reduce the duration of treatment, number of tablets being taken can also be reduced. May be in future one stat dose takes care of the disease. Previously the patient needed to be treated for four week but now two weeks therapy is also considered satisfactory. We need to look for much better, safe, effective drugs with least side effects. We need to continue our efforts for much better management of this disease, he remarked.

. Prof. Wasim Jafri presenting mementoes to the speakers at the Otsuka Pakistan scientific meeting held
at Karachi recently from L to R) Prof. Bader Fiyaz Zuberi, Prof. Zahid Azam, and Dr. Mahfouz Alam
while on extreme right Prof. Shamsudidn is presenting the memento to Prof. Wasim Jafri.

Dr. Mahfouz Alam discussed management of NSAIDs induced Gastritis and Gastric Ulcer. He discussed at length how commonly NSAIDs are used, their side effects in GI tract even with short term use. He was of the view that we need to prevent and minimize the use of NSAIDs induced gastritis, check misuse of NSAIDs. At present its consumption through OTC in United States was thirty billion tablets while one hundred million tablets are prescribed. Their side effects include dyspepsia, esophagitis, esophageal strictures, gastritis, erosions, ulceration, bleeding perforation, gastric and duodenal Petechiae esophagitis. NSAIDs use also leads to mucosal ulceration.

Speaking about the risk factors for NSAIDs induced Gastropathy, he mentioned age, ulcer history, dose of NSAIDs, steroid therapy besides smoking. Monitoring of these patients, Dr. Mahfouz Alam opined was essential otherwise they might end up with serious problems. That is why treating physicians must ensure proper follow up. Dose of NSAIDs being used was also important. Sometime more than therapeutic dose is used or at times more than one NSAIDs is prescribed at the same time. If need be it is advisable to add central acting narcotic and analgesics, he added.

All painful disorders, Dr. Mahfouz Alam stated are not necessarily inflammatory in nature, hence one does not need to use NSAIDS all the time. One can alleviate pain with some other drugs. NSAIDs, he opined, should be reserved for those patients with inflammatory disorders. One can use NSAIDs for one to two weeks. After its use for more than four weeks, gastric injury is noted. He then talked about risk of hospitalization after upper GI bleeding with Coxibs. NSAIDs risk of hospitalization is highest if the patients are taking these medications without any protection. The lowest incidence of upper GI bleeding is if the patients do not take the NSAIDs at all, he remarked. Now Misoprostol, Rebamipide are available. In order to have real impact, we have to use the full anti-inflammatory dose of these drugs which is 200-220mg per day. We can reduce acid with H2ARA, PPIs can be used for ulcer healing, and one can avoid NSAIDs or use alternate Cox2 inhibitors. Use of PPIs with NSAIDs is more common and there are serious problems with long term use of NSAIDs. Many a times the use of Cox2 inhibitors and PPIs is not justified, hence it is better to avoid it or reduce the dose of PPI as well, he added.

Prof. Zahid Azam’s presentation was on New Insights in management of H. Pylori infection. This, he stated, was a very common GI infection. All the healthcare professionals come across this. People are scared of this infection as they think it may be gastric cancer or lymphoma. When they get positive H. Pylori results, the patients come to us. He then discussed the natural history of H. Pylori infection, H.Pylori induced gastric inflammation and gastric cancer. He also discussed the management of two cases one of which was of dyspepsia.

He also referred to the Guidelines by American College of Gastroenterologists regarding management of undiagnosed dyspepsia and functional dyspepsia. Risk factors for H. Pylori acquired infection he said include people in the poor socio economic group, increased number of siblings, infected parents, contaminated water supply. Patients on ASA and NSAIDs should be treated. Similarly patients with positive peptic ulcer disease also needs treatment. Patients with GERD without PU disease should also be treated. Triple therapy is quite effective which leads to eradication of H. pylori in 85-90% of the cases. At times four drugs may have to be used. One can use different antimicrobials in different combinations. Take care of resistance to various antibiotics. The treatment can be for five to seven days or in some cases it may be continued for ten to fourteen days. The treating physician must ask himself/herself have I eradicated H. pylori infection?. Do not recheck the patient time and again but those suffering from gastric ulcer or lymphoma may need to be re-checked. UBT, fecal antigen test, biopsy based testing were discussed at length. These tests, he said, should be done one to two weeks after stopping of PPIs. Document eradication after at least four week’s therapy. Know the resistance to various antimicrobial agents and avoid using antibiotics used previously. Probiotics are healthy bacteria. They are also being used for H. Pylori eradication but the data is not yet strong enough so far, he added. Cut off point for upper GI endoscopy was sixty years but if there are symptoms, then do investigate. Red flags include low hemoglobin and in such cases undertake proper investigations.

During the discussion it was pointed out that food habits, life style modification were important. Taking meals at wrong time, may lead to some disorders. Role of Dietary restrictions, smoking and alcohol use was also discussed. Prof. Saeed Minhas remarked that one should take full breakfast and then take early dinner which was quite common in China. Timing of the meal is very important because sometime people suffer at night. Safety and efficacy of Rebamipide (Mucosta), in inflammatory bowel disorders and pregnancy was also highlighted. Prof. Saeed Minhas also laid stress on good history taking and physical examination before writing the prescription. Prof. Bader Fiyaz Zuberi laid emphasis on proper diagnosis of peptic ulcer before starting treatment. Prof. Zahid Azam said one should be careful of melena, weight loss. Positive history of gastric cancer should be tested and treated. Dr. Mahfouz Alam stressed the judicious use of NSAIDs in painful disorders. Prof. Shamsudidn from Nawabshah said that most often NSAIDs are the cause of GI upset. When the patient has ulcer, they have to be careful about their diet.

Prof.S.M.Wasim Jafri in his concluding remarks thanked all the presenters for their informative talks. Peptic Ulcer, he said, was an entity which needs to be properly diagnosed. PU is not for life. It is treated and cured. One might see acidity but ulcer is not there all the time. Ulcers heal naturally. With the use of acid suppressing agents, the healing is accelerated. He reiterated that serology for H. Pylori should not be repeated. Positive H.Pylori is not Peptic ulcer which is a definite diagnosis. Peptic Ulcer should be diagnosed on history, physical examination, lab values and on endoscopy. Positive H. Pylori does not mean peptic ulcer or gastric ulcer. PU should be a definite diagnosis. In the days to come and during emergency, we will have more usage of drugs like Rebamipide. For reflex esophagitis, we need further studies. Positive RA factor should also not be treated as Rheumatoid Arthritis. Always ensure precise diagnosis. Rebamipide is a new addition to this class of drugs and we must ensure intelligent use of these medications, he remarked.

The theme of the seminar was “Changing perceptions”. In his introductory remarks Mr. Moin stated that Otsuka started its operations in Pakistan in 1988 with IV solutions and medical devices. We are now marketing a new drug after almost a decade. This molecule provides total gastric protection.