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.     

Endometriosis; a review

The Billroth I gastric resection, with and without vagotomy, was used in 20 selected cases of peptic ulcer. Vagotomy and pyloroplasty is considered the operation of first choice for duodenal ulcer. The cases for Billroth I resections were selected from cases not suitable for pyloroplasty. Operations for peptic ulcer which preserve the gastrointestinal continuity are considered to be physiologically superior. Vagotomy and pyloroplasty, and Billroth I gastric resection both qualify in this regard. The postoperative digestive symptoms after Billroth I gastric resection in the present series were minimal, which tends to confirm this theoretical superiority.     

RELATIONSHIP OF DELIVERY DATE TO PREDICTED DATE

Gastroduodenostomy after gastric resection is a procedure which can be readily performed if the short gastric vessels are first divided. It makes for a more physiological restoration of the gastrointestinal tract than is accomplished with gastrojejunostomy and permits proper admixture of the food with the bile and pancreatic enzymes. It avoids several potential dangers such as leakage from the duodenal stump, the possibility of a gastrocolic fistula, and malfunction of the anastomosis due to distortion of a jejunal loop. Apparently the "dumping syndrome" does not occur after gastroduodenostomy as it sometimes does after gastrojejunostomy.     

RELATIONSHIP OF DELIVERY DATE TO PREDICTED DATE

Gastroduodenostomy after gastric resection is a procedure which can be readily performed if the short gastric vessels are first divided. It makes for a more physiological restoration of the gastrointestinal tract than is accomplished with gastrojejunostomy and permits proper admixture of the food with the bile and pancreatic enzymes. It avoids several potential dangers such as leakage from the duodenal stump, the possibility of a gastrocolic fistula, and malfunction of the anastomosis due to distortion of a jejunal loop. Apparently the “dumping syndrome” does not occur after gastroduodenostomy as it sometimes does after gastrojejunostomy.     

The role of gastric and duodenal pH in the cysteamine-induced duodenal ulcer in the rat

Many secretory studies reported an increase in gastric acid secretion by the duodenal ulcerogen cysteamine. A detailed analysis of these experiments, especially the results from rats with chronic gastric fistula suggest that direct stimulation of gastric acid secretion may not be the primary mechanism of the duodenal ulcerogenic action of cysteamine. We used a different approach and measured the pH at the site of ulceration in the proximal duodenum. A duodenal ulcerogenic dose of cysteamine did not change the pH at the anterior or posterior wall of the duodenum during 4 hr. In the same dose and by the same route of administration, cysteamine nevertheless induced duodenal ulcers in 24 hr. These experiments demonstrate that in addition to the effect on gastric acid secretion, other factors are needed to the effect on gastric acid secretion, other factors are needed to explain the early duodenal ulcerogenic action of cysteamine.     

The role of secretin in the control of gastric secretion and emptying in the dog

It is well established that duodenal acidification strongly inhibits gastric acid secretion, gastric emptying rate and gastrin release. These effects are at least partly mediated via hormonal pathways, but it is not known whether they are mediated by the release of one peptide named in the past enterogastrone, or by several peptides acting together. The effects of duodenal acidification on gastric acid secretion and gastrin release can be reproduced by infusion of small doses of secretin and plasma secretin levels increase during duodenal acidification or after a meal. This peptide is thus the most probable candidate as an enterogastrone. It has however never been clearly shown that administration of low doses of secretin do decrease gastric emptying rate as well as acid secretion. Experiments were performed on four dogs with gastric fistulas. A peptone solution was infused into the stomach. The experiments were repeated during infusion of synthetic secretin. Our results indicate that infusion of low doses of secretin reproduce all the effects of duodenal acidification: a significant inhibition of gastric acid secretion, gastrin release and gastric emptying rate.     

Relationship of gastric metaplasia and age, sex, smoking and Helicobacter pylori infection in patients with duodenal ulcer and duodenitis

Gastric metaplasia is one of the factors in duodenal ulcer appearance. The aim of this study was to investigate the frequency of gastric metaplasia and its connection with age, sex, cigarette smoking and H. pylori infection. In the study 216 patients were included. There were 98 patients with duodenal ulcer, 60 with duodenitis, and 58 healthy control subjects. There was no statistically significant difference in gastric metaplasia frequency according to age and sex. Gastric metaplasia was statistically more significant in patients with duodenal ulcer (p < 0.01). In all the subjects cigarette smoking did not significantly influence gastric metaplasia. In smokers with duodenal ulcer, and those who besides duodenal ulcer and smoking had H. pylori infection gastric metaplasia was more frequent (p < 0.01). However, in patients with duodenal ulcer, there was no statistically significant difference of gastric metaplasia related to H. pylori presence. It may be suggested that H. pylori infection is not of indispensable significance for gastric metaplasia appearance.     

COMPARATIVE CONCURRENT RESULTS OF VAGOTOMY PROCEDURES,CONVENTIONAL GASTRIC RESECTION AND HEMIGASTRECTOMY WITH SUBTOTAL VAGOTOMY

The question of the best surgical treatment of duodenal ulcer remains unanswered.In a series of 132 patients, results following gastric resection and hemigastrectomy with subtotal vagotomy were better than those following vagotomy procedures alone.     

Comparative concurrent results of vagotomy procedures,conventional gastric resection and hemigastrectomy with subtotal vagotomy

The question of the best surgical treatment of duodenal ulcer remains unanswered. In a series of 132 patients, results following gastric resection and hemigastrectomy with subtotal vagotomy were better than those following vagotomy procedures alone.     

The effect of different prostaglandins on cysteamine-induced duodenal ulcer in the rat

Most of the experiments have verified the cytoprotective effect of prostaglandins on the gastric mucosa and only few observations are known to deal with "cytoprotection" exerted on the duodenal or intestinal mucosa. Duodenal ulcers were produced by cysteamine (CEA). The treatment with different prostaglandins (PGI2, PGF2 alpha, PGE2) was carried out every six hours during the 48-hour experimental period. The obtained results indicate that neither prostacyclin nor prostaglandin-F2 alpha has any significant effect on CEA-induced duodenal ulceration, while prostaglandin-E2 exerts a slight anti-ulcerogenic effect. It is possible that cytoprotection is not the result of the same process in the duodenal and gastric mucosa: alternatively, three prostaglandins are not involved in the pathomechanism of CEA-induced duodenal ulceration.     

Stasis Gastric Ulcer: A Complication of Duodenal Ulcer

A causal relation between gastric stasis and gastric ulceration is suggested by the literature reviewed. In obstructive duodenal ulcer disease it is important to know that a concomitant gastric ulcer may be present and causing the symptoms. In combined ulcers, symptoms are more severe and treatment is more difficult.A clinical study of 60 cases of stasis gastric ulcer associated with chronic duodenal ulcer disease is presented. Twenty-six of these patients with gastric ulcers were bleeding at the time of their admission. The mortality rate was at least twice that for solitary ulcer. Early warning symptoms of stasis were fatigue, anorexia, fullness and weight loss; vomiting was a late manifestation. X-ray findings were often inaccurate; evidence of retention was reported in only 21. Gastric residue measurements were particularly useful in showing gastric retention.Since the basic disease in combined ulcers is the duodenal lesion, surgical treatment is primarily that for duodenal ulcer.     

TNF/LTA polymorphisms and risk for gastric cancer/duodenal ulcer in the Korean population

The tumor necrosis factor-alpha (TNF) and lymphotoxin-alpha (LTA) are proinflammatory cytokines with immunoregulatory effects. TNF is also known to inhibit gastric acid secretion. Previously we have shown that the known proinflammatory genotypes, IL-1B -31C/+ and IL-1RN *2/*2, were not associated with increased risks for gastric cancer/duodenal ulcer in the Korean population. In this study, we tested the association between the polymorphisms of another candidate cytokine TNF/LTA and 341 gastric cancers, 133 duodenal ulcers, and 261 healthy controls. Five TNF promoter polymorphisms (-1031, -863, -857, -308, and -238) and two LTA polymorphisms (intron 1 and Thr26Asn) were analyzed. Individual polymorphisms were not associated with the gastric cancer and/or duodenal ulcer risk. When a haplotype analysis was performed with seven polymorphisms, differences in haplotype profile between the controls and gastric cancer and/or duodenal ulcer were not statistically significant. However, the frequencies of individual haplotypes C and D, which had opposite alleles at -1031, -863, and -857, showed statistically significant differences between the gastric cancer and duodenal ulcer (P=0.005 and P=0.02, respectively), suggesting that the TNF/LTA genotypes might play an opposite role in the pathogenesis of gastric cancer and duodenal ulcer.     

Cysteamine induced-duodenal ulcers are associated with a selective depletion in gastric and duodenal calcitonin gene-related peptide-like immunoreactivity in rats.

We have measured the endogenous levels of gastric and duodenal calcitonin gene-related peptide (CGRP)-, neurokinin A (NKA)-, galanin-vasoactive intestinal polypeptide (VIP)- and neuropeptide Y (NPY)-like immunoreactivity (li) in relation to cysteamine-induced gastric lesions and duodenal ulcers in rats. CGRP-li but not NKA-, galanin-, VIP- or NPY-li was decreased in gastric and duodenal samples following a single ulcerogenic dose of cysteamine (900 mg/kg p.o.). Temporal relationships of this phenomenon showed that CGRP-li was selectively decreased (stomach 45%, duodenum 68% as compared to controls, respectively after 24 h) concomitantly to the formation of acute gastric lesions and duodenal ulcers. Animals bearing healed ulcers 12 days after cysteamine, had gastroduodenal CGRP-li similar to control values. Pretreatment with the selective sensory neurotoxin capsaicin decreased gastroduodenal CGRP-li but not NKA-, galanin-, VIP- or NPY-li, showing that CGRP might be considered a marker of the afferent innervation of the gastroduodenal tract. The residual gastroduodenal CGRP-li levels in capsaicin-pretreated animals were not decreased by cysteamine administration, indicating that the effect of cysteamine is restricted to a peptide pool of primary afferent origin. Duodenal CGRP-li is selectively decreased by the duodenal ulcerogen cysteamine during the acute phase of ulcers formation and might be among the local mediators which afford protection against the ulcerogenic stimuli.     

Stress-induced reduction of gastric acid in the rat is not associated with increased tissue somatostatin

In zero, mildly and severely stressed rats, gastric acid secretion, aortal and portal venous gastrin, venous glucagon and somatostatin in gastric, duodenal mucosa and in pancreas were examined. Serum gastrin and gastric acid secretion are reduced markedly by both kinds of stress, whereas plasma glucagon rises steadily with stress. As somatostatin in the tissues of stressed rats is not different from unstressed controls, gastrin and gastric acid reduction may not be attributed to an endocrine or paracrine action of somatostatin.     

Gastric emptying of liquids in patients with peptic ulcer disease

This study was designed to determine the rates of gastric emptying of water, saline and a 20% glucose solution in patients with gastric and duodenal ulcers. In all subjects, gastric emptying was fastest after administration of the saline, slower with water and the slowest with glucose. Significant statistical differences (p less than 0.05) in emptying rates between normal subjects and the group with duodenal ulcer were seen when water and saline but not glucose were used. We conclude that inhibitory effects of the osmotic receptors are not changed in gastric and duodenal ulcer patients. However, the emptying rates were higher when osmotic stimulus was withheld.     

Changes of gastroduodenal peroxidase activity of rats by cerebellar modulation

The effect of vestibulo-cerebellar lesion and its stimulation by rotation on gastric and duodenal peroxidase activity of rats was studied. Vestibulocerebellar lesion by kainic acid produced gastroduodenal ulceration and peroxidase activity of these tissues were decreased. Mucosal thickness of gastric and duodenal tissue were also decreased. It was observed that when vestibulo-cerebellar lesioned rats were subjected to vestibular stimulation, the peroxidase activity was increased together with increased mucosal thickness of gastric and duodenal tissue. At the same time, it was noted that the severity of ulceration was decreased. We conclude that the study of peroxidase activity is a sensitive and potentially useful estimate of gastric and duodenal injury produced by cerebellar lesion that can be valuable in assessing ulcerogenesis and healing.     

Transcytosis of gastric leptin through the rat duodenal mucosa

Leptin is secreted into the gastric juice by epithelial Chief cells and reaches the duodenum in a biologically intact active form. We assessed the possibility that this gastric leptin crosses the intestinal mucosa by transcytosis through enterocytes to reach blood circulation. Endogenous gastric leptin secretion was triggered by cholinergic stimulation. In another set of experiments, recombinant leptin was inserted in vivo into the duodenal lumen. Plasma levels of leptin were assessed by enzyme immunoassay and Western blot, and duodenal tissue was processed for immunocytochemistry. We first observed that leptin was found inside duodenal enterocytes from fed rats but not inside those from fasted ones. Stimulation of gastric secretion by a cholinergic agent led to rapid increases in plasma leptin levels (202 +/- 39%) except when the pylorus was clamped. Insertion of recombinant leptin into the duodenal lumen raised plasma leptin concentrations (558 +/- 34%) quite rapidly, whereas carrier solution without leptin had no effect. The use of FITC-tagged leptin reinforced these results. Light and electron microscopy revealed the cellular compartments involved in its transcytosis, namely, the enterocyte microvilli, the endocytotic vesicles, the Golgi complex, and the basolateral interdigitations. Leptin was also present in the lamina propria, in capillary endothelial cell plasmalemmal vesicles, and in capillary lumina. These results demonstrate that gastric exocrine leptin is internalized by duodenal enterocytes and delivered to the lamina propria and blood circulation. It may thus be able to play important paracrine and endocrine functions for the control of gastric emptying and nutrient absorption.     

Operative mortality and postoperative morbidity of highly selective vagotomy.

In a world-wide survey of the results of 5539 highly selective vagotomies (HSVs) performed electively for duodenal ulcer the operative mortality was found to be 0-3%. This was lower than that found in collected series after either vagotomy with drainage (0-8%) or gastric resection with or without vagotomy (over 1%). Necrosis of the lesser curvature occurred in 10 patients (0-2%) after HSV and caused death in 5(0-1%). Such necrosis is probably ischaemic in origin. Hence reperitonealisation of the raw area on the lesser curvature and prompt laparotomy if the patient develops signs of peritonitis might lower the mortality still further. Three deaths were due to pulmonary embolism, one to mesenteric vascular occlusion, and four to myocardial infarction; such deaths might be reduced by the prophylactic use of low-dose heparin. Persisting gastric stasis requiring drainage occurred in only 0-1% of the patients in the early postoperative period and in 0-6% of the patients later. Hence drainage procedures, which produce side effects such as early dumping, bilious vomiting, and diiarrhoea, could be abandoned if the mean incidence of recurrent ulceration after HSV remains close to its present level. HSV is probably the safest operation for duodenal ulcer because the alimentary tract is not opened and there is no anastomosis, suture line, or stoma.     

Species-related variations in antioxidant components of gastric and duodenal mucosa

Enzymatic and non-enzymatic antioxidant profiles of the gastric and duodenal mucosa of rat, rabbit, cat and pig were investigated and found to exhibit significant variations. Rat gastric and duodenal mucosa exhibited the highest levels of basal glutathione of the various tissues examined. The highest activity of glutathione reductase was found in the gastric and duodenal mucosa of rat as compared with that in these tissues from the other species. The gastric mucosa of cat and pig showed similar activities of glutathione peroxidase, which was significantly lower than those in rat or rabbit gastric mucosa. The activity of this antioxidant enzyme was similar in rat, rabbit and pig duodenal mucosa and lower than that in cat duodenal mucosa. Strong correlations were found between activities of the functionally coupled antioxidant enzymes glutathione peroxidase and glutathione reductase in gastric but not in duodenal mucosa. The activity of superoxide dismutase showed negligible regional or species-related variations in activity.     

Prostaglandins: effects on the gastrointestinal tract

Several prostaglandins have been shown to exert five major gastrointestinal actions. Inhibition of gastric acid secretion, orally and parenterally. Antiulcer activity (they prevent gastric and duodenal ulcers produced experimentally in animals, and they accelerate the rate of healing of duodenal ulcers in humans). Cytoprotection for the stomach, the small and the large intestine. Cytoprotection is defined as the property of many prostaglandins to protect the mucosa of the stomach and intestine from becoming inflamed and necrotic when this mucosa is exposed to noxious agents. Cytoprotection is separate from, and unrelated to, inhibition of gastric secretion. In humans, certain prostaglandins of the E type given at very low doses prevent gastric bleeding produced by aspirin and indomethacin. Stimulation of intestinal secretion, through increase of cyclic AMP formation. Stimulation of smooth muscle contraction. Certain prostaglandins are likely to be beneficial in the treatment of gastric ulcers, stress ulcers, duodenal ulcers, and perhaps gastritis and certain forms of inflammatory bowel disease.