Diagnosis of Zollinger-Ellison Syndrome—Ulcerogenic Tumor of the Pancreas

A small proportion of patients with peptic ulcer disease harbor a hormone-secreting pancreatic tumor as the cause of the ulcer diathesis, and if this is not recognized, they may suffer undue morbidity and mortality. Close attention to the patient''s history, roentgenographic findings and gastric secretory studies will allow identification of ulcerogenic tumors of the pancreas. Other clues to the diagnosis include associated endocrine abnormalities and diarrhea.     

Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment

Although the role of Helicobacter pylori infection on noncomplicated peptic ulcer disease has been definitively established, the precise relationship between the organism and complicated ulcer has hardly been studied. The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is of only about 65-70%, which contrasts with the almost 90-100% figure reported in noncomplicated ulcer disease. However, H. pylori infection rates in various studies range markedly from 0% to 100%, suggesting that differences in variables as number and type of diagnostic methods used to diagnose H. pylori infection, or frequency of nonsteroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. Recurrent ulcer disease after peptic ulcer perforation mainly occurs in patients with H. pylori infection, which suggests that the microorganism plays an important role in this complication. All patients with perforated peptic ulcer should be treated by simple closure of the perforation and with therapy aimed at healing of the ulcer and eradicating the H. pylori infection, as disappearance of the organism prevents, or at least decreases, ulcer recurrence and ulcer perforation in patients with H. pylori-associated perforated ulcers after simple closure. Therefore, H. pylori eradicating treatment should be started during the immediate postoperative period. The patients with intractable recurrent symptoms of peptic ulcer despite adequate medical treatment, but without H. pylori infection (e.g. a patient using nonsteroidal anti-inflammatory drugs), is probably the only remaining indication for elective definitive surgical treatment of peptic ulcer disease.     

ANNULAR PANCREAS—Peptic Ulcer as Late Postoperative Sequela

Two cases of annular pancrease with late postoperative sequelae of duodenal and gastric ulcer are presented. In each case operation was limited to the annulus. Because symptoms are not permanently relieved by this procedure and subsequent peptic ulceration is not prevented, it is suggested that partial gastric resection be performed and decompression of the duodenal stump be effected by resection of the pancreatic ring.     

CALIFORNIA MEDICAL ASSOCIATION

Two cases of annular pancrease with late postoperative sequelae of duodenal and gastric ulcer are presented. In each case operation was limited to the annulus. Because symptoms are not permanently relieved by this procedure and subsequent peptic ulceration is not prevented, it is suggested that partial gastric resection be performed and decompression of the duodenal stump be effected by resection of the pancreatic ring.     

COMPLICATIONS OF PEPTIC ULCER IN THE AGED

Peptic ulcer is not an uncommon disease among the aged population. Thirty-five per cent of the patients admitted to the Los Angeles County General Hospital in a period of 12 months for treatment of peptic ulcer were more than 60 years of age.The severity of this disease in the elderly group was evidenced by the high incidence of lethal complications requiring operation—one case in every four.The mortality rate from operation for peptic ulcer complications is related to the factors of concurrent disease, the urgency of operation and the selection of a suitable operation.     

Fatal peptic ulcer complications and the use of non-steroidal anti-inflammatory drugs,aspirin, and corticosteroids.

Although non-steroidal anti-inflammatory drugs are known to cause peptic ulcer and its complications, controversy exists about the number of deaths from ulcer which are attributable to their use. A case-control study was therefore performed to determine whether prior use of non-steroidal and other anti-inflammatory compounds was associated with an increased case fatality rate from complications of peptic ulcer. Non-steroidal anti-inflammatory drugs were used by 39% of a series of 80 patients who had died from peptic ulcer complications and by 37% of 160 controls who were survivors matched for sex, age, ulcer site, and nature of complication (odds ratio 1.1; 95% confidence interval 0.6 to 2.1). Similarly, the rates of prior use of aspirin by cases and controls were almost identical (odds ratio 1.2; 95% confidence interval 0.5 to 1.9). Thus neither nonsteroidal anti-inflammatory drugs nor aspirin were associated with increased case fatality rates from peptic ulcer complications. In contrast, corticosteroids were associated with an increased mortality (odds ratio 4.2; 95% confidence interval 0.9 to 25.6). Although this increase in the estimated relative risk was not statistically significant, a review of the case records indicated that most deaths in steroid users were due to serious sepsis, indicating that there might be a causal association between use of the drugs and the mode of death.     

Dyspepsia: is a trial of therapy appropriate?

Dyspepsia is a common, benign condition that may be distinguished from gastroesophageal reflux, irritable bowel syndrome and pancreatobiliary, coronary or musculoskeletal disease by a careful history and physical examination. However, the presence or absence of a peptic ulcer in dyspepsia can be determined only by an endoscopic examination or a barium-contrast radiograph. Although the American College of Physicians has recommended trying drug therapy for patients with dyspepsia before diagnostic tests are done, new data support early diagnosis. Although therapy is initially cheaper than endoscopic examination, over a year the costs even out because most patients with dyspepsia eventually need an endoscopic examination, and many patients with nonulcer dyspepsia are given medication unnecessarily. Endoscopic examination, if available to general practitioners, is the most cost-effective approach to dyspepsia. An approach that does not include endoscopy lacks the opportunity to offer patients convincing reassurance that their illness is not serious, which is arguably the most important treatment in cases of nonulcer dyspepsia. Studies supporting the use of endoscopic examination predate the treatment of peptic ulcers with antibiotics, which makes an initial endoscopic examination to determine whether the patient has an ulcer even more important.     

PERFORATED PEPTIC ULCER—Selective Gastric Resection in Emergency Treatment

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death.In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50.From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage.During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included.In this series also the mortality increased steeply from age 50 onward.Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture.The mortality of perforated ulcers in females was higher than in males.Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.     

A Review of Seasonal Periodicity in Peptic Ulcer Disease

Although several pathogenetic factors have been identified in recent years, the etiology of peptic ulcer disease is yet unknown. During the past few decades several investigators have reported seasonal patterns in peptic and duodenal ulcer disease. A review of the literature reveals vast differences between studies with respect to the type and number of patients selected, diagnostic techniques, the number of examinations and the interval of time between each as well as the method of data analysis. Nevertheless, there is solid evidence to conclude that peptic ulcer disease is lower during the summer than the other seasons of the year. Although many investigators have reported peptic ulcer disease to be more common in the spring and/or autumn, the evidence based on group studies thus far is not persuasive. On the other hand, initial findings on a small sample of patients studied by endoscopy at frequent intervals over at least a one-year period suggest that the season of peptic ulcer disease is a characteristic of each individual patient. Some experience recurrence of disease only in the spring while others experience such only in the autumn. Studies utilizing protocols which call for frequent endoscopic examination at regular (3-month or less) intervals for at least a one-year period are likely to clarify aspects of the seasonality of peptic ulcer disease.     

A Review of Seasonal Periodicity in Peptic Ulcer Disease

Although several pathogenetic factors have been identified in recent years, the etiology of peptic ulcer disease is yet unknown. During the past few decades several investigators have reported seasonal patterns in peptic and duodenal ulcer disease. A review of the literature reveals vast differences between studies with respect to the type and number of patients selected, diagnostic techniques, the number of examinations and the interval of time between each as well as the method of data analysis. Nevertheless, there is solid evidence to conclude that peptic ulcer disease is lower during the summer than the other seasons of the year. Although many investigators have reported peptic ulcer disease to be more common in the spring and/or autumn, the evidence based on group studies thus far is not persuasive. On the other hand, initial findings on a small sample of patients studied by endoscopy at frequent intervals over at least a one-year period suggest that the season of peptic ulcer disease is a characteristic of each individual patient. Some experience recurrence of disease only in the spring while others experience such only in the autumn. Studies utilizing protocols which call for frequent endoscopic examination at regular (3-month or less) intervals for at least a one-year period are likely to clarify aspects of the seasonality of peptic ulcer disease.     

Results of the Surgical Treatment of Duodenal Ulcer Between 1946 and 1966

The experience with various surgical procedures performed for duodenal ulcer at the Winnipeg Clinic between 1946 and 1966 has been analyzed. Operative mortality has been low and ulcer control has been provided in a large proportion of patients treated. Of 864 cases, 719 (83%) have been available for follow-up study.All procedures employed provided satisfactory ulcer control. The vagotomy-with-gastric-resection group, although small, showed no ulcer recurrence and good general results. This outcome justifies the consideration of antrectomy and vagotomy as the operation of choice, with other procedures as alternatives. The combined procedure represents a more technically involved operation and possibly is indicated only in cases where the symptoms, complications and very marked acid secretion suggest a strong possibility of ulcer recurrence. Concern that a patient''s ulcer diathesis may return as time elapses after vagotomy has not been borne out by our experience.     

RAPID HEALING OF PEPTIC ULCERS IN PATIENTS RECEIVING FRESH CABBAGE JUICE

Thirteen patients with peptic ulcer were treated with fresh cabbage juice, which, experiments have indicated, contains an antipeptic ulcer factor. This factor (vitamin U) prevents the development of histamin-induced peptic ulcers in guinea pigs.The average crater healing time for seven of these patients who had duodenal ulcer was only 10.4 days, while the average time as reported in the literature, in 62 patients treated by standard therapy, was 37 days.The average crater healing time for six patients with gastric ulcer treated with cabbage juice was only 7.3 days, compared with 42 days, as reported in the literature, for six patients treated by standard therapy.The rapid healing of peptic ulcers observed radiologically and gastroscopically in 13 patients treated with fresh cabbage juice indicates that the anti-peptic ulcer dietary factor may play an important role in the genesis of peptic ulcer in man.     

Homeostasis of the gastric mucosa and blood circulation. 2. Role of ischemia in disruption of the gastric mucosa

To date there is a lot of data of literature indicating that microcirculatory disorders play the main role in the development of gastric mucosal damages induced by stress, ethanol, nonsteroidal antiinflammatory drugs and tobacco smoke. Under stress gastric mucosal blood flow disorders may be caused by the actication of sympathetic nervous system. Ulcer healing is accompanied by the angiogenesis and by the increase of blood flow in the ulcer border and tissues surrounding the ulcer. Therefore now the main studies are concentrated on the search of defence-enhancing agent rather than drugs for antisecretory therapy. Therapeutic strategy suggests the use of some potential vasodilators such as NO donors, prostaglandin analogues, oxygen radical scavengers, endothelin, leukotrienes, platelet-activating factor antagonists and/or their synthesis inhibitors. At present, the therapeutic possibilities seem to be restricted and nothing indicates that stimulation of the defensive factor only, is more effective in the treatment of peptic ulcer than inhibition of aggressive factors. However we suggest that blood flow correction may be very important for the treatment of refractory ulcers or for prophylaxis of stress ulceration and peptic ulcer recurrence.     

Comparative studies on starvation - and indomethacin - induced ulcerations in albino rats.

Experimental models of chronic and acute peptic ulcerations were produced in the albino rats by means of prolonged starvation and indomethacin administration. In the case of acute indomethacin-induced peptic ulceration, the effects of anticholinergic drugs on the ulcers produced were also studied. Starving the rats for a period of seven days produced gastric ulceration in all the rats used while indomethacin produced gastric ulceration within five hours in all the rats used. Severe ulceration of the degree found in human peptic ulcer disease was produced only by chronic starvation. Anticholinergic drugs ameliorated indomethacin-induced gastric ulceration, partly at least, by reducing intra-gastric acidity.     

Helicobacter pylori in pediatrics

This article reviewed the important publications on Helicobacter pylori research with children between April 2010 and March 2011. The most interesting studies in the last year lend further weight to the evidence for vertical transmission of H. pylori. The discovery of a potential role for jhp0562, the gene which encodes for the cell envelope protein glycosyltransferase, in the progression to peptic ulcer disease is also very interesting as it may provide a novel way to distinguish children at risk of peptic ulcer disease from those who are not, and so determine those who requires treatment to eradicate H. pylori. The rise in non-H. pylori-associated ulcers and erosions continues to be reported with no apparent risk factors for these ulcers identified to date. High levels of treatment failure continue to be reported, and there remains an urgent need for more effective treatment regimes for children.     

Helicobacter pylori and peptic ulcer disease.

Medical therapy for duodenal or gastric ulcer disease has traditionally involved gastric acid antisecretory therapy for 4 to 8 weeks to promote initial healing and indefinitely to prevent recurrences of ulcer. The discovery of Helicobacter pylori in most patients with peptic ulcer disease has led to a change in this approach. Therapy designed to eradicate H pylori may facilitate ulcer healing with acid antisecretory agents and, more important, may greatly reduce the incidence of ulcer recurrence, obviating the need for maintenance antisecretory therapy. Regimens designed to eradicate H pylori are difficult to comply with, however, and are associated with adverse effects in some patients. In this article we review the diagnosis and treatment of H pylori infection in patients with peptic ulcer disease and make recommendations regarding the use of conventional ulcer therapies and therapies designed to eradicate H pylori.     

The prevalence of peptic ulcer not related to Helicobacter pylori or non-steroidal anti-inflammatory drug use is negligible in southern Europe

BACKGROUND AND AIM: Helicobacter pylori is the major cause of peptic ulcer disease, but the proportion of H. pylori-negative peptic ulcers seems to be increasing in developed countries. We investigated the frequency of H. pylori-negative peptic ulcer without intake of nonsteroidal anti-inflammatory drugs (NSAIDs) in a Mediterranean European country. MATERIALS AND METHODS: We prospectively collected consecutive patients with an endoscopically verified active peptic ulcer over 6 months from different areas of Spain. Helicobacter pylori infection was assessed by rapid urease test and histologic examination (corpus and antral biopsies). A (13)C-urea breath test was performed if H. pylori was not detected with the invasive test. Patients were considered H. pylori-negative if all three tests were negative. NSAID use was determined by structured data collection. RESULTS: Of 754 consecutive peptic ulcer patients, 16 (2.1%) were H. pylori-negative and had not used NSAIDs before the diagnosis. Of the 472 patients who had duodenal ulcers, 95.7% (n = 452) were H. pylori-positive and only 1.69% (n = 8) were negative for both H. pylori infection and NSAID use; 193 patients had benign gastric ulcers and 87% (n = 168) of them were infected by H. pylori (p <.001 vs. duodenal ulcers). NSAID intake was more frequent in gastric ulcer patients (52.8%) than in duodenal ulcer patients (25.4%; p <.001). Consequently, the frequency of H. pylori-negative gastric ulcer in patients not using NSAID was 4.1% (n = 8). CONCLUSION: Peptic ulcer disease is still highly associated with H. pylori infection in southern Europe, and only 1.6% of all duodenal ulcers and 4.1% of all gastric ulcers were not associated with either H. pylori infection or NSAID use.     

Coexistent coccidioidomycosis of the meninges and pulmonary cavitation due to Coccidioides

A clinical study was undertaken to evaluate the effectiveness of concentrated cabbage juice in the treatment of peptic ulcers. Patients at San Quentin Prison with a diagnosed ulcer crater were treated in a double blind control experiment. They were given either concentrated cabbage juice or placebo facsimile. The evaluation of the merit of this treatment was based upon repeated x-ray examinations of the ulcer crater. A period of 22 days was allowed for ulcer crater healing time. The results of this experiment indicated concentrated cabbage juice to be effective in healing of peptic ulcer.     

Coexistent Coccidioidomycosis of the Meninges and Pulmonary Cavitation Due to Coccidioides

A clinical study was undertaken to evaluate the effectiveness of concentrated cabbage juice in the treatment of peptic ulcers. Patients at San Quentin Prison with a diagnosed ulcer crater were treated in a double blind control experiment. They were given either concentrated cabbage juice or placebo facsimile. The evaluation of the merit of this treatment was based upon repeated x-ray examinations of the ulcer crater. A period of 22 days was allowed for ulcer crater healing time.The results of this experiment indicated concentrated cabbage juice to be effective in healing of peptic ulcer.