History Of Peptic Ulcer Research Articles

Incidence of gallstone disease in Italy: Results from a multicenter, population-based Italian study (the MICOL project)

To evaluate gallstone incidence and risk factors in a large population-based study. Gallstone incidence and risk factors, were evaluated by structured questionnaire and physical examination, respectively, in 9611 of 11 109 (86.5%) subjects who were gallstone-free at the cross-sectional study. Six centers throughout Italy enrolled 9611 subjects (5477 males, 4134 females, aged 30-79 years), 9517 of whom were included into analysis: 424 subjects (4.4%) had gallstones and 61 (0.6%) had been cholecystectomized yielding a cumulative incidence of 0.67% per year (0.66% in males, 0.81% in females). Increasing age, a high body mass index (BMI), a history of diabetes, peptic ulcer and angina, and low cholesterol and high triglyceride levels were identified as risk factors in men while, in females, the only risk factors were increasing age and a high BMI. Increasing age and pain in the right hypocondrium in men and increasing age in females were identified as predictors of gallstones. Pain in the epigastrium/right hypocondrium was the only symptom related to gallstones; furthermore, some characteristics of pain (forcing to rest, not relieved by bowel movements) were significantly associated with gallstones. No correlation was found between gallstone characteristics and clinical manifestations, while increasing age in men and increasing age and BMI in females were predictors of pain. Increasing age and BMI represent true risk factors for gallstone disease (GD); pain in the right hypocondrium and/or epigastrium is confirmed as the only symptom related to gallstones.

Helicobacter pylori infection influences the acidity in the gastric tube as an esophageal substitute after esophagectomy

It is commonly considered that acidity in a gastric tube used as an esophageal substitute after esophagectomy decreases due to truncal vagotomy. However, there have been few, if any, studies on the factors influencing the acidity in the gastric tube. It is well known that Helicobacter pylori (H. pylori) plays an important role in acid secretion of the stomach. The aim of this study was to investigate whether or not H. pylori infection also influenced the acidity in the gastric tube as an esophageal substitute. We investigated the changes in the levels of gastric acidity and the status of H. pylori infection from the preoperative period to 1 year after surgery. In 65 Japanese patients who underwent resection of esophageal cancer followed by reconstruction using a gastric tube, 24-h gastric pH monitoring and examination of H. pylori infection using the 13C-urea breath test and biopsy specimen obtained from the gastric mucosa under upper gastrointestinal endoscopy were performed pre- and postoperatively. Twenty-seven among the 65 patients underwent the same examinations at 1 year after surgery. The levels of postoperative gastric acidity and at 1 year after surgery were significantly lower than that of preoperative gastric acidity (P = 0.031, P = 0.001, respectively). There was no difference in the levels of gastric acidity between 1.5 months and 1 year after surgery (P = 0.282). The levels of gastric acidity in the stomach and in the gastric tube were significantly influenced by H. pylori infection, while age, gender, and past history of peptic ulcer showed no influence. The level of gastric acidity in patients who had H. pylori infection pre- and postoperatively were significantly lower than that in patients who had no H. pylori infection pre- and postoperatively (P < 0.0001). H. pylori infection was indicated to be an important factor influencing the levels of gastric acidity in the reconstructed esophagus as well as in the stomach before surgery.

Whistler Summary: “The Slow Rate of Rapid Progress”

Whistler Summary: “The Slow Rate of Rapid Progress”

Effect of Proton Pump Inhibitor or H2 Receptor Antagonist on Prevention of Bleeding from the Ulcer After Endoscopic Submucosal Dissection of Early Gastric Cancer: A Prospective Randomized Controlled Trial

Adjusted for Helicobacter pylori status, age, sex, smoking, NSAIDs use past 7 days, history of peptic ulcer, endoscopist, location of main tumor, and number of tumors.

Gastrointestinal Perforation Due to Bevacizumab in Colorectal Cancer

Bevacizumab is the first U.S. Food and Drug Association-approved vascular endothelial growth factor-targeted agent that greatly increases progression-free and overall survival in combination with standard chemotherapy regimens in patients with metastatic colorectal cancer. Although bevacizumab is generally well tolerated, some serious adverse events have occurred in some patients in clinical trials, including arterial thromboembolism and gastrointestinal (GI) perforation. GI perforation was first observed in the pivotal phase 3 trial, in which six events occurred in bevacizumab group (1.5%), compared with no events in the control group. Since then, similar rates of GI perforation have been observed in other large trials. Typical presentation was abdominal pain associated with constipation and vomiting. Such events occurred throughout treatment and were not correlated with duration of exposure. No difference in rate of GI perforations was found in patients who did and did not have a baseline history of peptic ulcer disease, diverticulosis, and history of chronic use of nonsteroidal anti-inflammatory drugs. However, the incidence of GI perforation seemed to be higher in patients with primary tumor intact, recent history of sigmoidoscopy or colonoscopy, or previous adjuvant radiotherapy, but it is necessary to confirm these preliminary findings by multivariate analyses. The mechanism responsible for causing GI perforation is not known and may be multifactorial. Bevacizumab should be permanently discontinued in patients who develop GI perforation. This article reviews the incidence, presentation, pathogenesis, risk factors, and management of GI perforation in patients with colorectal cancer who are treated with bevacizumab.

Mentally ill prisoners in Australia have poor physical health

Our objective was to compare the physical health status of adult prisoners with and without a mental illness. Mental illness was diagnosed in a sample of 557 Australian prisoners using the Composite International Diagnostic Interview (CIDI). Physical health measures included self‐reported chronic health conditions, recent health complaints and symptoms, self‐assessed health using the Short‐Form 36 Health Survey (SF‐36), and markers of infectious diseases known to be highly prevalent among prisoner populations (hepatitis A, hepatitis B, and hepatitis C). Men and women with a mental illness had lower scores on the SF‐36 compared with those without a mental illness indicating poor overall health. Adjusting for age and sex, a diagnosis of any mental illness (symptoms of psychosis, anxiety or affective disorder) was positively associated with a history of head injury, back problems, asthma, peptic ulcers, cancer, and epilepsy/seizures. There was a significant association between post traumatic stress disorder and asthma, a history of head injury, peptic ulcers, and cancer. There was no significant difference in the proportion of current tobacco smokers in the mentally ill and nonmentally ill groups (81% vs. 77%, p = 0.33). However, those with a mental illness were less likely than those with no diagnosis to exercise in the past 4 weeks (79% vs. 89%, p = 0.002). Mentally ill prisoners also have significant physical co‐morbidity compared with the non‐mentally ill. These findings suggest that those providing mental health services to prisoners should adopt a holistic approach embracing both mental and physical health.

Inappropriate Prevention of NSAID-Induced Gastrointestinal Events Among Long-Term Users in the Elderly

Although use of NSAIDs and aspirin (acetylsalicylic acid) is well known to be associated with gastrointestinal (GI) complications and potential mortality, these medications continue to be widely prescribed in the elderly. Age is a significant risk factor for NSAID-induced GI events; indeed, patients >75 years of age carry the highest risk and are similar in this respect to patients with a history of peptic ulcer. Prevention of NSAID-induced gastropathy is indicated in patients at risk. It is accepted that patients >60 years of age taking NSAIDs should participate in prevention strategies such as co-therapy with proton pump inhibitors (PPIs) or misoprostol, or use of cyclo-oxygenase (COX)-2 selective NSAIDs (also called coxibs). Although up to 33% of subjects with no risk factors who receive NSAIDs over-utilise GI preventive therapies, under-utilisation of gastroprotective therapy is more prevalent among those with risk factors, of which the most frequent is age. At least half of those at risk do not receive appropriate preventive therapy, either because they do not receive co-therapy with PPIs or misoprostol or are not treated with COX-2 selective NSAIDs, or because they receive co-therapy with antacids or histamine H(2) receptor antagonists, which are not effective. Adherence to the prescribed preventive therapy is an additional problem for those who are prescribed a PPI or misoprostol. Over 30% of patients are non-adherent and the lowest rate of non-adherence is associated with the first NSAID prescription, which increases the risk of ulcer bleeding compared with those who are fully adherent. Predictors of nonadherence include long-term use of NSAIDs and a high average daily dose of NSAIDs. Predictors of adherence include a history of upper gastrointestinal events, anticoagulant use, rheumatological disease and use of low-dose salicylates, among others. Another important aspect is self-medication; this is common in the elderly, who also have several risk factors for GI complications, and may be a factor in over one-third of all NSAID-related complications. In summary, aging is a key risk factor for GI complications in patients taking NSAIDs. Appropriate prevention strategies should be used in the elderly and those at risk; special attention should be paid to compliance and self-medication.

NSAIDs: GI risk with a past history of peptic ulceration

AbstractIn this Drug points article the author describes a case of osteoarthritic pain where prescribing diclofenac resulted in gastrointestinal ulceration and comments on the issues it raises. Copyright © 2006 Wiley Interface Ltd

Cardioprotective aspirin users and their excess risk of upper gastrointestinal complications

BackgroundTo balance the cardiovascular benefits from low-dose aspirin against the gastrointestinal harm caused, studies have considered the coronary heart disease risk for each individual but not their gastrointestinal risk profile. We characterized the gastrointestinal risk profile of low-dose aspirin users in real clinical practice, and estimated the excess risk of upper gastrointestinal complications attributable to aspirin among patients with different gastrointestinal risk profiles.MethodsTo characterize aspirin users in terms of major gastrointestinal risk factors (i.e., advanced age, male sex, prior ulcer history and use of non-steroidal anti-inflammatory drugs), we used The General Practice Research Database in the United Kingdom and the Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria in Spain. To estimate the baseline risk of upper gastrointestinal complications according to major gastrointestinal risk factors and the excess risk attributable to aspirin within levels of these factors, we used previously published meta-analyses on both absolute and relative risks of upper gastrointestinal complications.ResultsOver 60% of aspirin users are above 60 years of age, 4 to 6% have a recent history of peptic ulcers and over 13% use other non-steroidal anti-inflammatory drugs. The estimated average excess risk of upper gastrointestinal complications attributable to aspirin is around 5 extra cases per 1,000 aspirin users per year. However, the excess risk varies in parallel to the underlying gastrointestinal risk and might be above 10 extra cases per 1,000 person-years in over 10% of aspirin users.ConclusionIn addition to the cardiovascular risk, the underlying gastrointestinal risk factors have to be considered when balancing harms and benefits of aspirin use for an individual patient. The gastrointestinal harms may offset the cardiovascular benefits in certain groups of patients where the gastrointestinal risk is high and the cardiovascular risk is low.

Discontinuation of proton pump inhibitors in patients on long‐term therapy: a double‐blind, placebo‐controlled trial

The proportion of proton pump inhibitor users on long-term therapy who can discontinue proton pump inhibitor (PPI) medication without developing symptoms is unknown. To determine the proportion of patients on long-term PPI therapy who are able to discontinue PPIs without developing symptoms. Patients on long-term PPIs, without a history of peptic ulcer or esophagitis underwent upper endoscopy. Patients were randomized double-blindly to taper down or continue a constant dosage of omeprazole for three weeks. Thereafter, all patients discontinued PPIs. Of the 97 patients enrolled, had used PPIs for 48 months, 78% had GERD. A total of 27% did not use PPIs during the year after discontinuation, 31% of the patients randomized to tapering discontinued PPIs and 22% of those who did not could discontinue therapy (NS). Gastro-oesophageal reflux disease (GERD) patients were more prone to continue PPIs than non-GERD patients. Only 16 (21%) of GERD patients were off PPIs vs. 48% of patients without GERD (p < 0.05). Serum gastrin was higher at baseline in GERD patients who resumed PPIs versus non-resumers (p < 0.05). GERD and serum gastrin were independent predictors of PPI requirement. Discontinuation of PPI was successful in 27% of long-term PPI users. GERD patients had more difficulty discontinuing PPIs than non-GERD patients.

Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin

Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin

Selective cyclooxygenase inhibition: its role in pain and anaesthesia

Cyclooxygenase inhibitors reduce inflammation and hyperalgesia by decreasing prostaglandin E 2 production. Traditional NSAIDs (inhibiting both COX-1 and 2) though ubiquitous in peri-operative pain practice, have well-known gastrointestinal (GI), cardiovascular and other risks. This article systematically addresses the main efficacy and safety issues pertaining to NSAID and selective COX-2 inhibitors (coxibs) use, focusing on the acute pain context, particularly post-operative pain management. NSAIDs and coxibs are of proven analgesic efficacy in post-operative pain control, and their opioid-sparing role in multimodal analgesia, leads to significantly reduced opioid related side effects. Although GI risk is regarded as less of an issue in short-term therapy, in patients with a past history of peptic ulceration who are denied NSAIDs, coxibs may be considered a suitable alternative. In the peri-operative setting, coxibs confer an additional advantage over NSAIDs by preserving the platelet thromboxane production and clotting. Cardiovascular safety has been assessed for the parenteral parecoxib and its active moiety valdecoxib, and was found to be satisfactory in major non-cardiac surgery, but increased thromboembolic complications occurred in coronary artery bypass surgery leading to contra-indication for this type of surgery. Coxibs and NSAIDs have similar renal effects and caution or avoidance is required with renal disease or reduced peri-operative renal perfusion. Coxibs may be safer in aspirin-sensitive asthmatics. Bone healing effects remain controversial, but only a few days therapy appears to be safe.

Hyperplastic polyposis and cancer of the colon with gastrinoma of the duodenum

A 64-year-old woman presented to the emergency room with a 3-month history of intermittent abdominal cramps, accompanied by nausea, vomiting, anorexia, and decreased bowel movements consistent with a partial intestinal obstruction. She had a 12-year history of peptic ulcers, which had been treated with histamine-2 blockers. Physical examination, abdominal X-ray, abdominal CT scan, colonoscopy and assessment of gastrin levels. Duodenal neuroendocrine neoplasm showing gastrin expression and stage III (T3N2M0), poorly differentiated adenocarcinoma of the cecum arising from hyperplastic polyposis. Right-sided hemicolectomy with ileocolonic anastomosis, duodenal resection, leucovorin and 5-fluorouracil chemotherapy, annual colonoscopic surveillance, and polypectomy.

Portal pseudo-hypertension

Authors present a case report of a 51 years old man, with a past history of peptic ulcer, arterial hypertension and dislipidemia. Three weeks before hospitalization he did a upper endoscopy that revealed a duodenal ulcer and oesophageal varices (grade II/III). During etiologic investigation, hepatic disease and portal hypertension were excluded. He had a goiter that invaded the anterior mediastinum. After thyroidectomy the oesophageal varices disappeared.

A prospective study of dietary salt intake and gastric cancer incidence in a defined Japanese population: The Hisayama study

The results of prospective studies of the association between dietary salt intake and gastric cancer occurrence remain controversial. To examine this issue in a cohort study of a general population, 2,476 subjects aged 40 years or older were stratified into 4 groups according to the amount of daily salt intake: namely, <10.0, 10.0-12.9, 13.0-15.9, and > or = 16.0 per day and were followed up prospectively for 14 years. During the follow-up period, 93 subjects developed gastric cancer. The age- and sex-adjusted incidence was significantly higher in the second to fourth groups than in the first group (age- and sex-adjusted hazard ratio [95% confidence interval], 2.42 [1.24-4.71] for the second group; 2.10 [1.03-4.30] for the third group; 2.98 [1.53-5.82] for the fourth group). This association remained substantially unchanged even after adjusting for other confounding factors such as age, sex, Helicobacter pylori infection, atrophic gastritis, medical history of peptic ulcer, family history of cancer, body mass index, diabetes, total cholesterol, physical activity, alcohol intake, smoking habit and other dietary factors. In the stratified analysis, a significant salt-cancer association was observed only in subjects who had both Helicobacter pylori infection and atrophic gastritis (age- and sex-adjusted hazard ratio, 2.87 [1.14-7.24]). Our findings suggest that high dietary salt intake is a significant risk factor for gastric cancer; moreover, this association was found to be strong in the presence of Helicobacter pylori infection with atrophic gastritis.

Helicobacter pylori eradication prior to initiation of long-term non-steroidal anti-inflammatory drug therapy in Chinese patients – a cost-effectiveness analysis

Recent randomized clinical trials suggested that eradication of Helicobacter pylori prior to initiation of non-steroidal anti-inflammatory drug (NSAID) therapy would reduce the rate of peptic ulcer disease (PUD). To analyze the cost-effectiveness of H. pylori eradication prior to initiation of long-term NSAID therapy for prevention of NSAID-induced PUD in a cohort of Chinese patients at high risk for PUD. Clinical and economic data of 100 participants from a previously reported clinical trial conducted in Hong Kong were analyzed. Patients with a history of peptic ulcers were randomized to 1-week omeprazole 20 mg, amoxicillin 1 g and clarithromycin 500 mg twice daily (eradication group; n = 51) or 1-week omeprazole 20 mg twice daily (omeprazole group; n = 49) before initiation of diclofenac 100 mg daily for 6 months. The rates of PUD and healthcare utilization for routine follow-up as well as for management of symptomatic PUD of the 2 groups were retrieved from medical records. The rate of symptomatic ulcers in eradication group and omeprazole group were 3.9% and 18%, respectively. The mean direct medical cost of the eradication group was significantly lower than that of the omeprazole group by 30% (US dollar 797 (95% CI = 685 - 909) versus US dollar 1,128 (95% CI = 879 - 1,377)) (p = 0.018). The results were robust to variation of all the cost items. H. pylori eradication prior to initiation of NSAID therapy appeared to reduce the ulcer rate and mean direct medical cost when compared to no eradication for Chinese H. pylori-infected NSAID users at high risk for PUD.

Comparison of Proton Pump Inhibitor with H2 Receptor Antagonist for Prevention of Bleeding from Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancers: A Non-Blind Randomized Controlled Trial

Background: Proton pump inhibitor (PPI) and H2 receptor antagonist (H2RA) have similar effect on prevention of bleeding after endoscopic mucosal resection (EMR) for early gastric cancer (EGC) by conventional strip biopsy method. Introduction of wide spread EMR by endoscopic submucosal dissection (ESD) technique caused higher rate of bleeding after procedure than the conventional methods in our center. Objective: To evaluate preventive effects of PPI and H2RA on bleeding from ulcer after EMR by ESD. Design: A non-blind randomized controlled trial. Setting: Endoscopy unit at a cancer center. Patients: A total of 105 patients (84 men and 21 women, mean age 67 years old) with EGC treated by ESD technique between January and November 2005. Median (range) tumor size was 15 (5-105) mm. Patients having administration of anticoagulant and severe organ failure were excluded. Written informed consent was obtainted from all patients and the study protocol was approved by the institutional review board. Interventions: Patients were randomized to two groups; labeprazole 40 mg p.o. bid (PPI group) from one day before procedure, and cimetidine 800 mg div two days followed by cimetidine 800 mg p.o. bid (H2RA group). Treatments were continued for 8 weeks. Main outcome measurements: Bleeding that was defined as hematoemesis and melena required endoscopic hemostasis, and decreased Hb of less than 2 mg/dl. Results: Significant differences were not available in age, sex, history of peptic ulcer, status of Helicobacter pylori, mean tumor size, and location of the tumor between the groups. Bleeding rate of the PPI group (1.8%; 1/55) was significantly less than that in the H2RA group (12%; 6/50, p = 0.043). Late perforation was occured in two patients in the H2RA group. Limitations: Non-blind design and a relatively small number of subjects. Conclusion: PPI inhibits bleeding from ulcer and the adverse effect after ESD for EGC.

Association of the Predominant Symptom With Clinical Characteristics and Pathophysiological Mechanisms in Functional Dyspepsia

Functional dyspepsia (FD) is considered a heterogeneous disorder with different pathophysiological mechanisms contributing to the symptom pattern. The Rome II committee proposed that subdividing patients with FD into groups with predominant pain versus discomfort might identify subgroups with homogeneous pathophysiological and clinical properties. The aim of this study was to analyze the relationship of predominant pain or discomfort with pathophysiological mechanisms and to evaluate whether considering individual predominant symptoms yields better results. Consecutive FD patients (n = 720; 489 women; mean age, 41.3 +/- 0.6 years) filled out a dyspepsia questionnaire and identified a single most bothersome symptom. We analyzed the association of this predominant symptom with demographic, clinical, and pathophysiological features (Helicobacter pylori status, gastric emptying in 592 patients, and gastric sensitivity and accommodation testing in 332 patients). According to Rome II criteria, 22% were pain predominant and 78% discomfort predominant. Patients with predominant pain had a higher prevalence of hypersensitivity (44% vs 25%) and delayed gastric emptying was observed less frequently in these patients (16% vs 26%), but there was major overlap. Detailed analysis showed that any of 8 dyspeptic symptoms could be predominant. Predominant early satiety or vomiting was associated with significantly higher prevalences of weight loss (89% and 75%, respectively) and of acute onset (61% and 60%, respectively). Impaired accommodation was found in 79% of patients with predominant early satiety. The highest prevalence of delayed emptying was found in predominant fullness (38%) and of hypersensitivity in predominant pain (44%). Subdividing FD patient groups according to the predominant symptom does not reliably identify subgroups with a homogeneous underlying pathophysiological mechanism.

A past history of gastric ulcers and Helicobacter pylori infection increase the risk of gastric malignant lymphoma

Helicobacter pylori (H. pylori) is a causative agent for peptic ulcers as well as some types of gastric lymphoma; however, the relationship between a peptic ulcer history in combination with H. pylori infection and the risk of gastric lymphoma has not been fully evaluated. To examine this point, we conducted a case-control study with 645 patients histologically diagnosed as having malignant lymphomas and 3225 non-cancer controls. Plasma H. pylori IgG status was assessed for subgroups for which blood samples were available (116 cases and 114 controls). An association with a history of gastric, but not duodenal ulcers was found for gastric lymphoma [odds ratio (OR) = 5.41, 95% confidence interval (CI): 3.12-9.39]. In the examination according to histological subtype, the OR was high for both gastric mucous-associated lymphoid tissue (MALT) lymphoma (OR = 5.54, 95% CI: 2.56-12.01) and diffuse large B-cell lymphoma (DLBCL) (OR = 7.23, 95% CI: 2.62-19.90). In the analysis of H. pylori antibody, the risk of total gastric lymphoma was associated with H. pylori infection (OR = 5.34, 95% CI: 1.42-20.05). A high prevalence of H. pylori infection was also found for both gastric MALT lymphoma (8 out of 10: 80.0%) and DLBCL (8 out of 9: 88.9%). Further, in subgroup analysis of subjects with H. pylori infection, gastric ulcer history, but not duodenal ulcer history was associated with the risk of gastric lymphoma (OR = 4.15, 95% CI: 1.02-16.89). In conclusion, we found a positive association with a past history of gastric ulcer and H. pylori infection for gastric lymphoma, while duodenal ulcer history was no association. These results suggested the risk of gastric lymphoma increased by interaction between H. pylori infection and gastric ulcer history. Further studies are warranted.

Incidence and predictors of upper gastrointestinal bleeding in patients receiving low-dose aspirin for secondary prevention of cardiovascular events in patients with coronary artery disease

The use of low-dose aspirin to prevent cardiovascular disease events is well established. However, the incidence and predictors of upper gastrointestinal bleeding (UGIB) with its use are unknown. We studied prospectively the incidence and outcome of peptic ulceration in low-dose aspirin users. A total of 991 patients with coronary artery disease (CAD) on low-dose aspirin were prospectively followed-up for two years for the occurrence and clinical features of first hospitalized episode of UGIB. UGIB had a bimodal presentation with 45% occurring within four months of aspirin initiation and had an overall prevalence of 1.5% per year. There was no UGIB-related death. Hypertension (OR = 4.6, 95%CI 1.5-14.7, P = 0.009), history of peptic ulceration (OR = 3.1, 95%CI 1.1-9.0, P = 0.039), tertiary education (OR = 3.08, 95%CI 1.1-9.0, P = 0.039) and higher lean body mass (P = 0.016) were independent factors associated with UGIB. Use of nitrate did not reduce UGIB. The incidence of UGIB in patients with CAD on long-term low-dose aspirin is low, but is accompanied with significant morbidity. With prolonged use of aspirin, UGIB continues to be a problem for those with risk factors and especially in patients with a history of peptic ulcers, in which UGIB tends to occur early after aspirin therapy.