Relationships between gastric acid secretion and recurrent duodenal ulcer after selective vagotomy and pyloroplasty in men

Relations between gastric acid secretion measurements and recurrence of duodenal ulcer within 1 to 4 years after selective vagotomy and pyloroplasty were evaluated in a series of 117 men. The discriminatory ability of spontaneous, histamine- and insulin-activated acid secretion measurements was significant and similar to that after truncal vagotomy and drainage. The measurements were of no practical value for the diagnosis of recurrent duodenal ulcer after vagotomy, but they provided a rationale for selective surgery in patients with duodenal ulcer and patients with recurrent duodenal ulcer after vagotomy.     

Gastric emptying in control subjects and patients with duodenal ulcer before and after vagotomy

The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.     

Helicobacter pylori infection after gastrectomy and vagotomy in duodenal ulcer patients

The eradication of Helicobacter pylori (Hp) is known to reduce the recurrence rate of duodenal ulcer (DU) to similar extent as gastrectomy but it is not clear what is the prevalence of Hp in DU patients after surgical interventions such as gastrectomy or vagotomy. The purpose of this study was to evaluate the influence of gastrectomy or truncal vagotomy with pyloroplasty on the prevalence of Hp in 51 DU patients just before and 6-8 months after these procedures. Using C14-urea breath test (UTB), rapid CLO-test and histology of the biopsy samples of gastric mucosa obtained during gastroscopy, the Hp was detected in all DU subjects submitted to operation. Following distal gastric resection (antrectomy) with Billroth II anastomosis (N = 32) due to an ulcer resistance to conservative therapy, peptic ulceration was not observed during 6-8 months in any of the examined subjects and the Hp was only rarely observed (only in 3 out of 32 operated patients). Histologically, in antral biopsies taken prior to surgery, all DU patients presented chronic active gastritis. After the surgery, the absence of Hp was confirmed also by histology. Histological evaluation of gastrectomy stump biopsies revealed typical chronic gastritis with concomitant foveolar hyperplasia and focal gland dilation. Following selective vagotomy and pyloroplasty (N = 19), the scarring of duodenal bulb (without active ulcer) was seen in 4 out of 19 operated patients but the Hp was detected in all (100%) cases. Gastric biopsies prior and after vagotomy revealed chronic active gastritis associated with Hp infection. Basal plasma gastrin was reduced after gastrectomy by about 30% and basal and maximal pentagastrin-induced acid secretion was decreased by about 60% and 70%, respectively. Vagotomy did not reduce activity of the mucosal inflammation and the incidence of Hp. Basal plasma gastrin level was increased by about 60%, while basal and pentagastrin induced acid secretion was decreased by 25% and 40%, respectively. Because of the high ulcer recurrence rate after vagotomy as opposed to low recurrence after gastrectomy, it is reasonable to conclude that (1) the disappearance of Hp and reduction in plasma gastrin and gastric acid secretion were probably the major factors responsible for the high efficacy of gastrectomy in prevention of ulcer recurrence, (2) in non-complicated DU, gastric surgery should be avoided and replaced by conservative anti-Hp therapy involving both antisecretory or bismuth agents and antimicrobial drugs which should provide similar therapeutic effects as surgery and (3) vagotomy should be eliminated as the method of treatment of DU because of the high recurrence of peptic ulceration and the failure of this procedure to affect the Hp status.     

Gastritis duodenitis, and circulating levels of gastrin in duodenal ulcer before and after vagotomy

Biopsy specimens have been taken from five standard sites in the stomach and from the duodenal bulb in order to investigate the association of gastritis and duodenitis with duodenal ulcer. Twenty patients with chronic duodenal ulcer were investigated in this manner and in addition had gastric secretion tests and a radio-immune assay of serum gastrin under differing conditions. The patients were then treated either by a truncal vagotomy and pyloroplasty (TVP) or by a highly selective vagotomy without a drainage procedure (HSV). All the investigations were repeated three months postoperatively. Duodenal ulcer was usually associated with gastriitis, although this varied in extent and severity from patient to patient. In nearly all the patients, gastritis was present at the pyloric end of the stomach and along the lesser curve. In more than half of the patients, gastritis was also present in the body of the stomach but the fundus was usually spared. Chronic duodenitis was found in the duodenal bulb in all these patients. After vagotomy there was a marked increase in both the extent and severity of the proximal gastritis in both treatment groups but the distal gastritis remain almost unchanged. There was little change in the incidence of duodenitis after vagotomy but its severity was lessened. No correlation was found between the peak acid output (PAO) in response to Histalog and the severity of the gastritis or the duodenitis either before or after operation, with one exception. The postoperative PAO was significantly less in those patients who developed a severe proximal gastritis after vagotomy. No relationship was found between the severity of the distal gastritis and the levels of serum gastrin. No correlation was found between either the basal or peak acid output and the corresponding serum gastrin levels before or after vagotomy.     

Intragastric proteolysis after vagotomy in perforative duodenal ulcer

The examination of intragastric proteolysis in patients operated on the perforative duodenal ulcer has been performed in 80 patients in the period up to 16 years after the surgery. The selective proximal vagotomy was performed in 65 of the patients, the trunk vagotomy--in 15 of the patients. In 55 patients the vagotomy was combined with ulcerrraphy, in 25 patients--with draining operations. The 30-35% decrease of the intragastric pepsin proteolysis was detected in patients after the vagotomy. There was no any signs of restoration of the suppressed proteolytic activity in the time period up to 16 years after the surgery. The draining operations lead to suppression of pepsin proteolysis in long-term period after the surgery and to its substitution with digestion with the pancreatic proteinases.     

Analysis of normal parameters of gastric chemism after pentagastrin stimulation, its diagnostic value in duodenal ulcer

The development of puberty, the sexual debut and the sexual function were investigated in a longitudinal study of an unselected material of 220 primary cases of hypospadiacs, treated during the period 1965 to 1969 and followed-up during the period 1965 to 1974. The development of puberty in hypospadiacs strongly resembled that in a normal male population. Out of 121 hypospadiacs between 13 and 30 years of age 66 had had sexual intercourse. The median age for the sexual debut was 16.9 years compared to 16.6 years in a normal male population. Thirty out of 55 hypospadiacs without experience of sexual intercourse were in the age-group 13-16. Hypospadiacs with experience of sexual intercourse continued their sexual function was normal. Forty-one out of 66 were married and 24 out of 41 had children. In order to study the influence of the surgical treatment on the sexual debut and sexual function the 121 hypospadiacs were divided into two groups: those in whom treatment was completed before or at the age of 12 years, and those in whom treatment was completed at 13 years of age or later. The median age for the sexual debut was 15.5 years in the former group and 17.6 in the later group. An interesting finding was that almost half of the hypospadiacs in whom treatment was complted at 13 years of age or later had had a preoperative sexual debut despite the presence of curvature in all cases, and despite the fact that all types of hypospadias were represented. The median age for the sexual debut in this group was 17.1 years.     

Relationship between fundic endocrine cells and gastric acid secretion in hypersecretory duodenal ulcer diseases

BACKGROUND: Acid hypersecretion is associated with duodenal ulcer disease in the following conditions: Zollinger-Ellison syndrome (ZES) and antral gastrin cell hyperfunction (AGCH) due to hypergastrinaemia, or hypersecretory duodenal ulcer (HDU) without hypergastrinaemia. AIM: To evaluate whether quantitative changes in fundic ECL and D cells may be involved in acid hypersecretion. PATIENTS AND METHODS: Seven ZES, six AGCH and six HDU Helicobacter pylori-positive patients were compared. Basal (BAO) and pentagastrin-stimulated gastric acid secretions (PAO), and morphometry of fundic ECL and D cells were performed. The six AGCH and six HDU patients were investigated again using the same tests 1 year after H. pylori eradication. RESULTS: Median PAO values were no different in all the hypersecretory conditions studied. The median volume density of ECL cells in ZES was significantly higher than in controls (2.75, range 1.74-5.8 vs. 0.73, 0.52-1.11: P < 0.05), whereas it was in the control range in AGCH and HDU patients (0.77, range 0.20-1.39 and 0.99, range 0.42-1.51; respectively). The count of fundic D cells was significantly lower in AGCH patients than in all other investigated groups (median 0.16, range 0.1-0.52; P < 0.05). Cure of infection in AGCH and HDU patients did not modify the ECL cell volume density, whereas a significant increase in the count of fundic D cells was observed in AGCH patients. Thus, the ECL/D cell index was significantly affected in AGCH patients (P < 0.05), being higher during H. pylori infection (median 6, range 0.7-9.25) than after the cure (median 2.12, range 1.10-3.5). BAO and PAO were not affected by H. pylori eradication in either group. CONCLUSIONS: The study provides evidence, for the first time, that quantitative alterations in the fundic endocrine cells are not involved in acid hypersecretion of patients with hypersecretory states, and that eradication of H. pylori does not restore normal acid secretion values.     

Selective proximal vagotomy with duodenoplasty in the treatment of duodenal stenosis in patients with duodenal ulcer]

The results of surgical treatment of 118 patients with duodenal ulcer complicated with stenosis that have been operated on from 1981 to 1992 have been analysed. Selective proximal vagotomy (SPV) and duodenoplasty was performed in 58 (49.2%) patients (study group). SPV and gastroduodenal anastomosis by the method of Jabulay was performed in 60 (50.8%)-control group. The rate of postoperative morbidity in the study group-5.1%, in the control group-8.4%. The long-term follow up is from 1 year to 10 years (mean 5 + 0.6). The rate of recurrence of peptic ulcer is 8.6% in the study group and 10% in the control group. The modified scale (D. Johnson, 1976) was used for comparative evaluation of efficacy of two types of surgery. SPV and duodenoplasty was estimated in 175.1 points, that is 2.5 times less that SPV and gastroduodenal anastomosis (406.1 points). This demonstrates the advantages of SPV and duodenoplasty. The authors advocate SPV and duodenoplasty as a method of choice in the treatment of stenotic duodenal ulcer.     

Inhibition of basal and pentagastrin-stimulated gastric acid secretion after treatment with benzilonium bromide and after selective proximal vagotomy

50 consecutive patients with radiographically verified duodenal ulcer and a history of peptic ulcer disease for more than 3 years and with elevated gastric acid secretion in the basal state and after stimulation with pentagastrin were randomly allocated to two groups. The first group of 25 patients was treated with benzilonium bromide (Ulcoban Prolongatum, Parke, Davis & Co.) and the second group was subjected to selective proximal vagotomy (SPV). The patient's gastric acid secretion was determined before the start of treatment and after 1, 6, and 12 months. After one year the basal acid output had decreased by 58.2% in the group treated with benzilonium bromide and by 82.9% in the patients who had undergone SPV. The peak acid output fell by 49.4% in the benzilonium group and by 66.1% in the SPV group.     

Eradication of Helicobacter pylori in patients with duodenal ulcer lowers basal and peak acid outputs to gastrin releasing peptide and pentagastrin

BACKGROUND: Patients with duodenal ulcer (DU) have high basal (BAO) and peak (PAO) acid outputs. The effect of Helicobacter pylori eradication on these variables is unclear. AIM: To discover if gastric acid hypersecretion in patients with DU is caused by H pylori. PATIENTS AND METHODS: BAO, gastrin releasing peptide (GRP), and pentagastrin stimulated PAO in 10 H pylori negative controls, and in 10 H pylori positive patients with DU was measured before and six months after H pylori eradication. H pylori status was determined by histology, culture, and by the 13C-urea breath test. After collecting a 30 minute basal aspirate, GRP 40 pmol/kg/h was infused for 45 minutes, and after a 30 minute washout, pentagastrin 6 micrograms/kg was injected intramuscularly. RESULTS: Basal and stimulated acid output (PAOGRP and PAOPg) were significantly higher in H pylori positive DU than in H pylori negative controls. Six months after H pylori eradication, basal and stimulated acid outputs were all significantly lower than before H pylori eradication. CONCLUSIONS: This study has shown that BAO, PAOGRP, and PAOPg are higher in H pylori positive DU than in H pylori negative controls. All decreased significantly six months after H pylori eradication, to fall within the range of controls. These results are compatible with a hypothesis that acid hypersecretion in duodenal ulcer disease is caused by H pylori infection.     

Vagal and hormonal influences on gastric secretion in duodenal ulcer disease

Current concepts on the pathophysiology of gastric hypersecretion in duodenal ulcer disease have been presented and the role of vagal nerves and gastrointestinal hormones particularly gastrin has been discussed. Duodenal ulcer patients form a heterogenous group with regard to the gastric acid and pepsin secretion and gastrin release. They may differ from healthy subjects by several wall defined defects including an increased mass of parietal and peptic cells, increased capacity to secrete acid and pepsin, increased vagal drive to the parietal cells, hyperreactivity of antrum, decreased effectiveness of antral and duodenal autoregulatory mechanisms, defective release of secretin, increased gastric emptying and defective removal of gastric acid load from the duodenum. Very little is known what proportion of duodenal ulcer patients suffer from various pathologic disturbences and what are the mechanisms underlying these changes.     

The effect of antral distension on acid secretion and plasma gastrin in duodenal ulcer patients

The effect of antral balloon distension on acid secretion and the plasma gastrin concentration was studied in 8 duodenal ulcer patients. Antral distension significantly increased the acid secretion to about 30% of the peak acid response to pentagastrin without any change in the plasma gastrin concentration. Antral distension and concomitant intragastric neutralization, with the intention of facilitating release of antral gastrin, produced about the same acid response and did not evoke any plasma gastrin increment. The results suggest that the acid response to antral distension in duodenal ulcer patients is evoked without contribution of the gastrin mechanism, and that the acid response is probably mediated via a pyloro-oxyntic reflex. In this respect the duodenal ulcer patient seems to differ from the healthy subject, in whom antral distension produces no acid response, and from the dog, in which release of gastrin as well as pyloro-oxyntic reflex participate in the acid response to antral distension.     

Gastric acid and serum gastrin responses to insulin and 2-deoxy-d-glucose in duodenal ulcer patients before and after partial gastrectomy

Gastric acid and serum gastrin (radioimmunoassay) responses to insulin (0.2 U/kg i.v.) and 2-deoxy-D-glucose (2DG) (50 mg/kg i.v.) were determined in 11 male duodenal ulcer patients before and after partial gastrectomy involving complete antral resection. In 8 of the patients the acid response to pentagastrin (6 mug/kg subc.) was also determined. Before operation, 2DG produced higher acid and gastrin responses than insulin. Partial gastrectomy reduced basal acid secretion by 54% but did not alter the basal gastrin level, suggesting that this gastrin is of extra-antral origin. Partial gastrectomy reduced the acid responses to insulin and 2DG by 66% and 78%, respectively; after operation the acid responses to these stimulants were equal. The ratio for the acid response to insulin and pentagastrin was 65% before and 56% after partial gastrectomy; corresponding ratios for 2DG and pentagastrin were 112% and 48%. Partial gastrectomy abolished the peak gastrin response to insulin hypoglycemia and reduced that to 2DG by 64%. The integrated gastrin response to insulin and 2DG was insignificant in the operated patients. Both insulin and 2DG release mainly antral gastrin which appears to be of greater importance for the acid response to 2DG than insulin.     

Assay and identification of histamine in human gastric aspirate by a fluorometric--fluoroenzymatic technique. Its application in patients with chronic duodenal ulcer

Histamine assays can be unreliable in individual subjects or samples even though the particular method is in general working very well. Therefore the specificity and accuracy of histamine determination in the gastric aspirate of individual duodenal ulcer patients was thoroughly examined and shown to be satisfactory. Pitfalls of the fluorometric assay were investigated. A native (non-histamine) fluorescence in gastric aspirate which occurs before the addition of OPT was not removed by the original Shore procedure. In the combined assay (Dowex 50 + butanol extraction) this fluorescence no longer interferes with the assay. For the identification of histamine in a single gastric aspirate of an individual duodenal ulcer patient, the reversed blank (3 M HCl added to the reaction mixture before OPT instead after OPT), excitation and fluorescence spectra, the heating test with spectra recorded and the HMT test were found to be reliable. The formaldehyde test and the heating test without recording the spectra were useless since they gave false negative results. Since the HMT test was regarded as a reference method it was thoroughly investigated both by theoretical considerations (enzyme kinetics) and by a series of measurements in a single patient as well as in a group of nine subjects. Samples from the period of peak acid output in response to pentagastrin showed an average histamine concentration of about 8 ng/ml and a histamine output of 1.5 microgram/30 min.     

Body weight and gastric acid secretion in rats with subdiaphragmatic vagotomy and lateral hypothalamic lesions.

Investigated the role of the vagus in the lateral hypothalamic (LH) syndrome to body weight loss in 80 male Sprague-Dawley albino rats. Ss were divided into 4 groups: (a) Ss with bilateral LH lesions that were subsequently given a bilateral subdiaphragmatic vagotomy, (b) LH Ss that received a control vagotomy operation, (c) nonlesion Ss that were given a subdiaphragmatic vagotomy, and (d) nonlesion Ss that received a control vagotomy operation. Both LH lesions and vagotomy reduced body weight levels, though the effects differed in terms of the length of time required to reach initial maximal loss, the time required to reach chronic levels of maintenance, and the severity of body weight reduction. Fasting gastric acid secretion was lowered by LH lesions, and the extent of this reduction was positively correlated with the reduction in body weight. Gastric contents after a 24-hr fast were greater in vagotomized than in nonvagotomized Ss. These data are discussed in relation to the role of the vagus in maintaining body weight levels and in relation to the changes in gastric functioning after LH lesions and vagotomy. (42 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)