BOOK REVIEWS

Infections of the , pylori, although more inclusive about clinical presen- 2nd Edition tation, seemed somewhat lacking. For example, the Blaser MJ, Smith PD, Ravdin JI et al, eds section on diagnosis did not mention the importance Lippincott, Williams and Wilkins, 2002 of prevalence on the accuracy of serology. Although ISBN: 0-7817-2847-9; $170.00 the authors state that proton pump inhibitor therapy Infections of the Gastrointestinal Tract is a compre- can cause false negative urea breath test and rapid ure- hensive multi-authored text of over 1300 pages cover- ase test, no specific recommendations were given as ing luminal infection of the mostly adult gastrointesti- to what to do with such patients. Finally most chapters nal tract excluding the liver and . The text only briefly mention the possible role of endoscopy in is logically organized into ten different sections (a total evaluating gastrointestinal infections. For example, of 81 chapters) with the first three sections covering the otherwise excellent chapter on C. difficile s t a t e d epidemiology, physiology, and pathogenesis; the next that endoscopy is rarely used for diagnosis; in my two sections covering gastrointestinal syndromes in experience the reflexive reaction to inpatient immunocompetent and immunocompromised hosts; by most internists and surgeons is to order stool stud- and section six covering gastric infections, the bulk of ies and a flexible sigmoidoscopy knowing that one which is on H. pylori. The remainder of the book is can often get an endoscopy faster than a stool study. composed of detailed discussions of various infectious The chapters on H. pylori mentioned that multiple agents in section 7 followed by diagnosis, therapy, and biopsies are often required for diagnosis but does not prevention and control. discuss where or how; for example in patients with Infections of the Gastrointestinal Tr a c t is an infec- recent antibiotic use, proton pump inhibitor use, and tious diseases textbook rather than a bleeding. In my opinion, Infections of the Gastro i n - is an excellent reference resource for text with emphasis on infectious diseases—not surpris- testinal Tract most practicing gastroenterologists who have ques- ing given that most of the authors and editors are infec- tions about infectious organisms, especially about the tious diseases specialists rather than gastroenterologists. laboratory aspects, but those looking for a compre- Infections of the Gastrointestinal Tract is the only hensive clinical discussion about the infection syn- book a practicing gastroenterologist will ever need if dromes could probably obtain the same information he or she desires information on the bugs and drugs in from any gastroenterology textbook. the gut. For example, the chapter on Norwalk virus John Lee. MD contained everything I ever wanted to know about the Irvine, CA viral structure, genome (including a map of the capsid protein), and virulence of the organism. The chapter on Whipple’s disease was similarly detailed and com- : A Textbook of , prehensive enough to prepare a fellow lecture on the 4th Edition subject. On the other hand many chapters present a Zakim D and Boyer J, eds relatively cursory discussion of clinical symptoms, W. B. Saunders, Philadelphia, PA, 2003 something which I suppose is not unreasonable since ISBN: 0-7216-9051-3; $325 most the viral infections cause self-limited diarrhea. No gastroenterology library is complete without at least Still the brief paragraph on Norwalk agent didn’t one of the two standard hepatology texts. Of course, seem to paint a clear picture of the viral illness, some- Zakim and Boyer’s Hepatology: A Textbook of Liver thing which many of my patients had seen on the six D i s e a s e is one of them. Now in its fourth edition, this o’clock news and inquired about. In my opinion, the reference remains essential and timely. The editors main deficiency of most of the chapters is the lack of have again assembled an array of authors with expertise clinical information about the infection relative to the that spans from the basic science of liver cell biology, detailed presentations on the laboratory findings of b i o c h e m i s t r y, and physiology to the clinical art and sci- the infectious agents. Even the three chapters on H . ence of intrinsic and systemic diseases of the liver.

PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 63 BOOK REVIEWS

As with all texts, it is not possible to keep pace ters cover such topics as—Postoperative recurrence of with the rapid expansion of science and medicine. C r o h n ’s disease, Complications of the ileal pouch-anal However, I was impressed with the timeliness of this anastomosis, Pregnancy and fertility with IBD, and latest edition of Hepatology. Special considerations for pediatric and adolescent The two-volume set includes 61 chapters in 1761 patients with IBD. Many authors are highly distin- pages, approximately 30 pages per chapter including guished and recognized experts in the field of IBD. references. This length allows for a comprehensive This book is simple to read and is very "user- overview of each topic with detailed references for the friendly." Each chapter provides a critical up-to-date reader who wishes more depth. The use of tables, overview with important references. Some of the charts, figures, and color plates adds considerably to information is repetitive: for example, there are chap- the ease of using this reference. ters entitled "Medical therapy for Crohn’s disease" and Personally, I continue to use this text frequently "Medical therapy for Ulcerative " as well as a for both clinical and research related questions. My chapter titled, "Medical approach to the patient with only complaint is that I often lend my copy to students, IBD." These could have been consolidated into two residents, and fellows who enjoy it so much that they chapters. The chapters in the book could have been hesitate to return it promptly. A current edition of this arranged in a better sequence (e.g., the chapters on text is truly essential for every gastroenterologist’s treatment could follow the chapter on evaluating library. patients with IBD; chapters on surgical therapy could Christopher Bowlus have followed chapters on medical therapy ). In some U.C. Davis School of Medicine chapters though bibliography is provided, the refer- Sacramento, CA ences are not annotated in the text. There is an occasional omission of important data like long term remission of Crohn’s disease after (allo- The Clinician’s Guide to Inflammatory graft) bone marrow transplantation. Different versions Bowel Disease of Crohn’s Disease Activity Index could have been Lichtenstein G, ed effectively presented in detail (in a table format) in an Slack, Inc, 2003 easy to calculate form. ISBN: 1-55642-554-6; $44.95 (soft cover) This book is an excellent resource and its cost is The Clinician’s Guide to Inflammatory Bowel Disease easily affordable by GI fellows who would get the is a multiple authored text that provides a good maximum benefit by reading this book. Overall, I overview of the epidemiology of IBD, the changing enjoyed reading the book and highly recommend this course of the disease, and newer approaches to man- book as an important addition to any GI library. agement and therapy. The title of the book describes it Sangeeta Agrawal, M.D. a c c u r a t e l y. It is a quick reference resource for any clin- Assistant Professor of Medicine ician, especially for gastroenterology (GI) fellows. This Wright State University book is organized in chapters in which the authors have Dayton, OH addressed epidemiology, clinical features, complica- tions and extraintestinal manifestations of IBD, and George W. Meyer, M.D., Book Editor, is on the Editorial medical and surgical therapy for IBD. Additional chap- Board of Practical Gastroenterology

P R A C T I C A L G A S T R O E N TE R O L O G Y

64 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 FROM THE LITERATURE

Chronic Anal Fissure baseline and placebo conditions. There were no signifi- A literature review on MEDLINE Database was cant differences between conditions on ratings with nau- reported, including all treatments addressing the anom- sea and bloating. During Colchicine administration, mean aly of a high anal pressure, associated with chronic anal abdominal pain was greater than the baseline or placebo fissure and addressing the concerns about the incidence conditions. However, the pain decreased significantly by of after surg e r y, exploring the phar- the last week the patient was on that therapy. macological means to treat chronic anal fissures. Sev- It was concluded that Colchicine increases the fre- eral studies have investigated the effect of topical glyc- quency of bowel movements and hastens colonic tran- erol trinitrate ointment and healing ranged from 30 to 86 sit in patients with chronic . Colchicine percent. Therapy was limited because of a high inci- may be an effective agent available to practitioners to dence of moderate to severe headaches in up to 84 per- treat a subset of patients with chronic constipation who cent of patients. are refractory to standard medical therapy. (Verne GN, Comparable results were observed after injection Davis RH, Robinson MD, et al. “Treatment of Chronic of into the anal sphincter (43 to 96 per- Constipation With Colchicine: Randomized, Double- cent). Minor incontinence from flatus and soiling has Blind, Placebo-Controlled Cross-Over Tr i a l . ” G a s - been reported in up to 12 percent of patients. Further t ro e n t e ro l o g y, 2003; Vol, 98, pp. 111 2 – 111 6 . ) pharmacological approaches included treatment by way of calcium channel blockade and treatment with alpha-adrenoreceptor antagonists, still in a develop- Aminotransferase Levels mental stage. Data on adults age 17 years and older were analyzed It was concluded that topical glycerol trinitrate from the 3rd National Health and Nutrition Examina- ointment and injection of botulinum toxin into the anal tion Survey from 1988 to 1994. Participants were clas- sphincter are advocated as the first line of treatment for sified as having elevated aminotransferase levels if chronic anal fissure. Lateral sphincterotomy should be either AST or ALT were elevated above normal, and o ffered to patients with relapse at therapeutic failure of were classified as explained if there was laboratory evi- pharmacologic treatment. (Utsig MJ, Kroesen AJ, Buhr dence of B or C infection, or a HJ. “Concepts in Pathogenesis and Treatment of history of alcohol consumption. Chronic Anal Fissure: A Review of the Literature.” Analyses were weighted to provide national esti- American Journal of Gastro e n t e ro l o g y, 2003; Vol. 98, mates, 15,676 records were reviewed. The prevalence pp. 968–974.) of aminotransferase elevation in the United States was 7.9 percent, and more common in men (9.3 percent vs. 6.6 percent) in Mexican Americans and non-Hispanic Colchicine in Chronic Constipation blacks, compared to non-Hispanic whites. High alcohol Sixteen patients, including 15 women and one man consumption, hepatitis B or C infection and high trans- with a mean age of 47 years with chronic idiopathic ferrin saturation were found in only 31 percent of cases. constipation who were refractory to standard medical Aminotransferase elevation was unexplained in the t h e r a p y, participated in the study. The patients ran- majority (69 percent). In both men and women, amino- domly received either Colchicine 0.6 mg p.o. t.i.d. or an transferase elevation was significantly associated with identical placebo for a total of 4 weeks in a double- higher body mass index, waist circumference, triglyc- blind-crossover fashion. Daily frequency of bowel erides, fasting insulin and lower HDL and with type II movements and symptoms of daily , abdominal diabetes and hypertension in women. It was concluded pain and bloating were noted. Mean colonic transit was that aminotransferase elevation was common in the calculated at baseline at weeks 5 and 12. United States and the majority could not be unex- Colchicine increased the number of bowel move- plained by alcohol consumption, or ments and accelerated colonic transit, compared with (continued on page 74)

70 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 FROM THE LITERATURE

(continued from page 70) hemochromatosis. Unexplained aminotransferase ele- Propanolol With or Without Isosorbide-5 vation was strongly associated with adiposity and other Mononitrate in Prevention of Variceal Bleeding features of a metabolic syndrome and thus may repre- A multicenter prospective, double-blind, randomized sent nonalcoholic . (Clark JM, Bran- control trial evaluated whether combined drug therapy cati FL, Dodihl AM. “The Prevalence and Etiology of could be more effective than Propanolol alone in pre- Elevated Aminotransferase Levels in the United venting variceal bleeding. 349 consecutive cirrhotic States.” American Journal of Gastro e n t e ro l o g y, 2 0 0 3 ; patients with gastroesophageal varices were random- Vol, 98, pp. 960–967.) ized to receive Propanolol plus placebo or Propanolol plus Isosorbide-5 mononitrate. The only independent Reliability of Commercially Available predictor of variceal bleeding was variceal size greater Assays For HCV RNA than 5 mm. However, among patients with varices To evaluate the impact of the international unit standard greater than 5 mm, there were no significant diff e r e n c e s for measuring HCV RNA in the management of patients than the incidence of variceal bleeding between the two with chronic , three assays were reviewed, groups. Survival was also similar. Adverse effects were including Amplicor monitor PCR, the National Genet- significantly more frequent in the combined group, due ics Institute PCR assay and Branched Chain DNA. to a greater incidence of headache. There were no sig- HCV RNA were measured at four points (baseline), nificant differences in the incidence of new onset or three months after the start of therapy, at the end of treat- worsening ascites or an impairment of renal function. ment and six months after discontinuation of therapy in It was concluded that Propanolol effectively pre- 106 consecutive patients who received Interferon and vents variceal bleeding. Adding Isosorbide-5 mononi- ribavirin for chronic hepatitis C. Of the 424 samples trate does not further decrease the low residual risk of analyzed, 82 to 89 percent of values were within one log bleeding in patients receiving Propanolol. However, the unit and 85 to 92 percent were within two log units by long-term use of this combination drug therapy is safe the various assays. This variability was not dependent and may be an alternative in clinical conditions associ- upon HCV genotype. HCV RNA was undetectable in ated with a greater risk of bleeding. (Garcia-Pagan JC, 1.4 to 6.8 percent of samples when virus was detected Morillas R, Banares R, et al. and Spanish Va r i c e a l by another assay. The mean HCV RNA in these discor- Bleeding Study Group. "Propanolol Plus Placebo Ve r- dant samples was 1.47 to 6.3 logged i.u./mL. It was con- sus Propanolol Plus Isosorbide-5 Mononitrate in the cluded that approximately 90 percent of serum values Prevention of a First Variceal Bleed: A Double-Blind for HCV RNA were within one log unit by the interna- R C T." H e p a t o l o g y, 2003; Vol. 37, pp. 1260-1266.) tional unit standard, regardless of which virologic assay was used. However, false positive and false negative results, as well as variations in HCV RNA levels of NAFLD With Normal ALT Values more than one to two log units can occur with any of the Fifty-one subjects with nonalcoholic fatty liver disease assays, and these results may have an impact upon the and normal ALT levels were identified and compared management of patients receiving Interferon therapy. with 50 consecutive subjects with nonalcoholic fatty It is therefore unwise in clinical practice to base liver disease and elevated ALT. The major indications important treatment decisions upon a single HCV for liver biopsy in those with normal ALT were unex- RNA determination. (Shiffman ML, Ferreira-Gonza- plained hepatomegaly and evaluation as a potential lez A, Reddy KR, et al. "Comparison of Three Com- donor for living donor liver transplantation. The two mercially Available Assays for HCV RNA, Using the groups were comparable. International Unit Standard: Implications For Manage- Approximately 80 percent of patients in both groups ment of Patients With Chronic Hepatitis C Virus Infec- had at least one feature of the metabolic syndrome as a tion in Clinical Practice." American Journal of Gas - major risk factor for NAFLD. The two groups were com- troenterology, 2003; Vol. 98, pp. 1159-1166.) (continued on page 76)

74 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 FROM THE LITERATURE

(continued from page 74) parable in respect to the grade of individual histologic Fecal Lactoferrin For IBD Vs. IBS parameters of NAFLD. A total of 12 subjects with nor- One hundred and four Crohn’s disease patients and 80 mal ALT levels had bridging fibrosis and six had cirrho- patients, 31 sis. Diabetes was the only factor independently associ- patients and 56 healthy controls were recruited. Fresh ated with an increased risk of advanced fibrosis. stool samples were collected and assessed. Fecal lacto- The mean steatosis and perisinusoidal fibrosis ferrin concentration was determined, using a poly- scores were lower in those with low normal versus clonal antibody-based, enzyme-linked immunoassay. high normal ALT. However, the prevalence of Fecal lactoferrin was 90 percent specific for identify- advanced fibrosis was similar. It was concluded that ing inflammation in patients with active inflammatory the entire histologic spectrum of NAFLD can be seen bowel disease. Elevated fecal lactoferrin was 100 per- in individuals with normal ALT values, and that the cent specific in ruling out irritable bowel syndrome. histologic spectrum in these individuals is not signifi- It was concluded that fecal lactoferrin is sensitive cantly different from those with elevated ALT levels. and specific for detecting inflammation in chronic A low normal ALT value does not guarantee freedom inflammatory bowel disease. This noninvasive test from underlying with advanced fibro- may prove useful in screening for inflammation in sis. (Mofrad P, Contos MJ, Haque M, et al. "Clinical patients presenting with abdominal pain and diarrhea. and Histologic Spectrum of Nonalcoholic Fatty Liver (Kane SV, Sandborn WJ, Rufo PA, et al. "Fecal Lacto- Disease Associated With Normal ALT Values." Hepa - ferrin is a Sensitive and Specific Marker in Identifying tology, 2003; Vol. 37, pp. 1286-1292.) Intestinal Inflammation." American Journal of Gas - troenterology, 2003; Vol. 98, pp. 1309-1314.) Capsule Endoscopy Vs. Enteroclysis Forty patients were studied and reviewed from Decem- ber 2001 to April 2002, all with normal upper and in HIV Disease lower endoscopies and small bowel barium studies Seventy-three HIV-infected patients with acute pancreati- before wireless capsule endoscopy was performed. tis were identified retrospectively. Sixty-three had AIDS. Two patients with chronic iron deficiency anemia had The majority of the cases were medication-induced (46 multiple small bowel ulcers and referred after capsule percent), or idiopathic (26 percent). The incidence endoscopy for repeat small bowel barium studies by seemed to be declining in the late 1990 ’s. Eleven patients biphasic enteroclysis performed by experienced GI (15 percent) had a severe course as defined by death, radiologists and the radiologists were aware of the cap- admission to intensive care unit or local complications sule findings. Both studies were considered technically requiring surg e r y. Eighteen cases (24.6 percent), were to be of perfect quality. Despite this, both studies were considered severe by criteria established at the "Interna- negative. All three patients improved. One patient with tional Symposium on ," in Atlanta in ileal ulcers and abdominal pain had an enteroclysis at 1992. APACHE II criteria best predicted outcome, with another hospital before the wireless capsule endoscopy, an overall accuracy of 75 percent. which was reviewed and which study was considered It was concluded that HIV-infected patients have a of excellent quality and was considered normal. clinical outcome similar to those of the general popula- It was concluded that wireless capsule endoscopy tion, with the occurrence of pancreatitis. Clinical predic- may be more sensitive for small bowel ulcers than the tive scales are applicable and useful in this population. best enteroclysis available. (Liangphunakul S, (Gan I, May G, Raboud J, Cilley J, Enns R. "Pancreatitis Chadalawada V, Rex D, Maglinte V, Laptas T. "Wire- in HIV Infection: Predictors of Severity." American Jour - less Capsule Endoscopy Detects Small Bowel Ulcers nal of Gastro e n t e ro l o g y, 2003; Vol. 98, p. 1278-1283.) in Patients with Normal Results From State-of-the-Art Enteroclysis." American Journal of Gastroenterology, Murray H. Cohen, D.O., editor of “From the Literature” is a 2003; Vol. 98, pp. 1295-1298.) member of the Editorial Board of Practical Gastroenterology.

76 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 MEDICAL BULLETIN BOARD

American Red Cross Plasma Services and use because there is less waste. OMRIX biopharmaceuticals, Inc. Announce The American Red Cross Plasma Services markets a U.S. Launch of CROSSSEAL™ Fibrin Sealant broad range of plasma derivatives including immune (Human) globulin intravenous (human), antihemophilic factor VIII American Red Cross Plasma Services and OMRIX (human), albumin (human) and now a fibrin sealant biopharmaceuticals, Inc. have begun sales of (human) to the U.S. market. CROSSEAL™, an all human protein, bovine compo- For more information on Crosseal™ or the American nent-free fibrin sealant approved for U.S. sales as an Red Cross, please call 1-877-ARC-BIOS (1-877-272- adjunct to hemostasis in liver surg e r y. Crosseal, like all 2 4 6 7 ) . fibrin sealants, is derived from human blood plasma and contains the coagulation factors necessary to stop bleed- John Hopkins Researchers Find Potential New ing in surgical settings. Treatment For Children With Chronic Hepatitis C One of Crosseal's many advantages is its quick and easy preparation. "Crosseal™ will significantly help sur- Researchers from the Johns Hopkins Children's Center geons and nursing staff save valuable time in the operat- and five other institutions have found that a drug recently ing room," says Chris Lamb, Vice President and Chief approved for adults with chronic hepatitis C (CHC) also Operating Off i c e r, American Red Cross Plasma Services. may be a safe and effective treatment for children with "Because Crosseal™ requires no reconstitution, it can be the disease. The study is believed to be the first to exam- ready to use with less than one minute preparation time." ine how the drug, peginterferon alfa-2a, affects the young. Adds Robert Taub, President and Chief Executive The hepatitis C virus (HCV), the leading cause of O fficer of OMRIX, "Crosseal™ not only achieves hemo- liver disease in the United States, is responsible for an stasis quickly, but its transparent medium provides a clear estimated 10,000 to 12,000 deaths annually. It is spread tissue field for the surgeon. We believe Crosseal™ repre- primarily by contact with blood and blood products. sents a significant advance in patient care." Blood transfusions and the use of shared, unsterilized, or During clinical trials, Crosseal™ stopped bleeding poorly sterilized needles and syringes have been the main significantly faster than the conventional standard of care. causes of the spread of the virus in the U.S. among adults. Its efficient hemostatic sealing reduced post-hepatic The findings could change the way doctors treat chil- s u rgery complications. dren with CHC, according to the study's lead author, Crosseal™ is a unique fibrin sealant totally free of Kathleen B. Schwarz, M.D., director of the Division of bovine components, making it useable by a wider num- Gastroenterology and Nutrition at the Children's Center. ber of patients. Crosseal™ consists of two ready-to-use "At present, there is no FDA-approved treatment for components—BAC (biological active component) and children 18 years old and younger with the disease. Our thrombin. Crosseal™ delivers its active components in a results provide a basis for conducting a large-scale, ran- simple, easy-to-use proprietary pre-assembled applicator domized controlled trial to test this new form of inter- device that can be used for both dripping and spraying. feron alone, or in combination with ribavirin, an antiviral Shipped frozen, Crosseal™ can be available in one medication, which is the current treatment of choice for minute when thawed and requires no reconstitution, spe- adults with CHC," she said. "Such a study will be neces- cial heating or stirring devices. It is stable for up to 24 sary before the Food and Drug Administration can hours at room temperature and, unopened, can be stored approve the drug for children." in a refrigerator for up to 30 days. It will be available in Some children with CHC have been treated with three 1, 2 and 5-milliliter sizes. shots a week of interferon to increase the amount of the The advantages of Crosseal™ can be summarized naturally occurring infection fighter. Peginterferon alfa-2a almost as quickly as Crosseal™ works: it achieves hemo- is a new, longer acting version that, when taken weekly, stasis quickly and safely; it is easy to prepare and easy to maintains interferon levels in the blood for a longer period use with targeted delivery; lastly, it is more practical to (continued on page 80)

78 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003 MEDICAL BULLETIN BOARD

(continued from page 78) of time. The drug also has been shown more effective in to prove that NSAID-related intestinal damage is many adults with CHC than standard interferon. times more prevalent than originally thought." In the multi-center study, 14 pediatric patients with Forty patients with various types of arthritis were CHC were given peginterferon alfa-2a once weekly for enrolled in the study. Twenty took NSAIDS for more than 48 weeks. No serious side effects were observed, and 43 three months, while 20 took acetaminophen alone or percent of the children treated were free of the virus 24 nothing at all. All fasted overnight and then underwent weeks after the treatment ended. VCE. Two investigators, blind to therapy, reviewed each "Thanks to screening programs for blood donors, patient using definite erosions as the critical variable to transfusion-acquired HCV is now very rare. However, predict NSAID-induced damage. new pediatric cases continue to occur through mater- Results showed 71 percent of NSAID users had dam- nal-fetal acquisition," said Schwarz. "There are age compared to 10 percent of non-users. Severe injury approximately 150,000 children in the U.S. with CHC, was seen in 25 percent of NSAID users compared to zero and this new approach to treatment offers hope to both in the non-user group. Severe damage was associated the children suffering from this infection and their with high-dose indomethacin, naproxen and ibuprofen worried families." use. Numbers show that small intestinal damage is found This study was sponsored by Hoffmann La Roche in the majority of chronic NSAID users. Inc., manufacturer of peginterferon alfa-2a (40KD) These results open the way to studies comparing (Pegasys®). This study was presented during the Diges- NSAID, identifying methods to prevent this damage, and tive Disease Week conference and sponsored by the attempting to equate damage with symptoms. American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and the Society The PyloriTek® Test Kit, a Rapid Urease Test for Surgery of the Alimentary Tr a c t . for the Presumptive Diagnosis of Helicobacter pylori in Gastric Biopsy is Now Available NSAIDs Cause Ulcers and Bleeding You can now reach Serim's PyloriTek Order Services in the and Technical Service group via a single call to 800- 542-4670 or 574-264-3440. Same day shipping is stan- New study shows prevalence and severity much higher dard for all orders received by Noon E.S.T. with free than originally shown Ground Shipping. Training materials are available to Every day, 33 million Americans take OTC and prescrip- PyloriTek customers. tion non-steroidal anti-inflammatory drugs (NSAIDs). P y l o r i Tek offers the following unique features: While it has been widely known that NSAIDs can cause • Final positive and negative results within 60 minutes; stomach problems, the prevalence and severity of small built-in Positive and Negative Controls on every strip; intestinal lesions has remained unclear. A new study • Proven clinical results since 1996 with reprints from shows that NSAID-related small intestinal ulcerations, eight separate clinical studies available on request; lesions and bleeding, are as much as 40 percent higher • Convenient room temperature storage after the kit is than originally thought. opened for use. " P r e v i o u s l y, researchers relied on autopsy studies P y l o r i Tek is CLIA waived. showing that only a low number of NSAID users had For more information or to request a sample please non-specific small intestinal ulcerations," said David call 800-542-4670 or 574-264-3440. Fax: 574-266- Graham, lead investigator on the study. "Through the use 6222; email: [email protected] web site: of video capsule endoscopy (VCE) we were finally able www.serim.com

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80 PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2003