Management of non-variceal upper gastrointestinal tract hemorrhage:Controversies and areas of uncertainty

Upper gastrointestinal tract hemorrhage （UGIH） remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease （PUD） has revolutionized the treatment of UGIH. Despite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor （PPI） therapy has become standard empiric treatment for UGIH given that PUD is the leading cause of non variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. Howeve, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patientswith evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today＇s medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper en- doscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low risk lesions or admission for further moni toring and treatment in higher risk lesions. Concomitant pharmacotherapy with non steroidal antiinflammatory drugs （NSAIDs） and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severib/, and potential treatment of UGIH. Long term PPI use in patients taking chronic NSAIDs or clopidogrel is discussed thoroughly in this review.

Itopride therapy for functional dyspepsia:A meta-analysis

AIM:To evaluate the therapeutic effects of itopride vs other drugs(placebo,domperidone,mosapride) for functional dyspepsia(FD).METHODS:Randomized controlled trials(RCTs) of itopride for FD were retrieved from databases.Relevant information was extracted and analyzed,using the relative risk(RR) and weighted mean deviation,as appropriate.A random or fixed effect model was used,based on the heterogeneity of the included articles,and visual inspection of funnel plots was used to evaluate publication bias.RESULTS:Nine RCTs enrolling 2620 FD cases were included;1372 cases received itopride treatment and 1248 cases received placebo or other drugs(control groups).Compared with control groups,itopride had superior RR values of 1.11 [95%CI:(1.03,1.19),P = 0.006],1.21 [95%CI:(1.03,1.44),P = 0.02],and1.24 [95%CI:(1.01,1.53),P = 0.04] for global patient assessment,postprandial fullness,and early satiety,respectively.For the Leeds Dyspepsia Questionnaire score,the weighted mean deviation was-1.38 [95%CI:(-1.75,-1.01),P < 0.01].The incidence of adverse effects was similar in the itopride and control groups.The funnel plots for all indicators showed no evidence of publication bias.CONCLUSION:Itopride has good efficacy in terms of global patients assessment,postprandial fullness,and early satiety in the treatment of patients with FD and shows a low rate of adverse reactions.Itopride can greatly improve FD syndromes-score.

Lubiprostone:Clinical applications beyond constipation

In comparison to polyethylene glycol,lubiprostone offers other advantages and is increasingly being used as an adjunctive agent in diagnostic as well as management strategies not only in gastroenterology, but in other fields.For instance,lubiprostone exerts beneficial effects in cystic fibrosis tissues.It augmernts the chloride secretion in these cells by activating non-cystic fibrosis transmembrane regulator(CFTR) secretion of chloride by afflicted respiratory epithelia. Lubiprostone also seems to improve visualization of the gastrointestinal tract during procedures such as colonoscopy.This is especially true if the lubiprostone is administered prior to bowel cleansing with agents such as polyethylene glycol electrolyte(PEG-E). Lubiprostone also enhances and stimulates contraction in colonic as well as gastric muscles and may thus further contribute as a prokinetic agent.Besides these effects,lubiprostone also causes hyperpolarization in other tissues such as uterine muscle cells.This may prove to be of significant clinical benefit in the management of uterine pathologies in the near future.

Treatment of pediatric Ogilvie’s syndrome with low-dose erythromycin:A case report

Acute colonic pseudo-obstruction is a poorly understood syndrome, characterized by the signs, symptoms and radiological pattern of a large bowel obstruction without evidence for a mechanical obstruction. We report a case of a 2-year old boy who presented with progressive abdominal distention, vomiting and abdominal pain on postoperative d 3. Plain abdominal X-ray showed markedly dilated large bowel. Mechanical colonic obstruction was ruled out with hypaque enema. Ogilvie＇s syndrome was suspected. The patient received treatment with oral erythromycin which had an immediate beneficial effect. During the 6 mo follow-up, no recurrences of symptoms were observed. We provide a safe and effective therapy for Ogilvie＇s syndrome in pediatric individuals.

Current developments in pharmacological therapeutics for chronic constipation

Chronic constipation is a common gastrointestinal disease severely affecting the patient's quality of life. The traditional treatment of constipation is the use of laxatives. Recently, several new drugs including lubiprostone, linaclotide and prucalopride have been approved for treatment of chronic constipation. However, a significant unmet medical need still remains, particularly among those patients achieving poor results by current therapies. The 5-EF1'1 receptor modulators velusetrag and naronapride, the guanylate cy-clase C agonist plecanatide and die deal bile acid transporter inhibitor elobixibat are recognized as the most promising drugs under investigation. Herein, we give a comprehensive review on the pharmacological therapeutics for the treatment of chronic constipation, with the purpose of reflecting the drug development trends in this field. (C) 2015 Chinese Pharmaceutical Association and Institute of Materia Medica, Chinese Academy of Medical Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.orgicenses/by-ne-rid/4.0/).