Gastric Secretion Tests Research Articles

Association of residual gastric acid secretion with persistent symptoms in gastroesophageal reflux disease patients receiving standard-dose proton pump inhibitor therapy.

Although a third of gastroesophageal reflux disease (GERD) patients are refractory to proton pump inhibitor (PPI) therapy, the underlying mechanism of the refractoriness remains unclear. We compared the level of gastric acid suppression during PPI treatment between responders and non-responders by directly measuring gastric acid secretion in GERD patients taking PPIs. Seventy-five consecutive patients receiving standard-dose PPI therapy for GERD were prospectively recruited, irrespective of persistent GERD symptoms. They were asked about their GERD symptoms using a validated questionnaire, and simultaneously underwent both a routine endoscopic examination and a gastric acid secretory testing using an endoscopic gastrin test. Associations between residual gastric acid secretion during PPI treatment and persistent GERD symptoms were analyzed by a logistic regression analysis. Overall, 26 of 75 (34.7%) patients were judged to be positive for persistent GERD symptoms. The patients with and without persistent symptoms showed similar gastric acid secretion levels (1.3 [1.3]mEq/10min vs. 1.4 [2.0]mEq/10min). Sufficient gastric acid suppression, defined as < 0.6, was not significantly associated with persistent GERD symptoms (odds ratio 1.1, 95% confidence interval 0.40-3.5). This study provided solid evidence to support that the gastric acid suppression level during PPI treatment does not differ between patients with and without persistent GERD symptoms. The insignificant role of residual gastric acid in the persistent GERD symptoms suggests that the use of medications other than those that enhance gastric acid inhibitory effects would be an essential approach for the management of PPI-refractory GERD.

Gastric tubes as vectors of Helicobacter pylori transmission

Peptic ulcer was a rare disease before 1850. The prevalence of peptic ulcer increased gradually in persons born between 1870 and 1900. A similar decay in opposite direction of the prevalence occurred after the 1960–1970s. Although the pathogenesis of peptic ulcer is readily explained by the Helicobacter pylori infection, the bacterium occurred many thousands years ago and followed the migrations of human populations; consequently, its presence does not explain the increase in peptic ulcer prevalence. Gastric tubes for secretory testing were introduced from 1871 and their use was extended gradually in the then growing departments of gastroenterology, becoming a very popular, though unpleasant method. There is circumstantial evidence from the pre- H. pylori era that gastric/enteral infections could be transmitted though contaminated gastric tubes/electrodes. The author’s hypothesis is based on the temporary overlap of the increased peptic ulcer prevalence and the extensive use of gastric secretory testing. The use of contaminated gastric tubes in sick persons harbouring pathogenic strains of the bacterium could have led to the transmission of the infection by gastro-oral route to the patients’ ward-mates and on, to their family members: years later, new ulcer or dyspeptic patients may have come from such groups. The current decay in peptic ulcer prevalence could be due to the decreased use of secretory testing and implementation of rigorous disinfection rules.

The Anti-gastropathic and Anti-rheumatic Effect of Niga-ichigoside F1 and 23-Hydroxytormentic Acid Isolated from the Unripe Fruits of Rubus coreanus in a Rat Model

This study was undertaken to produce the clinical merits of two natural antinociceptive anti-inflammatory triterpenoids which synthetic anti-inflammatory drugs do not have. The triterpenoid glycoside niga-ichigoside F1 (NIF1) and its aglycone 23-hydroxytormentic acid (23-HTA), which were isolated from the unripe fruits of Rubus coreanus (Rosaceae), reduced rheumatoid arthritis (RA) factor and C-reactive protein (CRP) factor in Freund's complete adjuvant reagent-induced rats, suggesting that these two triterpenoids had an anti-rheumatic effect. It was also shown that treatment with NIF1 or 23-HTA reduced gastric lesion extent, acidity and total gastric acid output induced by EtOH plus sodium salicylate in a gastric secretion test. Moreover, 23-HTA had a greater effect than the glycoside, NIF1. To clarify the anti-gastropathic mechanism of these two compounds, their free radical scavenging activities in the gastric mucosa were examined in a rat EtOH-sodium salicylate-induced gastropathy model. The two compounds significantly increased superoxide dismutase and glutathione peroxidase activities, indicating that the healing effects of NIF1 and 23-HTA against gastropathy are associated with free radical scavenging enzyme activities. These results support the notion that the long-term administration of NIF1 or 23-HTA should overcome the adverse effects of synthetic anti-inflammatory drugs.

One hundred patients ten years after parietal cell vagotomy.

One hundred patients with duodenal or pyloric/prepyloric ulcer disease were operated with parietal cell vagotomy (PCV) and followed for a minimum of 10 years. At 6 weeks, 1,5 and 10 years postoperatively gastric secretory tests, haematological work-up and clinical examination or telephone interview were performed. There was no operative mortality and the frequency of postoperative sequelae was minimal. The cumulative ulcer recurrence rate was 18 per cent and another 14 per cent had slight to moderate symptoms of epigastric pain without any signs of ulcer. Upper gastrointestinal endoscopy was used to reveal recurrences but was performed only if the patient had symptoms of recurrence. A rise in basal acid secretion and in pentagastrin-stimulated secretion was observed the first year postoperatively, whereas insulin-stimulated peak acid output increased during the first 5 years. We conclude that PCV has a low rate of per- and postoperative complications and an acceptable recurrence rate. Therefore, it seems that PCV is the method of choice in chronic duodenal ulcer disease.

Treatment of gastric ulcer by highly selective vagotomy without a drainage procedure: an interim report.

Abstract Fourteen patients with gastric ulcer alone and 5 patients with combined gastric and duodenal ulceration- have been treated by highly selective (parietal-cell) vagotomy without a drainage procedure (H.S.V.) the past 3 years. Before operation no evidence of gastric stasis was found, clinically, radiologically, or during tests of gastric secretion. Spontaneous acid out was low. Acid output in response to a test meal of meat extract was also found to be low. There no evidence that in the patients with gastric ulcer alone the ulcer was due to pyloric channel disease with excessive release of gastrin by the antrum. Each gastric ulcer was proved by frozen-section examination to be benign at the time of operation. Problems with gastric stasis were encontered in early postoperative period. The vagotomy was shown to be complete on insulin testing in each of 17 patients tested. Follow-up ranges from 1 month to 3 years. The clinical progress of the patients has been good, and has symptoms suggestive of recurrent ulceration gastric retention. Barium-meal examination in 11 patients who were follwed up for more than 9 months showed satisfactory gastric emptying, without recurrent ulceration. While the need for much longer follow-up is obvious, these preliminary results are encouraging. Further trial of H.S.V. for gastric ulcer, preferably in the form of a prospective, randomized comparison with Billroth-I gastrectomy, now seems desirable.

The delayed insulin test and recurrent duodenal ulceration.

Abstract It has previously been shown that insulin tests of gastric secretion carried out within 2 weeks of vagotomy and pyloroplasty give no indication of the patient's liability to recurrent duodenal ulceration. Delayed insulin tests (done 6 or more months postoperatively) have been compared in 100 patients without and 50 patients with recurrence after operation for duodenal ulceration. Complete discrimination between the groups was not achieved but the incidence of recurrence was related to the magnitude of the acid response. As no dividing line could be established to separate tests into positive and negative results, it is preferable that the actual figures for the gastric acid response to insulin be quoted. It is suggested that the peak acid concentration should be selected for this purpose. Separate estimates of the probability of recurrence associated with various levels of peak acid concentration have been made for routine insulin tests and for tests performed in patients with clinical evidence suggestive of recurrent ulceration.

Long-term Outcome of Helicobacter pylori–Negative Idiopathic Bleeding Ulcers: A Prospective Cohort Study

Helicobacter pylori-negative idiopathic ulcers are increasingly recognized. The secular trend and long-term outcome of this condition are unknown. We prospectively studied consecutive patients with bleeding gastroduodenal ulcers from January to December 2000. The incidence and etiology of ulcers during this period were compared with that between September 1997 and August 1998. H. pylori-negative idiopathic ulcers were defined as negative tests for H. pylori, no exposure to analgesics within 4 weeks, and absence of other risk factors for ulcers. After the ulcers had healed, patients with H. pylori-negative idiopathic ulcers and patients with H. pylori ulcers who received eradication therapy were followed up for 12 months without anti-ulcer drugs. Six hundred thirty-eight patients had bleeding ulcers: 213 (33.4%) were H. pylori ulcers, and 120 (18.8%) were H. pylori-negative idiopathic ulcers (vs 480 [50.3%] H. pylori ulcers and 40 [4.2%] H. pylori-negative idiopathic ulcers in 1997-1998; P < .001). H. pylori-negative idiopathic ulcers accounted for 16.1% of patients who were admitted for bleeding and 42.4% of patients who bled while in the hospital (P < .0001); 28.3% of patients with H. pylori-negative idiopathic ulcers had histologic evidence of past H. pylori infection. The probability of recurrent ulcer complications in 12 months was 13.4% (95% CI: 7.3%-19.5%) in patients with H. pylori-negative idiopathic ulcers and 2.5% (95% CI: 0.4%-4.6%) in patients with H. pylori ulcers who received eradication therapy (P = .0002). The incidence of H. pylori-negative idiopathic bleeding ulcers is rising. These ulcers are prone to recurrent complications.

Effect of Helicobacter pylori infection on gastric acid secretion and meal-stimulated serum gastrin in children.

Comparative studies of gastric acid secretion in children related to Helicobacter pylori infection are lacking. The purpose of this study was to compare acid secretion and meal-stimulated gastrin in relation to H. pylori infection among pediatric patients. Thirty-six children aged 10-17 years (17 with H. pylori infection) undergoing diagnostic endoscopy participated in the study. Diagnoses included gastritis only (n = 23), duodenal ulcer (n = 5) and normal histology (n = 8). Gastric acid output was studied using the endoscopic gastric secretion test before and 2-3 months after H. pylori eradication. Meal-stimulated serum gastrin response was assessed before and 12 months after eradication. H. pylori gastritis was typically antrum-predominant. Acid secretion was greater in H. pylori-positive patients with duodenal ulcer than in gastritis-only patients or controls [mean +/- standard error (SE): 6.56 +/- 1.4, 3.11 +/- 0.4 and 2.65 +/- 0.2 mEq/10 minutes, respectively; p <.001]. Stimulated acid secretion was higher in H. pylori-positive boys than girls (5.0 +/- 0.8 vs. 2.51 +/- 0.4 mEq/10 minutes, respectively; p <.05). Stimulated acid secretion pre- and post-H. pylori eradication was similar (5.47 +/- 0.8 vs. 4.67 +/- 0.9 mEq/10 minutes, respectively; p =.21). Increased basal and meal-stimulated gastrin release reversed following H. pylori eradication (e.g. basal from 134 to 46 pg/ml, p <.001 and peak from 544 to 133 pg/ml, p <.05). H. pylori infection in children is associated with a marked but reversible increase in meal-stimulated serum gastrin release. Gastric acid hypersecretion in duodenal ulcer remains after H. pylori eradication, suggesting that the host factor plays a critical role in outcome of the infection.

Gastric acid secretion of normal Japanese subjects in relation to Helicobacter pylori infection, aging, and gender

Background: In Japan, where the incidence of gastric cancer is high, Helicobacter pylori infection could affect gastric acid secretion differently from that in Western countries. The aim of this study was to investigate the relationship between H. pylori infection, acid secretion, aging, and gender in normal Japanese subjects. Methods: The study comprised 193 Japanese subjects who had undergone routine endoscopy. Gastrin‐stimulated acid output was performed during the routine endoscopic examination using the endoscopic method of gastric acid secretory testing (EGT: endoscopic gastrin test), which has been reported previously. H. pylori status was determined by histology, rapid urease test, and serology. Results: Mean EGT values were 3.9 ± 1.5 mEq/10 min in H. pylori‐negative men, 1.6 ± 2.5 in H. pylori‐positive men, 2.2 ± 0.9 in H. pylori‐negative women, and 1.5 ± 1.2 in H. pylori‐positive women. Although acid secretion was lower in H. pylori‐positive subjects compared with H. pylori‐negative subjects in both men and women, the decrease was more marked in men with H. pylori infection. Multiple linear regression analysis showed that aging is positively associated with gastric acid secretion in the H. pylori‐negative subjects, whereas a negative association was found between them in the H. pylori‐positive subjects. Conclusions: In Japanese subjects, aging affects gastric acid secretion differently depending on the status of H. pylori infection. H. pylori infection showed a stronger inhibitory effect on the acid secretion in men than in women. This gender‐related difference in the susceptibility of acid secretion to H. pylori infection may explain the higher rates of gastric cancer in men in Japan.

Evaluation of gastric acid secretion at endoscopy with a modified Congo red test

Background: Markedly decreased or absent gastric acid production is associated with a number of clinically significant conditions, and identification of patients with hypo/achlorhydria may be important. However, current methods of assessing impaired acid secretion are unreliable, time-consuming, and/or complex. The aim of this prospective study was to evaluate a modified endoscopic Congo red test for the diagnosis of hypo/achlorhydria by correlation with a standard gastric acid secretory test. Methods: One hundred six consecutive outpatients with or without dyspeptic symptoms referred for endoscopy were evaluated by using a modified endoscopic Congo red test and a standard test of gastric acid secretion. The modified endoscopic Congo red test suggested hypo/achlorhydria when there was no color shift or a shift of small extent (less than one third of fundic mucosa). Hypo/achlorhydria by the standard gastric acid secretory test was defined as a maximal acid output of less than 6.9 mmol/hour in men and 5.0 mmol/hour in women. Results: The accuracy of the modified endoscopic Congo red test for the diagnosis of hypo/achlorhydria was 0.98 (95% CI [0.93, 0.99]). The sensitivity was 1.0 (95% CI [0.92, 1.00]) and specificity 0.96 (95% CI [0.88, 0.99]). All patients tolerated the modified endoscopic Congo red test well. Conclusion: The modified endoscopic Congo red is an accurate, simple, fast, inexpensive, and well-tolerated chromoendoscopic method for identification of patients with hypo/achlorhydria during routine upper endoscopy. (Gastrointest Endosc 2002;56:254-9.)

Gastric secretion in Zollinger-Ellison syndrome. Correlation with clinical expression, tumor extent and role in diagnosis--a prospective NIH study of 235 patients and a review of 984 cases in the literature.

We prospectively studied 235 patients with Zollinger-Ellison syndrome (ZES) (205 without and 30 with prior acid-reducing surgery) and compared the results with 984 patients from 182 reports in the literature. The aims of the study were to evaluate the sensitivity of proposed acid secretory criteria for the diagnosis of ZES, propose new criteria, evaluate the variability and methodology of gastric secretory testing, and correlate the symptoms and signs of ZES, tumor extent, and primary tumor size and location with the degree of gastric acid hypersecretion. Multiple endocrine neoplasia-type 1 (MEN1) occurred in 22% of patients. The mean basal acid output (BAO) in patients without and with prior acid-reducing surgery was 41.2 +/- 1.7 mEq/hr (range, 1.6-118.3 mEq/hr) and 27.6 +/- 3.5 mEq/hr (range 5.9-102.9 mEq/hr), respectively. In patients with MEN1, those with female gender, Hispanic, or Asian race had lower BAOs. Diarrhea, esophageal stricture, and pyloric scarring were associated with a higher BAO. Neither other symptoms nor the tumor extent, primary tumor location, or size correlated with the magnitude of acid hypersecretion. ZES diagnosis was delayed a mean of 5.5 +/- 0.4 yr. Patients who were misdiagnosed as having either Crohn or celiac disease had higher BAOs. The sensitivities from our study and the literature review of the proposed BAO criteria for the diagnosis of ZES in patients without previous gastric acid-reducing surgery were 91% and 90% for BAO > or = 15 mEq/hr, 86% and 82% for BAO > or = 18 mEq/hr, 69% and 67% for BAO > 25 mEq/hr, and 31 mEq/hr, respectively. The specificities of all the proposed BAO criteria were high. Both the criterion of BAO > or = 15 mEq/hr and BAO > or = 18 mEq/hr had good specificities and equal sensitivity. With prior acid-reducing surgery, the sensitivities in our study and from the literature review were 100% and 81% for BAO > or = 5 mEq/hr, 73% and 45% for BAO > 14.4 mEq/hr, and 37% and 31% for BAO > 19.2 mEq/hr, respectively. The reported mean specificity for the criterion of BAO > or = 5 mEq/hr was 85%, while it was 100% for the other 2 criteria. The maximal acid output (MAO) criterion of > 70 mEq/hr had sensitivities in the present National Institutes of Health (NIH) study and the literature review of 39% and 31%, respectively, and the criterion of MAO > 100 mEq/hr had a sensitivity of 0.6 had a low sensitivity. The proposed criterion of the ratio of basal and maximal acid H+ concentration (BAC/MAC ratio) > or = 0.6 had an excellent sensitivity-- > or = 89% in patients with or without previous acid-reducing surgery. The reported specificity for both the BAO/MAO criterion and the BAC/MAC criterion were similar, but BAC/MAC had a better sensitivity. Combination criteria of BAO generally did not improve sensitivity. The criterion of pH 160 mL/hr in patients without prior acid-reducing surgery occurred in > 86% of patients, and > 140 mL/hr in 87% of patients with prior acid-reducing surgery; these, thus, are neglected findings that have good sensitivities. Our analysis shows criteria based on MAO, pH, and BAO/MAO ratio do not have high sensitivities and thus are not useful. In patients without prior acid-reducing surgery, the criteria of BAO > or = 15 mEq/hr, BAC/MAC ratio > or = 0.6, and basal gastric volume > 160 mL/hr are useful for the diagnosis of ZES and have good specificities. In patients with prior acid-reducing surgery, the criteria of BAO > or = 5 mEq/hr, BAC/MAC ratio > or = 0.6, and basal gastric volume > 140 mL/hr have high sensitivities. In patients with sporadic ZES without acid-reducing surgery, the criterion of BAO > or = 18 mEq/hr is recommended as it has a similar sensitivity but higher specificity than the criterion of BAO > or = 15 mEq/hr. Only 1 patient in either data set (NIH or the literature) with or without previous acid-reducing surgery had a basal gastric pH > 2, therefore this finding essentially excludes the diagnosis of ZES. Gastric secretory measurements for 30 minutes, but not 15 minutes, give results comparable to those for a full hour. On the basis of these results, a number of gastric secretory criteria are proposed, including some for the first time, and alterations in methodology are proposed that should prove useful in the diagnosis of ZES.

Role of endogenous nitric oxide in duodenal bicarbonate response induced by mucosal acidification in rats: Interaction with prostaglandins

Background & Aim. The circulating peptide leptin produced by the fat cells, acts on central receptors to control food intake and body weight homeostasis. Contrary to initial reports, leptin expression has also been detected in the human placenta, the muscles and recently rat gastric chief cells. Here we investigate the possible presence of leptin and leptin receptor in human stomach. Methods. Immunohistochemistry, reverse transcriptase (RT-PCR) and western blot analysis on biopsy samples from 24 normal individuals was used to investigate leptin and leptin receptor expressions. These individuals were randomly selected from the files of our Gastroenterology Department. They included 15 healthy volunteers and 9 patients with non-ulcer dyspepsia (n=24) who gave informed consent for upper endoscopy and gastric secretory tests. Secretory studies upon pentagastrin (6J,Lg/kg/hr) or secretin (3Ul/kg.hr) infusions, available for 22 subjects (mean age 46.7::':: 3.lyears; range 15-67,9 women, l3 men) were analyzed. At the time of study, all had normal endoscopy and normal gastric mucosa on histological examination. Plasma, gastric juice and fundic mucosa leptin were determined by radioimmunoassay. Results. In fundic biopsies from normal individuals, immunoreactive leptin cells were found in the lower half of the fundic glands at the site of chief cells. mRNA encoding ob-protein was detected in the corpus of human stomach. The amount of fundic content of leptin was 10.4 ::':: 3.7 ng leptin/g mucosa as determined by radioimmunoassay. Intravenous infusions of pentagastrin or secretin caused an increase in circulating leptin levels and leptin release into the gastric juice from 24.5 ::'::.3.5 in basal condition to 109 ::':: 26 ng/h under pentagastrin and 1556 ::':: 107 ng/hr under secretin. Gel filtration of leptin incubated with stimulated gastric juice at pH 2 showed an only limited degradation of this peptide. Immunohistochemistry and immunoblotting detected leptin receptor protein and mRNA encoding Ob-RL in the corpus and the antrum. Conclusion. These data provide the first evidence for the presence of leptin and leptin receptors in human stomach. We suggest that gastric epithelial cells be direct targets of leptin. However, the physiological and/or pathophysiological meanings of these findings remain so far unknown.

4709 Effect of h. pylori eradication on gastric acid secretion and acid gastro-esophageal reflux in gastric ulcer.

Eradication of <i>H. pylori</i>has been reported to improve gastric atrophy and induce reflux esophagitis in some peptic ulcer patients. Purpose:To investigate the effect of eradication on acid secretion and acid gastro-esophageal reflux (GER) by 24 h monitoring of pH in the esophagus and stomach and by gastric juice examination before and after treatment, simultaneously. Methods: Sixteen <i>H. pylori</i>-positive gastric ulcer patients (11 males; mean age: 52.9±3.3 y.o.) were treated with 2-week-long dual therapy (omeprazole 40 mg + amoxycillin 1500 mg/day) after patient's informed consent. Eradication was defined by negative for culture and ¹³C urea breath test >4 weeks after ending the treatment. The two-channel pH probe equipped with pH monitor system (Digitrapper MK III; Synestics Medical) was inserted under the fluoroscope and one electrode was located on the esophageal lumen 5 cm orally from the E-C junction and another on the gastric corpus. Gastric juice test for acid secretion was performed after overnight fasting according to the standard protocol. pH monitoring and gastric acid secretion test were performed under hospitalization 72 h after stopping the drug(s) affecting gastric acidity. Borderline of atrophy and histology (inflammation, atrophy) of the antrum and corpus were evaluated by endoscopic finding and Sydney system, respectively. Results: 1) Eradication was succeeded in 12 patients. 2) Gastric mean pH, gastric pH>3 holding time ratio (pH3-HTR), and grade of endoscopic atrophy and histological inflammation were higher in eradicated group than those in persistent infection. 3) Nocturnal intragastric pH inversion (NIPI) phenomenon was observed in 10 among 12 eradicated cases. Endoscopic atrophy and active gastritis were more remarkable in NIPI. NIPI disappeared after success in eradication. 4) An improvement of gastritis, a decrease in gastric mean pH, pH3-HTR, and an increase in basal acid output and maximal acid output were demonstrated in patients with success in eradication. 5) GER after eradication was observed in 6 cases. Gastric mean pH and pH3-HTR were lower and an improvement of antral neutrophil infiltration was more apparent in GER-positive eradicated patients compared with GER-negarive ones. Conclusions: These results suggest that NIPI may reflect severe gastric atrophy accompanied by corpus neutrophil infiltration and that <i>H. pylori</i>eradication results in recovery of antral gastritis and gastric acid secretion, enhancing the potency of GER in gastric ulcer patients.

A new endoscopic method of gastric acid secretory testing

Objective: To date, the effect of Helicobacter pylori on acid secretion remains controversial. To evaluate changes in the gastric acid secretory response before and after H. pylori eradication in a large number of patients, we devised a new endoscopic method of gastric acid secretory testing, the endoscopic gastrin test (EGT). Methods: In EGT, endoscopy was begun 15 min after intramuscular injection of 4 μg/kg tetragastrin. Gastric fluid secreted between 20 and 30 min after gastrin injection was aspirated and collected during endoscopic examination. The amount of acid in the sample collected over this 10-min period was estimated by titration and expressed in H + mEq/10 min. Fifteen subjects underwent a conventional secretory test using a nasogastric tube (conventional method) and EGT on different days to assess the correlation between results obtained with the two methods. In 10 of these subjects, EGT was repeated under the same conditions to assess its reproducibility. Results: EGT values correlated very well with peak acid output determined by the conventional method (n = 15, r = 0.92) and had high reproducibility (n = 10, CV = 5.6). We noted that EGT takes just a little longer to perform than a routine endoscopic examination, and the influence of an endoscope in the stomach on acid secretion was not present. Conclusion: The EGT should be very useful as a rapid, simple substitute for conventional secretory testing when repeated gastric secretory tests are required, especially in investigating the effect of H. pylori on acid secretion in a larger population.

Pathogenetic factors affecting gastroesophageal reflux in patients with esophagitis and concomitant duodenal ulcer: a multivariate analysis.

AIM:To assess the relationship between gastric acid output (GAO) and both pattern of gastroesophageal reflux (GER) and esophageal lesions,and to evaluate the role of GAO and other potential pathogenetic factors in the development of esophagitis.METHODS:Gastric acid secretory testing and 24h intraesophageal pH monitoring were performed in 31 patients with esophagitis and concomitant duodenal ulcer (E+DU) and compared with those of 72 patients with esophagitis (E) alone.RESULTS: The GAO in patients with E+DU was significantly higher than in patients with E (P <0.05). There was no significant difference between the two groups of patients as to endoscopicl findings and parameters of GER (P >0.05). A multiple regression analysis with stepwise deletion showed that the pre-sence of hiatal hernia (HH), GER in upright position and age appeared to correlate significantly with the presence of esophagitis.CONCLUSION:No parallel relationship between GAO and severity of GER or esophageal lesions exists in patients with E+DU, and that GAO is not a major pathogenetic factor in GER disease.

Gastric tubes, meals, acid, and analysis: rise and decline

The stomach tube was first used to administer food and medication or to remove poisonous substances. Later, it served to aspirate the stomachs of patients with gastric retention. Chemical analysis of stomach contents after a meal was first suggested in 1871 and quickly became an important laboratory procedure as various test-meal stimuli and more flexible tubes were developed. Quantitative estimations of free and total acidity were made by titration with 0.01 mol/L sodium hydroxide and specific indicators. Pentagastrin has supplanted secretagogues such as histamine and betazole; meal stimulation, tubeless tests, and other tests of gastric secretion are no longer used clinically. Tests of gastric acid secretion have been used in the diagnosis of upper gastrointestinal lesions and to help select the type of surgical procedure for gastric and duodenal ulcers, but the tests have decreased in importance because of their limited diagnostic sensitivity and specificity. Today, fiberoptic endoscopy is replacing gastric analysis as well as radiologic examination.

Medical Therapy Versus Laparoscopic Surgical Treatment for Ulcer Disease.

The development of low morbidity vagotomy and H2 antagonists in the early 1970s began the debate as to which was the most appropriate treatment for uncomplicated duodenal ulcer. A review of Australian Medicare and Pharmaceutical Benefits Scheme data shows that medical treatment in this country was the preferred option. In the past 12 years, vagotomies have decreased 15-fold while, in the same period, H2 antagonist prescriptions have increased from 0 to 2.5 million per year, doubling in the past 3 years, and currently costs $96 million per year or 6.7% of the country's entire pharmaceutical budget. Similarly, upper gastrointestinal tract endoscopies have increased, costing $15 million per year, doubling in the past 6 years and representing a cost almost equivalent to all other upper gastrointestinal procedures combined. Despite known efficacy and recommendations for use, triple therapy for Heliobacter species is not being used with prescriptions for surface agents actually decreasing to 40,000 per year. A review of the outcome of medical and surgical therapy shows that this expense is not justified; surgery would be more costeffective than medicine at 2 years and safer than medicine after 4 years as a result of complications from failed medical treatment. This margin of benefit is predicted to be greater with laparoscopic vagotomy. Failed medical treatment needs to be redefined by limiting H2 antagonists to a 6-week course. Recurrences or failures are than evaluated endoscopically and those diagnosed with having chronic duoderal ulcers have biopsies taken. Heliobacter pylori positive patients are treated with triple therapy. Failures, recurrences, and originally H pylori negative patients have laparoscopic vagotomy. For such a trial protocol to be evaluated, it requires the long-term use of H2 antagonists to be restricted and laparoscopic vagotomists to document the efficacy of their surgery, including gastric secretion tests.

Duodenal ulcer, Helicobacter pylori, and gastric secretion.

Patients with chronic dyspepsia were categorised by macroscopic appearance at oesophagogastroduodenoscopy as having duodenal ulceration (DU), other diagnosed lesions such as reflux oesophagitis, carcinoma of stomach, etc, or no organic lesion (non-ulcer dyspepsia, NUD). Material was collected to identify gastric infection with Helicobacter pylori (H pylori) by CP urease test, culture, and histological examination and to make the microscopic diagnosis of active chronic gastritis. Each patient in the DU and NUD categories was then invited to volunteer for a gastric secretion study in which maximal gastric secretion in response to histamine was measured. Sixty two gastric secretion tests were performed (31 DU, 31 NUD). The presence of H pylori was associated with active chronic gastritis (100%). DU patients secreted more acid than the NUD patients. H pylori positivity was associated with decreased maximal gastric secretion in both groups. There was a positive correlation between smoking and maximal acid output shown only in H pylori negative but not in H pylori positive patients. These findings were clear cut when all corrections of maximal gastric secretion were made for pyloric loss, duodenogastric reflux, and stature. This study failed to show any aetiological link between H pylori and DU by increased maximal gastric secretion.

Effect of 7 years' daily oral administration of omeprazole to beagle dogs.

Ten beagle dogs were given omeprazole orally at a dose of 0.17 mg/kg (0.5 mumol/kg) daily for 7 years. Six dogs served as controls. Regularly evaluated criteria were clinical signs, body weight, food consumption, rectal temperature, electrocardiography, hematology, blood chemistry, urinalysis, ophthalmoscopy, gastroscopic examination including gastric mucosal biopsy sampling for histological evaluation, pharmacokinetics of omeprazole, and plasma gastrin levels. After approximately 5 years, a quantitative gastric acid secretion test was performed. No treatment-related adverse clinical signs or effects were observed in the dogs, and all animals survived to term. The annual gastroscopy with histological examinations of gastric mucosa did not show any treatment-related changes. At all investigations and in all dogs, the parietal cells were morphologically normal, and there were no changes of pattern or any increase in the number of argyrophil enterochromaffin-like cells compared to the control animals. In the plasma samples collected 24 h after dosing, there were no significant differences in either basal or meal-stimulated gastrin levels between the controls and the omeprazole-treated animals. Peak plasma concentration of omeprazole occurred within 2 h of dosing. The area under the concentration curve (AUC) was not affected by dosing over 7 years and was in good agreement with the AUC in humans given a dose of 20 mg omeprazole daily. Acid secretion tests after 5 years of treatment showed that the mean inhibition of acid secretion by omeprazole 4-7 h after dosing was as expected--about 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

The value of sham-feeding tests in patients with postgastrectomy syndromes.

The value of gastric secretory testing in surgical practice has been questioned. Sham feeding (SF) is a test of gastric secretion that determines the status of gastric vagal innervation or incomplete vagotomy. Our purpose was to show that the results of SF tests affect operative strategy and/or clinical management. The medical records of 30 consecutive patients studied with SF in our laboratory were reviewed to determine if patient management was affected by the results of SF. All 30 patients had prior vagotomies. Sham feeding was performed in patients (1) before planned reoperation for postgastrectomy syndromes (n = 17), (2) with peptic ulcerations/pain of unclear etiology (n = 8), or (3) postoperatively in those who were at high risk for recurrent ulcer (n = 5). Sham feeding indicated complete vagotomy in 16 patients and incomplete vagotomy in 14 patients. In 17 patients studied before planned reoperation, operative strategy was affected by results of SF in 15 cases; five patients had revagotomies performed at reoperation, 11 did not, and one patient had her operation canceled. In patients with atypical postoperative ulcers/pain, management was changed in only two of eight patients. In the high-risk patients studied postoperatively, management was affected in four of five patients. (1) We believe that our results justify the performance of SF before any reoperation on the stomach, since an operative plan was nearly always affected. (2) In patients with atypical peptic complaints after gastric surgery, SF usually (80%) confirmed acid hypersecretion, thereby affecting management less often. (3) Although unproved, we believe SF results can guide the use of "prophylactic" H2-blockers in treating selected high-risk postgastrectomy patients.