Complicated ulcer; prevention and therapy of upper gastrointestinal bleeding; indications for antacid therapy

Antacids reduce gastric acidity by neutralization, diminish peptic activity by increasing luminal pH above that optimal for proteolysis and provide thereby the rational for their use in ulcer disease. In clinical trials antacids fastened ulcer healing in patients with duodenal ulcer but not with gastric ulcer when compared to placebo. Furthermore, the prophylactic use of antacid medication can significantly reduce the frequency of acute bleeding when gastric content is titrated to a pH greater 3.5 on an hourly basis. Cimetidine does not adequately protect seriously ill patients from acute upper gastrointestinal tract bleeding. Antacids are better for this purpose. So far the efficacy of an antacid therapy has not been proven in controlled trials in patients with chronic ulcer disease, in patients with recurring ulcers following gastric surgery and in patients bleeding from acute or chronic gastroduodenal lesions.     

Cutaneous blood flow changes and weal induced by intradermal bradykinin following pretreatment with indomethacin and captopril

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases and accounts for over 70% of deaths associated with peptic ulcer disease. This case report details the management of a 67-year-old male with a ruptured duodenal peptic ulcer who presented to the emergency room with acute onset of severe abdominal pain. There was no past history of ulcer disease. An abdominal x-ray suggested the presence of free air, and diagnostic laparoscopy was performed. The superior exposure afforded by this minimally invasive technique not only permitted an exact diagnosis to be made, but also afforded a means to expeditiously correct the pathologic defect.     

Symptomatic Helicobacter pylori infection in a neurorehabilitation population

Helicobacter pylori infection has been associated with acute and chronic gastritis, peptic ulcer disease, hypertension, and possibly gastric carcinoma and coronary artery disease. The prevalence of H pylori infection is more than 50% in people older than 60 years; however, the prevalence is not known in patients with traumatic brain injury (TBI) or cerebrovascular accidents who are treated in inpatient rehabilitation services. This report describes 10 symptomatic patients with TBI and strokes who were diagnosed with and treated for H pylori infection after transfer to a neurorehabilitation unit during a 12-month period. Physicians who treat patients with TBI and stroke need to be aware of the possible high prevalence of H pylori infection in their patients. The authors recommend H pylori screening for symptomatic patients in neurorehabilitation units and providing definitive treatment to prevent recurrent gastrointestinal bleeding, peptic ulcer disease, and gastritis.     

Nodular duodenum after pediatric renal transplant due to Brunner''s gland hyperplasia

We studied mortality related to peptic ulcer bleed in a well defined cohort of patients in the month after the episode of peptic ulcer bleed. Our objective was to assess the contribution of peptic ulcer antecedents and other predictive factors on the risk of dying. The study cohort comprised 1,020 patients hospitalized for an episode of peptic ulcer bleed between January 1991 and March 1994 and identified in the General Practice Research Database in the United Kingdom. Six hundred twenty-three patients had no prior episode of peptic ulcer disease, and 384 had peptic ulcer antecedents; for 13 patients, information was not available. Forty-five patients died (mortality rate = 4.4 per 100 person-months; 95% confidence interval = 3.3-5.9) within 1 month of the peptic ulcer bleed. Patients with no peptic ulcer antecedent faced a greater risk of dying than patients with antecedents (relative risk = 3.0; 95% confidence interval = 1.2-7.1). Elderly patients, those undergoing surgery, and current users of acid-suppressing drugs or nonsteroidal antiinflammatory drugs all had an increased mortality risk. Patients presenting with their first-ever episode of peptic ulcer bleed have a higher case fatality rate than those with previous episodes of peptic ulcer.     

The clinical prognosis of the complication of peptic ulcer by acute hemorrhage

Clinical parameters have been studied in 45 peptic ulcer patients without and 47 ones with acute hemorrhage. Factors of acute hemorrhage risk in ulcer patients have been specified (old age, long history of the disease, previous hemorrhages, duodenal ulcer localization at the back and upper walls and gastric ulcer localization at the middle and upper thirds of the lesser curvature of the stomach, size of ulcer, penetration). Combined existence of the factors is conducive to acute hemorrhage.     

Treatment of Helicobacter pylori infection

Since acceptance of the association between Helicobacter pylori and peptic ulcer disease, eradication of H. pylori has become the standard of care in the treatment of peptic ulcer disease. Unfortunately, eradication therapy is no easy task, especially when one is faced with a myriad of drug combinations with varying degrees of efficacy and tolerability. The following is a review of the literature regarding the drugs and drug combinations used to eradicate H. pylori and their effectiveness both as single agents and in combination.     

Effects of indomethacin on intragastric pH and meal-stimulated serum gastrin secretion in rheumatoid arthritis patients

The effects of oral indomethacin on intragastric pH and serum gastrin were investigated in rheumatoid arthritis patients. Nine patients (1 male, 8 female) without a history of peptic ulcer disease and 6 patients with a history of peptic ulcer disease (5 male, 1 female) were studied. To obviate Helicobacter pylori infection as a confounding factor, only patients with positive H. pylori serology were included. After a 5-day period of placebo treatment and after a 5-day period of indomethacin (50 mg t.d.s.; total dose 750 mg), 24-h intragastric pH and basal and meal-stimulated serum gastrin levels were measured in a double-blind placebo controlled cross-over study. There were no differences in the median 24-h pH values between placebo and indomethacin users irrespective of peptic ulcer disease history. Indomethacin resulted in a higher basal and stimulated gastrin response than placebo in patients with a history of peptic ulcer disease. The basal and incremental responses were lower in patients with a history of peptic ulcer disease than in patients without a history of peptic ulcer disease, both during indomethacin and placebo. The same basal and stimulated incremental serum gastrin responses were found during placebo and indomethacin treatment in patients without a history of peptic ulcer disease. No correlation was established between median 2-h post-prandial intragastric pH and post-prandial incremental serum gastrin concentration. We conclude that indomethacin does not influence the intragastric pH of rheumatoid arthritis patients irrespective of history of peptic ulcer disease.     

Evaluation of a new chromogenic substrate assay for the measurement of the prothrombin time

Since the ingestion studies by Marshall and Morris, Helicobacter pylori has been known to cause both acute and chronic infection in the human stomach activating both the cellular and the humoral immune system. It is of little or no value to evaluate the causative relationship of an infectious agent using Koch's criteria. The more recent criteria for causative relationships used in the science of epidemiology are more useful. These criteria include: (i) the characteristic of the association which is fulfilled for most cases of both duodenal and gastric ulcer; (ii) the temporal relationship which is fulfilled for duodenal ulcer and has not been investigated for gastric ulcer; (iii) the biological gradient which has been fulfilled for duodenal ulcer in a few studies but not investigated for gastric ulcer; (iv) the biological plausibility which is easily fulfilled for both duodenal and gastric ulcer; (v) the effect of an intervention which has been fulfilled for duodenal ulcer and in a few studies for gastric ulcer; and (vi) the coherence of these data with what is known about the disease which is fulfilled for both duodenal and gastric ulcer. Even though there is no need for all criteria to be fulfilled, further studies are necessary to confirm the temporal relationship between H. pylori and peptic ulcer, and the biological gradient of H. pylori in relation to the gastric ulcer. Even so, there is a strong indication that most of the peptic ulcers, apart from those caused by non-steroid anti-inflammatory drugs and Zollinger-Ellison-like syndromes, are caused by H. pylori infection.     

Study of the role of sialic acids in the formation of bound form of insulin

In order to diagnose peptic ulcer, the "percussion" symptom in the right hypochondrium at the inhalation level was used in the flying personnel, aged 19-45. Peptic ulcer, specifically duodenal ulcer in the acute stage was diagnosed in 75 persons and in the remission stage-in 69 persons. The control group consisted of 29 healthy subjects. The diagnostic importance of this symptom was shown. It was found in 29.3, 14.5 and 3.4% of cases, respectively. In 8 subjects who concealed complaints or showed an atypical development of the disease there was a sharp response to "percussion" that suggested peptic ulcer which was confirmed by X-ray studies.     

Laparoscopic suture closure of perforated peptic ulcer. A nonrandomized comparison with open surgery

BACKGROUND: Laparoscopic vs open suture in the surgical treatment of perforated peptic ulcer were compared in a retrospective study. METHODS: The outcome of 10 patients having the laparoscopic procedure was compared with the outcome of 17 patients treated with suture via laparotomy during the same time period. RESULTS: The mortality rate and the complication rate were comparable. The laparoscopic procedure was more time consuming; hospital stay did not differ. CONCLUSIONS: The results indicate that surgery for perforated peptic ulcer can be performed with the laparoscopic technique with an outcome comparable to open surgery. No obvious advantages to the patient were noted with the laparoscopic method.     

Torsion of a malignant undescended testis

Cryptorchid testis have a greater risk of malignant change than do normally descended testis. The undescended testis would also be susceptible to torsion by the mechanism of increase in testicular size. A 36-year-old man of torsion of malignant undescended testis is presented. He was diagnosed as having incarcerated inguinal hernia on his first visit to general surgeon due to acute left lower abdominal pain. At laparotomy, a 7.5 x 5.5 x 3.0 cm3, greyish tan color mass was found. The pathological diagnosis is choricarcinoma and teratoma, mixed germ cell tumor. We would emphasise that in any patient presenting with acute abdominal symptoms and an absent scrotal testis, the possibility of a complication of torsion of undescended testis should be considered.     

Role of Helicobacter pylori in reflux esophagitis

It is now widely accepted that peptic ulcer disease (PUD) is a result of chronic infection of Helicobacter pylori (H. pylori). Thus, treatment of PUD should be aimed toward eradication of H. pylori with antibiotics. One the other hand, recent study from England suggested that eradication of H. pylori may provoke development of reflux esophagitis in duodenal ulcer patients. Despite duodenall ulcer patients with concomitant esophagitis is a specific type of esophagitis, it is important to recognize the development of reflux esophagitis after cure of H. pylori infection. Whether the development of reflux esophagitis is occurred in other H. pylori-related disease such as gastric ulcer remains to be studied.     

Helicobacter pylori--can the mechanisms of pathogenesis guide us towards novel strategies for treatment and prevention?

Helicobacter pylori establishes a chronic infection in the stomach of humans. The infection is associated with a low grade inflammatory response in the epithelium that can develop into chronic active gastritis, peptic ulcer disease or neoplasia. Antibiotics have dramatically decreased the rate of recurrence of peptic ulcers. However, antibiotic resistance is already evident, casting doubts on the future efficacy of these strategies. The link between childhood infection and severe health problems, including increased risk for gastric tumours motivate efforts to develop vaccines. Characterization of the molecular mechanisms of pathogenesis will pave the way for novel strategies for treatment and prevention of H. pylori infection.     

Isolation and characterization of Helicobacter pylori strains from peptic ulcer patients in Dhaka, Bangladesh

To study the association of Helicobacter pylori with peptic ulcer and the associated histopathological changes, to characterize the isolated strains in terms of their protein profile, 83 peptic ulcer cases were studied. A high association of H pylori with peptic ulcer (duodenal ulcer 77%, gastric ulcer 75%) and gastritis (74%) was observed. Age and smoking did not have any relationship with H pylori infection. The infection was predominantly associated with the 'quiescent' form of chronic gastritis. Comparative sodium dodecyl sulfate polyacrylamide gel electrophoresis of whole cell extracts of the local isolates and a reference strain from Australia showed a general homogeneity between the strains with obvious interstrain differences. However, the difference between the local isolates and the reference strain was more marked. Significant association of H. pylori with peptic ulcer along with strain variations were observed.     

Helicobacter pylori CagA antigen antibodies

BACKGROUND: CagA antigen of Helicobacter pylori is highly immunogenic in humans. There is an increasing evidence that infection with CagA-positive strains is related to the development of peptic ulcer disease, atrophic gastritis, or gastric cancer. The aim of our study was to assess seropositivity to CagA in a group of 95 clinically symptomatic adults who underwent gastroduodenoscopy and to correlate results to their disease characteristics. METHODS AND RESULTS: Serum immunoglobulin G antibodies to CagA detected by ELISA kit (Helicobacter p120, Viva Diagnostika, Germany) were compared to standard IgG specific antibodies against a pool of H. pylori antigens Synelisa Pin plate, ELIAS, Germany). Immunoglobulin G antibodies to CagA were present in 5/31 (16%) serum samples from H. pylori negative persons and 10/28 (36%) serum samples from H. pylori positive patients without peptic ulcer disease compared with 8/11 (73%) H. pylori positive patients with peptic ulcer disease in the past, 11/13 (85%) H. pylori positive patients with duodenal ulcers or duodenitis and 4/5 (80%) H. pylori positive (1/7, 14% H. pylori negative) serum samples from patients with gastric resection for peptic ulcers in the past. Serum levels of antibodies to CagA in the groups of patients with peptic ulcer disease in the past, with present duodenal ulcers of duodenitis and in H. pylori infected patients with gastric resection were significantly higher then those of H. pylori infected patients without peptic ulcer disease (P < 0.05). On the other hand, there was no significant difference in the presence of the specific antibodies against at pool of H. pylori antigens between these four groups. CONCLUSIONS: These data suggest that serologic response to the CagA antigen is more prevalent in H. pylori positive persons with present or past peptic ulceration than among infected persons without peptic ulcer disease. The presence of antibodies to CagA in H. pylori positive persons may be useful for the identification of patients with higher risk or more severe disease.     

Brush border enzyme activities in the small intestine after long-term gliadin feeding in animal models of human coeliac disease

BACKGROUND: Gastric outlet obstruction is commonly considered a complication of peptic ulcer disease. Malignancy accounts for up to 39% of gastric outlet obstruction. The object of this study was to evaluate the reliability of endoscopic biopsies in excluding malignancy as the cause of gastric outlet obstruction. METHODS: A retrospective study of 40 consecutive patients admitted with gastric outlet obstruction was conducted. Patient demographics, their use of H2-receptor antagonists or nonsteroidal anti-inflammatory drugs, and history of peptic ulcer disease were recorded. Histopathologic results of the endoscopic biopsy and surgical specimen were reviewed. The diagnosis based on the surgical specimen was considered the gold standard. RESULTS: Sixteen patients (40%) had malignant gastric outlet obstruction. Seven patients had gastric adenocarcinoma and nine had extragastric tumors. The patients with malignant obstruction were significantly older (> 55 years) (p = 0.03; odds ratio: 95% CI: 5.21 [1.05-23.49]). Gastric cancer patients had less frequently a history of peptic ulcer disease when compared with patients with benign gastric outlet obstruction (p = 0.04; odds ratio: 95% CI: 5 [1.04-38.13]). Endoscopic biopsy to detect malignant obstruction had poor sensitivity (i.e., 37%) when compared with biopsies of the surgical specimen. In three of seven patients with gastric cancer (40%), repeated jumbo biopsies were negative for malignancy. CONCLUSION: Patients with gastric outlet obstruction who had endoscopic biopsies negative for cancer should be explored surgically before embarking on medical therapy. The surgical exploration is especially important in gastric outlet obstruction patients who are considered at high risk for malignancy, that is, those who are older and have no history of peptic ulcer disease.     

Identification, diagnosis, and treatment of acid-related diseases in the elderly: implications for long-term care

Acid-related disorders such as peptic ulcer disease and gastroesophageal reflux disease occur frequently in the elderly and are associated with a high frequency of morbidity and mortality. The proton pump inhibitors lansoprazole and omeprazole produce faster rates of healing and greater symptomatic relief in patients with acid-related disorders than histamine2-receptor antagonists, are well tolerated, and are associated with few adverse events. Compared with omeprazole, which interacts with diazepam, warfarin, and phenytoin, lansoprazole produces only a minor increase in theophylline clearance. Proton pump inhibitors in combination with antibiotic therapy can eradicate Helicobacter pylori, the main risk factor in the recurrence of peptic ulcer disease, obviating the need for maintenance therapy. Long-term acid suppression with proton pump inhibitors may be necessary to prevent the recurrence of gastroesophageal reflux disease. The safety and efficacy profile of these agents makes them ideal for the treatment of acid-related diseases in elderly patients.     

Upper digestive tract dyspepsia and early gastric cancer

AIM: The study of the frequency and evolution of upper digestive tract dyspepsia in a group of patients operated for early gastric cancer (EGC) and to perform a strategy of diagnosis for the patients with long term upper digestive tract dyspepsia. METHODS: Clinical data of 35 patients operated for EGC were retrospectively evaluated. The frequency, characteristics and evolution time of upper digestive tract dyspepsia, main when it began more than 6 months before surgery, were analyzed. Radiologic and endoscopic exams carried out for diagnosis were also evaluated. Histological diagnosis of surgical specimens were considered, looking for the presence of chronic atrophic gastritis, intestinal metaplasia, and peptic gastric ulcer. RESULTS: Long-term upper digestive tract dyspepsia was present in 27 patients (mean evolution time of 43.4 months). Clinical changes of previous symptoms that suggested gastric carcinoma were not found in 15 patients. Concurrent peptic gastric carcinoma were not found in 15 patients. Concurrent peptic gastric ulcer along with EGC was diagnosed by histology in 11 patients, and chronic atrophic gastritis and intestinal metaplasia were both present in the non-tumoral gastric mucosa in all cases. CONCLUSIONS: 1) Unspecific upper digestive tract dyspepsia is frequently found in patients with EGC. 2) Endoscopy should be the first exam performed in patients with upper digestive tract dyspepsia. 3) The patients with gastric ulcer, chronic atrophic gastritis or intestinal metaplasia must be submitted to sequential endoscopic follow-up.     

Current aspects of using ketamine in childhood]

In this audit we tried to assess the effect of the detection of Helicobacter pylori on the change of outcome and symptoms of peptic ulcer disease outside well defined prospective studies, and its influence on treatment praxis by general practitioners. The study was carried out in the canton of Uri, a geographically closed area of Switzerland. The records of all patients with peptic ulcer disease diagnosed from 1991 to 1994 were evaluated retrospectively. In addition, the patients were followed by contact through their family doctors who were asked to fill out questionnaires on the immediate and long-term treatment of acute peptic ulcer, H. pylori therapy, recurrence of ulcers in light of symptoms or endoscopy, and on any surgery performed for ulcer disease. We found 453 patients with peptic ulcer disease proven by endoscopy, 134 patients presented with signs of ulcer bleeding, 45% of these had used nonsteroidal anti-inflammatory drugs previously. Only 9 of 453 patients required surgery. In 430 patients follow-up was possible (median of 18 months). H. pylori eradication was the primary treatment in 24% of the patients in 1991 and in 79% in 1994. Long-term prophylaxis with histamine H2 antagonists had been selected in 22%. Recurrence of the ulcer disease was seen in 157 patients during the follow-up period. The recurrence rate was 8% (3/39) in patients with documented H. pylori eradication, 43% (62/145) in patients with H. pylori eradication therapy without documentation of the result, 57% (31/54) in H. pylori positive and 50% (14/28) in H. pylori negative patients on long-term treatment with histamine H2 antagonists. 33% of the patients still had substantial abdominal pain despite using long-term histamine H2 antagonists as prophylaxis against recurrence, but this was the case in only 5% (2/39) after successful H. pylori eradication. The rate of successful antibiotic treatment improved substantially during this audit. This follow-up study demonstrates that patients with successfully eradicated H. pylori remain largely free of symptoms and of ulcer recurrence. Control of the eradication result seems to be necessary outside controlled studies. In contrast, symptoms and ulcer recurrence are frequent despite long-term treatment with histamine H2 antagonists. Few patients need surgery for ulcer disease today. Audits like this are a valuable method to improve acceptance and success of a new treatment modality.     

Preoperative sonographic diagnosis of sealed-off perforated gastric ulcer

Perforated peptic ulcer (PPU) is a common surgical emergency. Early diagnosis and intervention are necessary to reduce the morbidity and mortality. Radiographic or sonographic detection of free air is neither sensitive nor specific for PPU. We report a case of sealed-off PPU with direct sonographic demonstration of the perforation tract within the anterior wall of the gastric antrum. The diagnosis was confirmed at laparotomy.