Cases Of Peptic Ulcer Research Articles

Epidemiology of primary health problems in Beirut.

As a result of 12 years of civil war in Lebanon, it has been impossible to collect regular morbidity information at the primary level. This report is based on a case-control analysis of various health problems as identified from a population based health survey in Beirut in 1983-1984. Cases of headache, backpain and peptic ulcer, as identified from this survey of 2752 households, were matched for age, sex, and neighbourhood with controls from the same sample. Cases and controls were compared for the presence of various characteristics as collected in the household interview. Headaches were more prevalent in females and in the higher educational categories, and the odds ratio was 1.3 (95 per cent confidence interval 1.01-1.68) for the married compared to the non-married. In comparisons of backpain, the odds ratio for alcohol consumption was 2.40 (1.14-5.08), and for belonging to skilled and unskilled labour categories of occupation it was 2.33 (1.05-5.15) when the analysis was limited to the employed group only. Although the peptic ulcer cases were of lower educational background compared to their controls, no other findings were identified in this third case-control comparison. The methodological shortcomings of such studies and the various interpretations of the findings are presented in the discussion.

Nonoperative treatment of perforated duodenal ulcer.

This report concerns 35 adult patients in whom perforation of a duodenal or prepyloric ulcer was treated nonoperatively between July 1979 and April 1988 at the Los Angeles County--University of Southern California Medical Center, Los Angeles. Each patient had pneumoperitoneum with clinical evidence of peritonitis, and a gastroduodenogram documented a sealed perforation. The ulcer was believed to be acute in 27 patients and chronic in 8. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. An intra-abdominal abscess developed in 1 of the 35 patients. Reperforation did not occur. The mortality rate for the 259 cases treated operatively during this period was 6.2%; the mortality rate of the 35 cases treated nonoperatively was 3%. Duodenal ulcer can be safely treated nonoperatively when a gastroduodenogram documents self-sealing.

Risk and Cost of Gastrointestinal Side Effects Associated With Nonsteroidal Anti-inflammatory Drugs

A retrospective cohort study determined the risk and cost of gastrointestinal side effects associated with the use of nonsteroidal anti-inflammatory drugs for an at-risk period from January 1, 1985, through March 31, 1985. Overall relative risk, adjusted for sex and race, was 2.52 (95% confidence interval, 2.25 to 2.82) and varied from 1.64 (95% confidence interval, 0.92 to 2.91) for duodenal ulcer to 3.27 (95% confidence interval, 1.40 to 7.66) for gastrointestinal bleeding. After deleting cases with a history of steroid or anticoagulant use or an alcohol-related diagnosis, adjusted relative risk was 2.58 (95% confidence interval, 2.29 to 2.90) and varied from 1.45 (95% confidence interval, 0.73 to 2.89) for all other cases of peptic ulcer to 2.37 (95% confidence interval, 1.26 to 4.46) for disorders of stomach function. There was a bimodal distribution of expenditures of Medicaid-paid gastrointestinal side effects. Most patients had low hospitalization costs, but an important minority had high hospitalization costs. Median ambulatory treatment costs during the 3-month study period for persons with gastrointestinal side effects was $27 and varied from $14 for those diagnosed as having nausea, vomiting, or heartburn to $393 for those diagnosed as having gastrointestinal bleeding. Median inpatient costs were $2006 and ranged from $1487 for persons with nausea, vomiting, or heartburn to $2486 for those with duodenal ulcer. For patients who had undergone an inpatient surgical procedure other than endoscopy alone, median hospital costs were $7209. An approximately twofold increase in payment for the same services would be expected if private third-party payers were responsible for the bill.

TEN-YEAR STATISTICS OF SURGICAL TREATMENT OF PEPTIC ULCERS AT OUR DEPARTMENT

Possible changes in surgical treatment of peptic ulcers at the Kobe University Hospital (First Dept. of Surgery) over the past ten years were explored, dividing the 10 years into the first (1978-1982) and second (1983-1987) periods. The number of hospitalized peptic ulcer cases and the number of surgically treated peptic ulcer cases fel by 50% from the first to the second period. The decrease was particularly marked in duodenal ulcer cases (in comparison with ulcers of the other sites) and intractable ulcer cases (in comparison with ulcers of the other features). The percentage of patients who underwent urgent operation was 37.3% in the first period, which fell to 28.6% in the second period. The number of surgically treated intractable ulcer cases showed a 69.2% reduction in the second period compared to the first period. However, the percentage of cases whose excised specimen was rated as representing giant ulcer, linear ulcer, or U1 IV was higher in the second period than in the first period. Stenosis was found in 7 cases in the first period and 3 cases in the second period. The percentage of hemorrhagic ulcer cases who received conservative treatment or pallilative operation became higher in the second period than in the first period, while the percentage of hemorrhagic ulcer cases who underwent urgent operation decreased from 65.2% in the first period to 33.3% in the second period. In hemorrhagic ulcer cases, the death rate during or after uregent operation rose from 28.7% (first period) to 40.0% (second period). Perforated ulcer was found in 7 cases in the first period and 1 case in the second period. Of these 8 cases, 4 died (3 in the first period and 1 in the second period). Death rate was particularly high in elderly patients who had no history of ulcer and in patients who received surgery 12 hours or more after perforation.

Incidence of gastropathy in destructive arthropathies.

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving the symptoms of arthritis, but may have serious side-effects such as gastrointestinal lesions. This paper reviews the current status of knowledge concerning NSAID-induced gastropathy. In general, patients who present with bleeding peptic ulcers are more likely to be using a NSAID than are matched controls. The incidence of gastric lesions is increased in patients receiving more than one NSAID, suggesting a cumulative risk for these drugs. Endoscopic studies, which have attempted to relate the presence of a lesion to dyspeptic symptoms have shown a poor correlation, indicating a high risk of perforation and bleeding without prior symptomatic warning. Peptic ulcer disease is equally prevalent in patients with rheumatoid arthritis or with osteoarthritis, so the underlying condition does not appear to influence the onset of NSAID-induced gastropathy. Care is required when prescribing NSAIDs; they should not be used in trivial or self-limiting conditions or in existing cases of active peptic ulceration. In addition, caution should be exercised in patients with a history of peptic ulceration, and in the elderly.

STUDY OF SURGICAL TREATMENT FOR PEPTIC ULCER DURING PAST 10 YEARS

To clarilify effects of H2 receptor antagonists on surgical treatment of peptic ulcers, operated cases of the disease for one decade were divided into each early and late 5 years, and comparatively investigated. The number of operative cases of peptic ulcers was decreased by 40% in the late period, however, no difference was noted in the number of emergency operations between both periods. A ratio of emergency to the total operative cases was increased to 62.6% in the late from 39.9% in the early period. No change in causative symptoms of hemorrhage and perforation was noted between both periods, but intractable ulcers were decreased to 28 cases (17.1%) in the late from 93 (33.7%) in the early period. A study of treatment history of late cases revealed that emergently operated cases were more common in untreated cases. Thirteen death cases (3.0%) within a month after surgery were found, which were all poor risk cases operated emergently and having complications. Important prognostic factors appear to include age, preoperative complication, preoperative shock, and time-lag from the onset of the disease to operation.

Smoking, nonsteroidal anti-inflammatory drugs, and acetaminophen in gastric ulcer. A study of associations and of the effects of previous diagnosis on exposure patterns.

A study was conducted in Sydney, Australia to investigate whether the use of some nonaspirin nonsteroidal anti-inflammatory (anti-arthritic) drugs was associated with gastric ulcer in patients who had had neither a gastric nor a duodenal ulcer diagnosed previously (i.e., in new cases of peptic ulcer), and whether the use of anti-arthritic drugs, aspirin, acetaminophen, and cigarettes was influenced by the diagnosis of a peptic ulcer--either gastric or duodenal. Bleeding of gastric ulcer in new cases was studied in relation to smoking, use of aspirin or anti-arthritic drugs, and age. The 417 patients in the study lived in Sydney and were interviewed between 1982 and 1985 after diagnosis of a gastric ulcer; 192 patients had had a gastric or duodenal ulcer diagnosed previously (i.e., were recurrent cases of peptic ulcer), and the remaining 225 patients were new cases to whom 411 community controls were matched on sex, age, and prestige of area of residence. In new cases, odds ratios of gastric ulcer were 5.0 for daily aspirin use and 2.3 to 5.4 for daily anti-arthritic drug use. Fewer recurrent cases than new cases had used aspirin daily (odds ratio (OR) = 0.5) or anti-arthritic drugs daily (OR = 0.5), and more recurrent than new cases had used acetaminophen daily (OR = 2.5). Among new cases, bleeding of gastric ulcer was less common in smokers (OR = 0.6), and more common in daily users of aspirin (OR = 2.1) and, to a lesser extent, in daily users of anti-arthritic drugs (OR = 1.5), and in patients aged 60 or more years (OR = 2.3) independent of usage of the above drugs. It is concluded that 1) the use of anti-arthritic drugs increases gastric ulcer risk; 2) diagnosis of a gastric or duodenal ulcer causes a decrease in the use of aspirin and anti-arthritic drugs and an increase in acetaminophen use, but does not change smoking habits; 3) aspirin use or advancing age may add to the risk of bleeding ulcer although the role of anti-arthritic drugs is less clear.

Effect of continuous intravenous infusion of secretin preparation (secrepan) in patients with hemorrhage from chronic peptic ulcer and AGML.

This study was conducted to evaluate the hemostatic effect of continuous intravenous infusion of secrepan (secretin preparation, Eisai Company Ltd. Tokyo) on gastroduodenal hemorrhage in patients with chronic peptic ulcer and AGML (acute gastric mucosal lesion). The patients consisted of 37 cases of bleeding ulcer (13 cases of chronic peptic ulcer and 24 cases of AGML). Secrepan was infused at a rate of 2U/kg/hr for the first 3 days and 0.5U/kg/hr for the next 4 days. The cumulative hemostatic rate in the chronic peptic ulcer group was 53.9% after 36 hours, and 76.9% after 48 hours of infusion, but no significant change in rate was observed thereafter. The cumulative hemostatic rate in the AGML group was 52.2% after 36 hours, and 95.7% after 72 hours of infusion. The hemostatic rate in chronic peptic ulcer and AGML cases with only slight or moderate bleeding was 100%, and no recurrent hemorrhaging was observed. The hemostatic rate in chronic peptic ulcer cases with severe bleeding was 62.5% and in AGML cases with severe bleeding was 93.3%, and 7 of 15 cases showed recurrent hemorrhage. Our findings indicated that continuous intravenous infusion of secrepan had more favorable effects on AGML cases, than on chronic peptic ulcer cases.

Frequency of occurrence of campylobacter pylori and analysis of the systemic and local immune response

During gastroduodenoscopic examination of 225 patients, bioptic mucosal specimens were taken for bacteriological and histological examination (Table 1). Campylobacter (C.) pylori was isolated from 7 out of 9 patients (78%) with gastric ulcer, from 59 out of 60 (98%) with duodenal ulcer, from 24 out of 31 (77%) with gastric erosions, from 10 out of 10 (100%) with duodenitis, from 14 out of 16 (88%) with chronic active gastritis, from 40 out of 73 (55%) with chronic inactive gastritis and from none out of 26 patients (0%) with normal mucosa (Table 2). To study the immune response an ELISA was developed which proved to give well reproducible and specific test results (Fig. 1). IgA- and IgG-titres were strongly reduced after absorption with C. pylori, but not with other antigens (including C. jejuni and C. coli, Table 3). Some sera gave reactions at higher titres when tested with the patient's own strain than with the standard antigen which is a mixture of 4 strains (Table 4). This indicates differences of the antigen composition within the species C. pylori. Sera from patients with positive culture showed higher IgG- and IgA-titres than sera from patients without isolation of C. pylori. The IgM-titres, however, were comparable in both groups (Fig. 3). Partially, sera from patients without C. pylori also showed high IgG-titres which were positively correlated with the patient's age. About 60% of culturally positive patients had specific IgA in their gastric juice, whereas this was not so with patients without isolation of C. pylori (Fig. 6). Examination of sera from healthy children and blood donors revealed that IgG but not IgA or IgM rose significantly with increasing age (Figs. 7-9). As can be concluded from the results of cultural and serological tests, C. pylori seems to be responsible at least for a part of cases of gastritis and peptic ulcer.

Clinical course and prognosis of chronic pancreatitis.

Course and prognosis of 125 patients with chronic pancreatitis (CP) were evaluated. Follow-up period ranged from 1-20 years with a median of 6.3 years. The following conclusions were obtained. Recent increase of CP in our clinics was ascribed to alcoholic CP and idiopathic CP in the aged. Of 106 patients with pain, 74 showed improvement or disappearance of pain. Drinking habit and observation period were the main factors determining the rate of pain relief. Serial endoscopic retrograde pancreatography (ERP) showed aggravation in 17/47 patients, cholecystokinin-pancreozymin (CCK-PZ) secretin test in 4/40 patients, and oral glucose tolerance test (OGTT) in 7/25 patients. Exocrine function showed improvement in five patients, whereas endocrine function showed none. Improvement or aggravation of exocrine function was closely related to drinking habit. Main complications included 15 cases of peptic ulcer, 19 of pancreatic pseudocyst, and 15 of bile duct stenosis. Twenty-six patients died, often due to malignant neoplasms and diabetic complications. Those who continued drinking as much showed a lower survival rate than those who discontinued or decreased alcohol intake. The socioeconomic status deteriorated often due to pain or alcoholism. Three patients had to degrade jobs and six fell into inactive social life.

Famotidine: postmarketing clinical experience.

A postmarketing survey of famotidine usage (phase IV survey) tracked 6346 patients at 602 locations from August 1985 to April 1986. Through the survey, the efficacy and the safety of famotidine were studied. The patients included 4618 cases of peptic ulcer, 106 cases of reflux esophagitis, 1006 cases of upper gastrointestinal tract bleeding, 343 cases of bleeding and ulcer prophylaxis, and 273 cases of gastritis and other diseases, totalling 6346 patients. Efficacy was analyzed by type of disease in terms of overall improvement; results of intermittent hemostatic efficacy were obtained for upper gastrointestinal tract bleeding; and safety was assessed. Overall, the results were good; the 8-week healing rate was 92.4%, and 72.3% of patients had their bleeding controlled within 7 days of beginning famotidine therapy. Side effects occurred in only 0.43% of patients, and abnormalities in laboratory test results were observed in less than 1% of patients. Gastrointestinal side effects, especially constipation, occurred most frequently. Most side effects were mild. The results of this postmarketing survey indicate that famotidine is a safe and effective H2-receptor antagonist.

CLINICAL STUDIES OF PERFORATIONS OF THE ALIMENTARY CANAL

Ninety-four patients with perforation of the alimentary canal who were treated in Saiseikai Shiga Hospital during the past five years were studied with regard to diagnosis, treatment and prognosis. Perforations of the stomach and duodenum were caused most frequently by peptic ulcer, while those of the small intestine and colon most commonly resulted from trauma. Perforations of the stomach and duodenum were diagnosed more easily than those of the small intestine and colon, by marked physical signs of peritonitis and a high rate of recognition of free intraperitoneal air. Extended gastrectomy was performed in almost all the cases of peptic ulcer. Selective proximal vagotomy with pyloroplasty was preferred for the other four cases. In all the three cases of gastric carcinoma, gastrectomy was performed. As operative procedures for patients with abdominal trauma, closure of perforated portions and resection of intestine were performed. Colostomy was undertaken in almost all the cases of perforation of the colon. The prognosis of patients with perforation of the alimental tract was good on the whole. Two patients with duodenal perforation died from hemorragic shock or septic shock, and three with colonic perforation died of endotoxin shock.

CLINICAL STUDIES ON SURGICAL TREATMENT AND PROGNOSIS OF PEPTIC ULCER IN OLD AGE

In the past 15 years, 101 cases of peptic ulcer in patients over 60 years of age were treated in our department. Of 101 patients, 76 had gastric ulcer, 16 had duodenal ulcer and 9 had combined gastric and duodenal ulcer. The number of peptic ulcers treated surgically has been decreasing recently, while the percentage of peptic ulcers in the aged has been increasing. Of these 101 cases, 52.4% of the patients had no past history of ulcer, and 49.3% had suffered from the disease for less than six months. In regard to symptoms, 71.3% of patients complained of abdominal pain, and 36.6% showed gastrointestinal hemorrhage. The indications for laparotomy were hemorrhage, perforation and stenosis in 48.6% and intractability in 47.2%. The rate of preoperative complications and the rate of emergency operations tended to increase with age. Although there was a complete absence of mortality in the patients without preoperative complications, that among patients with preoperative complications in emergency operations was a high 46.2%. How to avoid emergency operations in the aged remains a problem to be solved in the future.

Studies on the Surgical Cases of Peptic Ulcer with Bleeding

Studies on the Surgical Cases of Peptic Ulcer with Bleeding

Complications of oesophagoplasty with isoperistaltic transverse colon.

An analysis is presented of late results in 144 reconstructions of oesophagus with transplants (137 isoperistaltic, 7 anisoperistaltic) from transverse colon for correction of stricture, mainly after corrosive trauma. The grafts were interposed retrosternally in 126 cases and intrathoracically in 18. Delayed passage due to excessive size of the colon segment was managed in four cases by plication of the intra-abdominal part of the graft or by jejunal by-pass. 'Pseudo-diverticulum' at the proximal anastomosis occurred in five cases as a complication of the standard by-pass procedure. Correction was made by closure of the pouching oesophagus below the cervical anastomosis. Transformation to end-to-end anastomosis is also recommended. The incidence of gastrocolic reflux was low. In two of the four observed cases the cause was late pyloric stenosis. There was no case of peptic ulceration. For good late results of colo-oesophageal reconstruction, appropriate length and type of colon segment, suitable site of gastric implantation and isoperistalsis are of primary importance.

Radioimmunoassay of serum group I and group II pepsinogens in normal controls and patients with various disorders

A radioimmunoassay (RIA) for human group I pepsinogens (PgI) in serum was developed, using Pgl purified from gastric mucosa. The sensitivity (0.7 μg/1) and reproducibility of the assay were satisfactory for clinical use. In normal controls, total serum pepsinogen (T-Pg) level was 58.9 ± 31.7 μg/1 (mean ± SD) (Pgl, 43.6 ± 25.0 μg/1; Pgll, 15.3 ± 11.1 μg/1). Peptic ulcer cases had elevated T-Pg levels (gastric ulcer, gastroduodenal ulcer and duodenal ulcer, in increasing order of magnitude). T-Pg levels were not useful for diagnosis of peptic ulcer because of a large overlap with normal controls. T-Pg levels were low in patients with gastric polyp and in aged subjects. In these groups, the decrease of Pgl was more marked than that of PgII.

Upper gastrointestinal bleeding

This study examines the frequency of upper GI bleeding in the United States population, and the use of diagnostic endoscopy in its evaluation. Data from the National Hospital Discharge Survey and National Ambulatory Medical Care Survey are used, as well as limited data from the Veteran's Administration and State of Wisconsin. There were almost 1.1 million discharges from U.S. hospitals in 1978 with diagnoses related to UGI bleeding. Using an indirect method of estimation based on cases of peptic ulcer specified as bleeding, we estimate the rate of hospitalization with UGI bleeding as 150 per 100,000 population per year. About one-sixth of these patients underwent gastroscopy and/or esophagoscopy in 1978, approximately a three-fold increase over five years previously. National mortality from UGI bleeding decreased approximately 40 percent between 1968 and 1977, but data are inadequate to infer a relationship to increased use of endoscopy. Suggestions for further research are specified.

Peptic ulceration and cardiovascular disease.

A post-mortem study of two series, a consecutive series of 513 cases and a retrospective study of 65 cases of peptic ulceration, was carried out to ascertain the relationship of atheroma, calcification and aneurysm of the abdominal aorta, severe atheroma of the coronary arteries and aortic stenosis to peptic ulceration. In the retrospective series, 41 cases had peptic ulceration or atrophic gastric mucosa. There was a high incidence of peptic ulceration associated with severe aortic stenosis, severe atheroma and calcification of the abdominal aorta and severe atteroma of the coronary arteries. In this study, there was no increased incidence of peptic ulceration with aneurysm of the abdominal aorta. It was concluded that in the elderly, giant, silent peptic ulcers were associated with pathological changes in the cardiovascular system resulting in a decrease in blood supply to the gastric and duodenal mucosa.

A variant of intestinal metaplasia associated with gastric carcinoma: a histochemical study.

Gastrectomy specimens including 32 cases of carcinoma and 35 cases of peptic ulcer were examined in detail histologically and histochemically to show the distribution of intestinal metaplasia (IM) and types of mucin secreted. A variant of IM, with extensive involvement of both antrum and body and excessive secretion of sulphomucin, was found to be associated with carcinomas showing appreciable extracellular sulphomucin secretion. The identification of such a variant of IM may help the interpretation of gastric biopsies.

The significance of the sweat test in chronic pancreatitis.

In order to study the disposition which is thought to be latent in chronic pancreatitis, we investigated the sweat chloride concentration of 95 normal subjects, 43 cases of chronic pancreatitis, 12 cases of cholelithiasis, 15 cases of peptic ulcers, 16 cases of hepatic diseases and 23 cases of diabetes mellitus with the sweat test, using the method of pilocarpine iontophoresis. We obtained the following results. (1) In normal subjects, the sweat chloride concentration was inclined to rise gradually with age from childhood to adulthood; the mean value of sweat chloride concentration was 30.0 mEq/liter in adults from 20 years old, and the upper limit was about 60 mEq/liter. (2) The mean value of sweat chloride concentration was 60.0 mEq/liter in chronic calcifying pancreatitis; this value was markedly higher than that of control subjects of the same age (p is less than 0.001). (3) The mean value of sweat chloride concentration in cholelithiasis, peptic ulcer and hepatic diseases did not differ significantly from control subjects. The mean value of sweat chloride concentration in diabetes mellitus was significantly higher than that of control subjects (p is less than 0.01), but was significantly lower than that in chronic pancreatitis (p is less than 0.01). (4) It was supposed that some cases of chronic pancreatitis have a congenital disposition toward abnormal secretion of sweat glands and epithelium in the pancreatic duct, resembling cystic fibrosis, and this disposition leads easily to pancreatic disorders when the individual is exposed to various external factors.