Peptic Ulcer Symptoms Research Articles

Gastrointestinal Series in Patients With Gallstones

To the Editor.— Symptoms related to the gallbladder and the upper GI tract are difficult to evaluate. Referring physicians often find it difficult to differentiate between the diseases involving the two systems. If a patient has classic peptic ulcer symptoms and the radiologist finds gallstones and does not perform the GI series, he leaves the surgeon with an unknown. The GI series removes this unknown or "influences his diagnostic thinking." His surgical approach is modified accordingly. A negative examination can be just as efficacious as a positive examination.

Coffee—Grounds for Reassurance

Medicine's accusing finger, habitually wagging at life's pleasures, has not bypassed the coffee cup. Although a comparatively recent arrival on the pleasure scene—it became fashionable in the Western world less than three centuries ago—coffee competes successfully with the older pleasures of the table, the bed, and the wine cellar as a target of medical attacks. A testimony to the intensity of these assaults is the Coffee Cantata composed by Bach in protest against a proposed ban on coffee for women, a discriminatory measure motivated not by bias but by the notion that coffee is an abortifacient. Other notions, some equally absurd, some well founded, some still in the realm of uncertainty, have followed since and many still persist. There is, for instance, little doubt that coffee can aggravate the symptoms of peptic ulcer by stimulating gastric acid secretion (curiously, the secretagogue may not be caffeine, but some other as yet

Primary hyperparathyroidism and peptic ulcer disease.

To determine whether primary hyperparathyroidism is related to peptic ulcer disease, we evaluated 46 cases of concomitant primary hyperparathyroidism and peptic ulcer disease. Among these patients, there was no sex preponderance. The pathologic findings at parathyroid surgery, as well as the features of peptic ulcer disease, were the same as in patients with primary hyperparathyroidism or with peptic ulcer disease alone. The ulcer symptoms of 58% of the patients with adequate follow up improved after parathyroidectomy. Sixty-six percent of the patients who had active peptic ulcer disease at surgery improved as compared with only 44% of the patients who had complicated peptic ulcer disease. None of the factors studied (age, sex, serum calcium and serum parathyroid hormone levels, location, and duration of ulcer) had any effect on the peptic ulcer symptoms after parathyroidectomy. Our results and a critical review of the experimental and clinical literature suggest that the association between primary hyperparathyroidism and peptic ulcer disease is no more than coincidental.

Acute upper-gastrointestinal hemorrhage new observations on an old problem

In a two-year period, 289 patients with acute upper-gastrointestinal hemorrhage were evaluated. The site of hemorrhage was proven by endoscopy in more than 90% of cases. The frequency of any particular bleeding site was characterized for several subgroups and was found to correlate with: (1) the severity of the bleeding episode; (2) the iatrotropic stimulus of hemorrhage, and (3) the history of ethanol consumption. No difference was found in the frequency of ulcer and acute mucosal lesions as sites of hemorrhage between patients who consumed aspirin and those who did not. A history of symptoms of peptic ulcer correlated with the presence of an ulcer as the bleeding site. It is possible that failure to identify important patient subgroups may be partially responsible for the disagreement between previous reports.

Peptic ulceration, gastric secretion, and renal transplantation.

Fifty-four patients on haemodialysis for chronic renal failure underwent renal transplantation. Basal and maximum acid output and the incidence of peptic ulcer before transplantation were not significantly different from those of controls. But after renal transplantation the incidence of symptoms of peptic ulcer was high (22%) and four out of six patients who developed gastrointestinal bleeding died from this complication. In men peak acid output was significantly increased after renal transplantation and was associated with a 30% incidence of symptoms of peptic ulcer compared with 10% in women, who showed no significant change in mean basal or peak acid output. Peptic ulceration after transplantation was not associated with steroid dosage, hyperparathyroidism, or the height of blood urea concentrations. Given criteria of a history of dyspepsia, abnormal barium meal findings, or gastric hypersecretion, it was not possible to identify patients at risk from peptic ulceration or life-threatening complications after renal transplantation. Thus the routine screening of these patients for peptic ulcer has no practical value, and the incidence of fatal complications is not high enough to justify routine prophylactic anti-ulcer surgery aimed at reducing acid secretion before renal transplantation.

Surgical prophylaxis of gastroduodenal complications associated with renal allotransplantation

AbstractFrom 1971 to 1975, 226 patients received kidney allografts, and prophylactic ulcer surgery was regularly performed prior to kidney transplantation in those who had a history of previous ulcer, symptoms of peptic ulcer, a demonstrable ulcer on x‐ray or endoscopy, gastric acid hypersecretion, or a temperament conducive to the development of peptic ulcer. The results of this prophylactic program were compared with those of the previous period from 1964 to 1970 when prophylactic ulcer surgery was not used in 77 kidney allograft recipients, and with those of the concurrent period obtained in 194 recipients who did not receive surgical prophylaxis. Initially, the prophylactic operation was truncal vagotomy with pyloroplasty, then it was proximal selective vagotomy (PSV) without pyloroplasty, and finally it was selective gastric vagotomy with pyloroplasty (SGV+P). The incidence of gastroduodenal complications in patients who did not receive prophylactic ulcer surgery was 22.1% during the period 1964–1970, and 15.9% during the period 1971–1975; the mortality rates from gastroduodenal complications were 10.4% and 4.6%, respectively. In contrast, only 1 of 32 renal transplant recipients who underwent prior prophylactic ulcer surgery developed a gastrointestinal complication, and there were no deaths in the prophylactic surgery group. Two patients developed fatal ischemic necrosis of the stomach following PSV, which led to the adoption of SGV+P as the prophylactic operation of choice.

The epidemiology of the gastrointestinal randomized clinical trial.

Has the randomized clinical trial (RCT), generally accepted as the method of choice for evaluation of most treatments, obtained a footing in gastroenterology? Among 35,228 citations on gastroenterologic therapy indexed in MEDLARS 1964-1974 306 (0.9 per cent) were RCT's. During the decade their frequency rose significantly (P less than 0.05) from 0.3 per cent in 1964 to 1.7 per cent in 1973. The "typical" RCT was a double-blind two-group comparison of a new and an established drug on the symptoms of peptic ulcer; 50 patients were followed for six weeks, and the number of dropouts was unknown. The new drug was found to be more effective. It is postulated that the RCT's in gastroenterology are quantitatively and qualitatively insufficient and that co-ordinated planning of RCT's and uninhibited publication of statistically proved negative results may help to ensure that the patient with gastrointestinal disease receives the best available treatment.

Peptic Ulceration in Childhood

The signs and symptoms of peptic ulceration in childhood are frequently misleading, and because most physicians consider the disease uncommon, the diagnosis is often not suspected until complications supervene. Experience with 81 gastric and duodenal ulcers in 78 children is reviewed.

Toxicity of Indomethacin

SINCE its recent introduction, the nonsteroidal chemical called indomethacin (1-[ p -chlorobenzoyl]-5-methoxy-2-methylindole-3-acetic acid) has been used extensively as a new antirheumatic 1 drug that has anti-inflammatory, 2 analgesic, and antipyretic 3 activity. The side effects have been described by various authors. These were usually limited to the central nervous system, with symptoms of headache, vertigo, light-headedness, and disturbed sensorium; and to the gastrointestinal system, with the symptoms of cramping, epigastric pain, and peptic ulceration. 4 We found no mention of pancreatic involvement recorded in the literature. In the case being reported, the patient's condition was not associated with biliary tract disease, alcoholism, or any of the other conditions usually considered important in the cause of pancreatitis. We believe this case gives evidence that indomethacin does have a direct and toxic effect on the pancreas. Report of a Case A 69-year-old Negro man was admitted to the hospital on Aug 21,

An Extended Study of Indomethacin

The effects of indomethacin were studied in the human on long-term therapy in 234 patient-trials and on largedose, acute toxicity trials in six patients. Side effects were limited to the central nervous system (CNS), with symptoms of headache, vertigo, light-headedness, and disturbed sensorium, and to the gastrointestinal system, with symptoms of epigastric pain, cramping, and peptic ulceration. The CNS side effects were quite frequent, reaching a total incidence of 47.1% and were severe enough in 20% to require discontinuance of the drug. These side effects are of a transient nature without residuals or sequelae and disappear promptly on cessation of the drug. The gastrointestinal symptoms were less frequent, and in only 12.5% were they severe enough to warrant cessation of the drug. The high incidence of side effects was influenced by the exceptionally high doses used in this experimental study; the incidence in clinical therapy would be much lower. No other complications or side effects could be detected.

An extended study of indomethacin. I. Clinical pharmacology

The effects of indomethacin were studied in the human on long-term therapy in 234 patient-trials and on largedose, acute toxicity trials in six patients. Side effects were limited to the central nervous system (CNS), with symptoms of headache, vertigo, light-headedness, and disturbed sensorium, and to the gastrointestinal system, with symptoms of epigastric pain, cramping, and peptic ulceration. The CNS side effects were quite frequent, reaching a total incidence of 47.1% and were severe enough in 20% to require discontinuance of the drug. These side effects are of a transient nature without residuals or sequelae and disappear promptly on cessation of the drug. The gastrointestinal symptoms were less frequent, and in only 12.5% were they severe enough to warrant cessation of the drug. The high incidence of side effects was influenced by the exceptionally high doses used in this experimental study; the incidence in clinical therapy would be much lower. No other complications or side effects could be detected.

THE ASSOCIATION OF PEPTIC ULCERATION, CHRONIC RENAL DISEASE, AND ANALGESIC ABUSE

Patients are described who have both peptic ulcers and chronic renal disease together with a history of prolonged analgesic abuse. Psychological instability may predispose to the high analgesic intake. The symptoms of peptic ulceration were frequently resistant to medical management and a gastrectomy had been performed in more than half the patients studied. The renal features are those of renal papillary necrosis and bacterial invasion of the kidney did not seem to play an important role. Although urinary tract infection was present at some time in two-thirds of the patients the most frequent urinary finding was a sterile pyuria. Patients with renal papillary necrosis showed a much higher incidence of hypertension than has been previously recorded. Anaemia is a prominent feature and seems to be due to occult gastrointestinal blood loss and uraemia. The diagnosis is frequently missed if only one radiological examination is made. Progressive changes in serial radiographs more often reveal it.

Amputation neuromas of vagus nerves

Ten cases of amputation neuromas of vagus nerve seen in the past five years are described. These appear to be due to trauma, irritation, and scar. It is believed that the nerves should be cut high and with a scalpel or sharp scissors and that ligature or clipping of the nerves should be avoided. Partial esophageal obstruction has been seen in two cases as a result of the neuroma irritation. The pain of vagus neuroma is not clear, but we are convinced there is sensation in the vagus neuromas. Reconstruction by converting these cases from Billroth II or gastroenterostomy procedures to Billroth I or pyloroplasty was in all cases performed with a complete vagotomy being carried out at the same time. Results thus far have been gratifying and suggest that this may be an approach to some of the perplexing recurrences of peptic ulcer symptoms and signs in patients previously operated upon.

Duodenal ulceration in children

Summary Out of a total of 483 barium meal examinations of children with symptoms of peptic ulcer, forty-six cases with ulcer craters in the duodenum were found. These cases are analysed with regard to sex incidence, age incidence and especially with regard to the presence or otherwise of associated indirect signs of duodenal abnormality. The significance of these signs is discussed and a plea is made for their greater recognition.

Multiple Phlebectasia Involving Jejunum, Oral Cavity, and Scrotum

Concomitant multiple phlebectasia of the jejunum, oral mucosa, tongue (caviar spots), and scrotum (Fordyce lesion) was seen in 3 patients at the Long Beach Veterans Administration Hospital. Gastrointestinal bleeding from the phlebectasia occurred in one of the patients. In our study of 100 consecutive patients, the mucocutaneous lesions occurred most often after the age of 40. Normal connective tissue support is lost as the tissues of the body age and a tendency for capillary and venous dilatation in the form of phlebectasia occurs. Duodenal ulcer or symptoms of peptic ulceration occurred in all 3 patients. Vascular malformations of the lips have been reported to occur more frequently in patients with peptic ulcer. If the mucocutaneous manifestations are present, multiple phlebectasia of the jejunum should be included in the differential diagnosis of obscure gastrointestinal bleeding.

Peptic ulcer in primary hyperparathyroidism

1. 1. Peptic ulcer proved by roentgenograms, surgery or autopsy was demonstrated in 9.1 per cent of a composite series of 429 unselected patients with primary hyperparathyroidism. A similar incidence of 7.7 per cent was noted in a smaller series of thirty-nine patients studied at the Peter Bent Brigham Hospital. Proved peptic ulcer in hyperparathyroidism appears to be only slightly more prevalent than that found among the general population. 2. 2. Although primary hyperparathyroidism was twice as common among females, peptic ulcer in hyperparathyroidism was observed more frequently in men (14.9 per cent) than in women (6.2 per cent). Duodenal ulcer predominated among the men and was present in all but one of the eighteen women with peptic ulcer disease. The ratio of duodenal to gastric ulcer for both sexes was 3.7:1. 3. 3. There were no unusual characteristics of peptic ulcer disease in hyperparathyroidism except for the high incidence of duodenal ulcer among women. 4. 4. Symptoms of peptic ulcer were often observed in patients with hyperparathyroidism in the absence of a demonstrable peptic ulcer. 5. 5. A review of the experimental data revealed that gastric secretion apparently is not increased in either man or animals with hyperparathyroidism. 6. 6. Peptic ulcer may not be directly related to hyperparathyroidism since (1) the symptoms of ulcer and hyperparathyroidism did not seem to parallel each other in severity, (2) the peptic ulcer generally preceded the onset of clinical hyperparathyroidism, and (3) the ulcers often persisted or became worse after removal of the parathyroid adenoma. 7. 7. Multiple parathyroid adenomas and polyendocrine adenomas were more common in the patients with hyperparathyroidism in whom peptic ulcer developed than in the group as a whole.

Carbonic anhydras inhibition in the management of symptomatic peptic ulcers. Clinical studies with diamox on 125 patients.

One hundred and twenty-five patients suffering from symptomatic peptic ulcer were treated with Diamox and a Sippy diet while in hospital, and with Diamox and a convalescent ulcer diet or regular diet following their discharge from hospital. Response, as based on subjective, x-ray, laboratory, and clinical studies, was very favorable in our series. Inhibition of carbonic anhydrase by Diamox produced a sustained prolonged metabolic acidosis in almost all our patients and this metabolic change could be maintained as long as the patient was taking Diamox. The mode of action of Diamox on the gastric mucosa, blood chemistry, and urine was discussed. A daily dose of 1.0 gm. Diamox was well-tolerated, and only 30 of 125 patients experienced mild tingling in their extremities. The hemogram failed to reveal any abnormalities even in those patients who were taking Diamox for 5 to 6 months or longer. We thus recommend combined Diamox and Sippy regimen in those patients who are subject to hyperacidity and symptomatic peptic ulcers and who are not subject to any systemic disease, which would contraindicate the use of Diamox. Diamox was found to be of prompt value in relieving symptoms in one patient who was subject to the “milk alkali syndrome.” It is our impression that patients taking antacids and an excessive amount of milk should supplement that regimen with at least 250 mg. of Diamox daily to induce a mild or moderate degree of metabolic acidosis, which has definite beneficial effects on gastric hyperacidity. Also Diamox with Sippy diet or Diamox with convalescent ulcer or regular diet are regimens well-suited to the treatment of peptic ulcers.

Anemia associated with a stagnant ("blind") jejunal loop.

That stagnant or "blind" loops of small and large bowel are often accompanied by megaloblastic anemias has been known for over 60 years.¹Neurologic changes resembling those in true Addisonian pernicious anemia have also been noted in the "blind" loop syndrome, and are summarized by Reilly in his review.² A case of anemia associated with neurologic changes that followed gastrointestinal surgery is presented. In April, 1944, after having peptic ulcer symptoms for two years, a 32-year-old man was explored as an emergency, and a perforated duodenal ulcer was closed. After surgery he was almost asymptomatic for four years and then developed a sudden recurrence of epigastric distress. In August, 1948, a 50% gastric resection with a gastrojejunostomy reconstruction was performed. The pathological report of the specimen revealed no peptic ulcer. Because of obstructive symptoms he was reoperated on in October, 1948, and a large enteroenterostomy between the afferent

Gastrointestinal bleeding during tolbutamide therapy.

Two diabetic patients, a 59-year-old man and a 72-year-old woman, had been receiving tolbutamide for some months. In the man 1 Gm. of tolbutamide per day had been adequate to control the glycosuria and hyperglycemia; the woman had required 2 Gm. Both were hospitalized for melena and other abdominal symptoms, and the man suffered an acute hemorrhage in addition. There was evidence that the bleeding was related to the months of medication with tolbutamide. When it was withdrawn, both patients recovered. Since there was a previous history of peptic ulcer symptoms in both cases, it is suggested that tolbutamide be used with care in patients of this type.

Effect of methoxsalen on liver function.

Four liver function tests were performed serially in 24 normal human subjects before, during, and after administration of 30 mg. of methoxsalen (8-methoxypsoralen) along with casual exposure to ultraviolet irradiation to 12 of the subjects, the remaining 12 subjects receiving placebos. In the group receiving methoxsalen, two subjects noted a slight increase in beard hair growth, and one reported peptic ulcer symptoms, which disappeared as the therapy was continued. Although a selected profile of liver function tests and blood constituents relating to liver function were within normal limits throughout the course of administration of methoxsalen, it cannot yet be concluded that the drug is safe for the general population.