Previous Peptic Ulcer Disease Research Articles

Prognosis and clinicopathologic features in patients with gastric stump cancer after curative surgery.

Gastric stump ("remnant") cancer is the development of a malignancy related to previous gastric surgery. Prognosis in gastric stump cancer, compared with that in primary gastric cancer, is still controversial. From January 1988 to December 2012 at a single medical centre in Taiwan, 105 patients with gastric stump cancer, including 85 with previous peptic ulcer disease and 20 with previous gastric cancer, were analyzed for clinicopathologic characteristics and overall survival (os). The 5-year os rates for patients with gastric stump cancer and with primary gastric cancer were 51.2% and 54.5% respectively (p = 0.035). Analysis of clinicopathologic characteristics indicated that, compared with patients having primary gastric cancer, those with gastric stump cancer had more lymph node metastasis (p < 0.001) and had been diagnosed at a more advanced stage (p = 0.047). Multivariate analysis with os as an endpoint showed that age [p = 0.015; hazard ratio (hr): 2.300; 95% confidence interval (ci): 1.173 to 4.509], tumour size (p = 0.037; hr: 1.700; 95% ci: 1.031 to 2.801), stromal reaction (p = 0.021; hr: 1.802; 95% ci: 1.094 to 2.969), and pathologic N category (p = 0.001; hr: 1.449; 95% ci: 1.161 to 1.807) were independent predictors in gastric stump cancer. The os rates for patients with gastric stump cancer who previously had gastric cancer or peptic ulcer disease were 72.9% and 50.0% respectively (p = 0.019). The Borrmann classification was more superficial (p = 0.005), lymph node metastases were fewer (p = 0.004), and staging was less advanced (p = 0.025) in patients with gastric stump cancer who previously had gastric cancer than in their counterparts who previously had peptic ulcer disease. Survival is poorer in patients with gastric stump cancer who previously had peptic ulcer disease than in those who previously had primary gastric cancer. Patients with gastric stump cancer who previously had gastric cancer and could receive curative gastrectomy tended to have a better prognosis because of a more superficial Borrmann classification. Regular follow-up in patients who have undergone gastric surgery is recommended for the early detection of gastric stump cancer.

Association Between Proton Pump Inhibitors and Asthma: A Population-Based Cohort Study.

ObjectiveThe relationship between proton pump inhibitors (PPIs) and asthma is controversial. The goal of this study was to determine the association between PPI use in non-asthma subjects and their subsequent asthma prevalence.DesignNationwide, population-based cohort study.MethodsWe conducted a nationwide, population-based retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) of Taiwan from 1999 to 2013. We identified 24,077 adult patients with PPI use for more than 3 months and 24,077 controls matched by propensity score on a one-to-one ratio for age, gender, comorbidities (hypertension, hyperlipidemia, gastroesophageal reflux disease, allergic rhinitis, atopic dermatitis, peptic ulcer disease, diabetes, and sleep apnea syndrome), and medications (histamine 2 receptor antagonists [H2RA], nonsteroidal anti-inflammatory drugs [NSAIDs], and acetaminophen). The cumulative asthma incidence for the two cohorts in the follow-up period was estimated with the Kaplan–Meier method, and the difference was examined using the log-rank test. Multivariate Cox regression models were used to calculate the adjusted hazard ratios (HR).ResultsThe overall incidence of asthma was 1.58-fold greater in the PPI cohort than in the non-PPI cohort (13.3 versus 8.4 per 1,000 person-years), with an adjusted HR of 1.76 (95% confidence interval [CI], 1.64–1.88). In patients without previous peptic ulcer disease, the adjusted HR of asthma associated with PPIs was higher than in the non-PPI group (1.95; 95% CI, 1.80–2.11). The risk of asthma due to PPI use was also more significant in patients not receiving H2RA (1.81; 95% CI, 1.66–1.96), NSAIDs (1.93; 95% CI, 1.73–2.15), and acetaminophen (1.88; 95% CI, 1.70–2.08).ConclusionsThis population base study demonstrated that patients with long-duration of PPI use are at a higher risk of developing asthma, regardless of age, gender, comorbidities, and medications.

Effect of Ramadan Fasting Upon Perforated Peptic Ulcer Patients: A Descriptive Analysis

Background: Perforated peptic ulcer (PPU) is relatively rare, but life threatening with the mortality varying from 10% to 40%. While common causes of peptic ulcer disease are H. Pylori, increased inadvertent use of NSAIDS, smoking and stress of modern life, the specific etiologic agent cannot be incriminated in the causation of its perforation.Objective: The aim of this study is to evaluate the effect of perforated peptic ulcer in fasting Muslims.Methods: This prospective analysis was conducted for the risk factors associated with perforated peptic ulcer (PPU) in patients attending Surgical Emergency hospital &amp; Sulaimaniyah Teaching Hospital on 312 cases (246 male &amp; 66 females) during the period of one month before Ramadan (Shaban), holy Ramadan and one month after Ramadan (Shawal) for ten successive years from 2006 to 2015. Descriptive analysis and Chi square test was used to find an association between studying variables.Result: The number of PPU per month was higher in Ramadan, 16.6 patients per month vs. 7.3 patients per each other month and also high among group 1 fasting patients. Predisposing factors played a major role in these differences.Conclusion: This study found that the incidence of PPU is relatively high among people who have predisposing factors, including young adults age, but earlier in non-fasting people , male gender, but no difference between the two groups in those using non -steroidal anti-inflammatory drugs, history of dyspepsia. Those patients have previous peptic ulcer disease diagnosed on esophagogastroduodenoscopy more prone to perforation. Long period day after day fasting, but not daytime length duration may increase PPU.Recommendations: This study recommends that the people with these risk factors must be well informed and need special care to avoid such complications. This study also suggests further studies regarding this subject.

A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria.

Gastro-duodenal perforations are common and may complicate peptic ulcer disease. Management is often by surgical closure. To determine the patterns of presentation and mode of management of duodenal ulcer perforations. Retrospective review of patients with duodenal ulcer perforations seen at the Obafemi Awolowo University Teaching Hospital between June 2001 and July 2011. Patients' records were reviewed for demography, duration of disease, probable risk factors, type of surgery and complications. Data obtained was analyzed using SPSS 15.0. Forty- five patients were reviewed. There were 37 males (82.2%). Mean age was 39.7years (range 15-78years). There were 10 (22.6%) students and 8(17.8%) farmers. NSAIDs abuse (11), previous peptic ulcer disease (2), and no prior dyspeptic symptoms (20) constituted 24.4%, 4.4% and 44.4% respectively of cases. Seven (16%) patients presented less than 24 hours of onset of illness. Forty one perforations (91.1%) involved the first part of duodenum. Twenty two (49%) patients had Graham's omental patch. We had one (2.2%) failed repair and six (13.3%) mortalities. Late presentation of duodenal ulcer perforation is common with high mortality. Pragmatic surgical intervention with Graham's omentopexy with broad spectrum antibiotics is still commonly practiced.

Gastrointestinal Bleeding in Patients Receiving a Combination of Aspirin, Clopidogrel, and Enoxaparin in Acute Coronary Syndrome

The combination of aspirin, clopidogrel, and enoxaparin (combination therapy) is the standard treatment for acute coronary syndrome but is associated with gastrointestinal bleeding. However, information in this area is scarce. This retrospective study aimed to determine the incidence of upper gastrointestinal bleeding in a real-life situation. The effect of proton pump inhibitor (PPI) treatment was also analyzed. From January 2002 to December 2006, all patients receiving combination therapy were analyzed. The end point was the occurrence of upper gastrointestinal bleeding during combination therapy or within 7 days of stopping enoxaparin. The patient group consisted of 666 patients (age 72.1 +/- 12.6 yr). Gastrointestinal bleeding occurred in 18 (2.7%) patients. The overall hospital mortality was 4.1% (27 patients). A cardiac event was the major cause (N = 24, 3.6%). Only one patient died of massive gastrointestinal bleeding (0.15%). Multiple logistic regression analysis demonstrated that previous peptic ulcer, cardiogenic shock, and the lack of PPI coprescription were significant risk factors for gastrointestinal bleeding. The age-adjusted odds ratio (95% confidence interval) for gastrointestinal bleeding was 5.07 (1.31-16.58) for previous peptic ulcer, 21.41 (2.56-146.68) for cardiogenic shock, and 0.068 (0.010-0.272) for the coprescription with a PPI. In real life, the incidence of gastrointestinal bleeding associated with the combination of aspirin, clopidogrel, and enoxaparin therapy was estimated to be 2.7%. Previous peptic ulcer disease or cardiogenic shock were significant independent risk factors. Coprescription with a PPI can significantly reduce the risk.

Pharmacological Management of Renal Colic in the Older Patient

Renal colic affects up to 12% of the population. Initial management of most patients is expectant. Acute symptom management of renal colic is best accomplished with a combination of parenteral opioids and NSAIDs. The elderly patient with a kidney stone should be screened for contraindications to NSAID therapy, such as renal failure or previous peptic ulcer disease. Use of parenteral opioids is often necessary during the acute setting, and downward-adjusted doses and monitoring are necessary to prevent associated confusion and respiratory depression. Novel therapy with desmopressin may also be effective for symptom control at the initial presentation, without the adverse effects of opioids or NSAIDs. However, use of desmopressin in the elderly must be undertaken cautiously, given the potential adverse effects of this agent. Many small, distal ureteral stones are treated initially with watchful waiting for the first 2-4 weeks after presentation. The patient should have effective, non-parenteral analgesics for use at home. Included in these agents are oral or suppository NSAIDs and oral opioids. Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious. alpha-Adrenoceptor antagonists such as the alpha(1A/)(1)(D)-selective tamsulosin are well tolerated in the elderly and increase the rate of spontaneous stone passage by approximately 50% for small distal stones. These agents also appear to decrease the severity of renal colic. Corticosteroids and calcium channel antagonists are also effective but their use in the elderly is not recommended as first-line therapy.

The Prevalence of Idiopathic Peptic Ulcer and Changing Trend of Peptic Ulcer Disease and Helicobacter Pylori Infection Between 10 Years in Korea

The Prevalence of Idiopathic Peptic Ulcer and Changing Trend of Peptic Ulcer Disease and Helicobacter Pylori Infection Between 10 Years in Korea Hyun Joo Jang, Jong Pyo Kim, Cheol Hee Park, Kyung Ho Kim, Kwang Ho Baik, Il Hyun Baik, Sea Hyub Kae, Hak Yang Kim Background and Aim: Helicobacter pylori (H. pylori) infection is the main cause of peptic ulcer disease (PUD). However, H. pylori-negative and idiopathic peptic ulcer disease (IPUD) seems to be increasing in some developed countries. We studied the prevalence and clinical characteristics of idiopathic peptic ulcer disease (IPUD). We also investigated the change in the prevalence of H. pylori infection and ulcer distribution in patients with PUD during the last decade. Methods: We prospectively evaluated H. pylori infection in patients with newly diagnosed PUD by endoscopy from September 2004 to February 2005 in Hallym Medical Center. H. pylori infection was examined by rapid urease test and histology using Giemsa stain. Medical records and history taking were carefully searched for the use of NSAID or aspirin and history of previous PUD before endoscopic examination. The prevalence of H. pylori infection was compared with that of our previous results reported 10 years ago. Results: Among the 895 patients enrolled, 428 patients (47.8%) had gastric ulcer (GU), 348 (38.9%) duodenal ulcer (DU), and 119 (13.3%) both GU and DU. H. pylori infection was found in 72.0% of all patients with PUD, which consisted of 73% in GU, 68% in DU, and 79% in both GU and DU. NSAIDrelated PUD was found in 13.0% and IPUD in 22.2% of patients. Patients with IPUD showed no significant differences in clinical features compared with those with H. pylorior NSAID-related PUD. Comparing with those 10 years ago, the prevalence of H. pylori infection was not significantly changed although the proportion of DU and prevalence of H. pylori infection in DU slightly decreased. Conclusion: There was no significant change in the prevalence of H. pylori infection in PUD during the last decade. The prevalence of IPUD is not uncommon. However, the clinical features of IPUD were not significantly different with those of H. pylorior NSAIDrelated PUD. Further investigations are warranted for the clinical significance and management of IPUD.

Reinfection after successful eradication of Helicobacter pylori: a 2‐year prospective study in Alaska Natives

Limited information exists regarding risk factors for reinfection after cure of Helicobacter pylori infection. To determine the 2-year reinfection rate of H. pylori in a cohort of urban Alaska Natives. Participants over 18 years of age undergoing oesophagogastroduodenoscopy had (13)C urea breath test, culture, CLOtest and histology performed. Those diagnosed with H. pylori who tested urea breath test-negative at 8 weeks after treatment were followed prospectively at 4 months, 6 months, 1 year and 2 years. Subjects experiencing H. pylori reinfection as defined by a positive urea breath test were compared with those who did not become reinfected using univariable and multivariable analysis. Risk of reinfection over time was estimated by the Kaplan-Meier method. Helicobacter pylori reinfection occurred in 14 of 98 subjects successfully treated. The cumulative reinfection rate was 5.1% (95% CI: 0.7%-9.5%) at 4 months, 7.2% (2.0-12.3%) at 6 months, 10.3% (4.2-16.3%) at 1-year and 14.5% (7.5-21.6%) at 2 years. In multivariable analysis, a history of previous peptic ulcer disease or presence of ulcer at time of study oesophagogastroduodenoscopy were the only risk factors associated with reinfection (P = 0.01). Based on the findings from our study, subjects with a history of or current peptic ulcer disease should be followed, after successful treatment for H. pylori, with periodic urea breath test to detect reinfection, as reinfection would put them at high risk for ulcer recurrence.

Gastrointestinal Complications of Dual Antiplatelet Therapy

Case presentation: A 59-year-old man with a history of hypertension, dyslipidemia, and smoking was hospitalized with acute coronary syndrome requiring emergency percutaneous coronary intervention with 4 drug-eluting stents. His discharge medications included dual antiplatelet therapy with aspirin 325 mg/d and clopidogrel 75 mg/d. Three weeks after discharge, he returned to the Emergency Department with bloody stools and a hematocrit of 23% (previously 36%) and required 3 U of packed red blood cells. Endoscopy showed a bleeding duodenal ulcer with adherent clot (Figure). Endoscopic image of bleeding duodenal ulcer with clot on top. This image was taken in a patient with a history similar to that of our patient. Arrow points to the base of duodenal ulcer with active bleeding. Picture contributed by Sarathchandra Reddy, MD, and Edwin Chun Ouyang, MD, PhD, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Mass. We prescribe dual antiplatelet therapy with aspirin and clopidogrel to prevent and treat cardiovascular, cerebrovascular, and peripheral arterial disease. According to American Heart Association statistics, 700 000 patients had stroke, 13 million had coronary artery disease, and 8 to 12 million suffered from peripheral arterial disease in 2002. Each year, 1.2 million patients in the United States receive dual antiplatelet therapy with aspirin and clopidogrel after percutaneous coronary intervention with drug-eluting stents. The number of patients in the United States who receive dual antiplatelet therapy for various vascular conditions such as coronary artery disease, transient ischemic attack, thrombotic stroke, and peripheral vascular disease probably exceeds several million. The use of aspirin compared with placebo reduces the risk of myocardial infarction, stroke, or death from vascular causes by ≈25%.1 In the Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial, administration of clopidogrel decreased the relative risk of vascular events by 8.7% compared with aspirin.2 The …

Cholecystectomy, peptic ulcer disease and the risk of adenocarcinoma of the oesophagus and gastric cardia.

Gastro-oesophageal reflux is a strong risk factor for oesophageal adenocarcinoma. Bile and pancreatic enzymes may be particularly carcinogenic. Cholecystectomy causes an increased gastric level of these constituents. A decreased risk of oesophageal adenocarcinoma has been observed in persons infected with cagA-positive Helicobacter pylori. There is a strong correlation between ulcer disease and Helicobacter pylori infection. The aim of this study was to determine whether previous cholecystectomy or peptic ulcer disease affects the risk of oesophageal carcinoma. Data were collected as a nationwide population-based case-control study in Sweden between 1995 and 1997. Multivariate adjusted odds ratios (ORs) were calculated with logistic regression. There was no statistically significant association between cholecystectomy and the risk of oesophageal carcinoma. Among persons with previous peptic ulcer, the adjusted OR for oesophageal adenocarcinoma was below unity (OR = 0.6, 95 per cent confidence interval 0.3-1.1). The relative risk estimates for cardia adenocarcinoma and oesophageal squamous cell carcinoma were close to unity. Cholecystectomy, despite its effect on the composition of gastric juice, does not appear to increase the risk of adenocarcinoma of the oesophagus or gastric cardia. While the data do not contradict a protective effect of H. pylori, the results are also consistent with absence of such an effect.

A clinical audit of the prescribing of celecoxib and rofecoxib in Australian rural general practice

The new cyclooxygenase-2 (COX-2) selective inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx), have been widely prescribed since their launch. No reviews currently appear in the literature of prescribing patterns in Australia. This paper describes a self-audit of the clinical use of selective COX-2 inhibitor therapy undertaken with rural general practitioners (GPs) in Australia. A structured audit form was developed and distributed to interested GPs. The form was self-administered and focused on issues about COX-2 inhibitors and the types of patients who were receiving them, e.g. indications, patient demographics, risk factors and drug interactions. A total of 627 patients were recruited (569 celecoxib and 58 rofecoxib). A range of doses was prescribed. Osteoarthritis was the most common indication (68.1%). Risk factors known for the nonselective nonsteroidal anti-inflammatory drugs were identified in 65.1% of patients, with the most common being advanced age, hypertension and previous peptic ulcer disease. Potential drug interactions were common. A variety of reasons for initiation of therapy was identified; these included perceived increased efficacy, safety and failure of other treatment. These results show that COX-2 inhibitors are being prescribed for patients with multiple risk factors that may place the patient at increased risk of adverse drug reactions to a COX-2 inhibitor. The perception of improved safety and efficacy was common and is of concern. Limitations of the study include the reliance on self-reporting.

ACP. Best practice no 154. February 1999. Helicobacter pylori.

Since the isolation of Helicobacter pylori by Marshall in 1982, much evidence has accumulated to show the important role it plays in the pathogenesis of chronic gastritis and peptic ulceration....

The cost-effectiveness of misoprostol in preventing serious gastrointestinal events associated with the use of nonsteroidal antiinflammatory drugs.

To reexamine the cost-effectiveness of misoprostol, using data from a recently published placebo-controlled trial of misoprostol in > 8,000 patients with rheumatoid arthritis (RA) taking nonsteroidal antiinflammatory drugs (the Misoprostol Ulcer Complications Outcome Safety Assessment [MUCOSA] study). Actual clinical events and the rates of endoscopies and upper gastrointestinal (GI) radiographic series, hospitalizations, and surgery for these events were derived from the MUCOSA study and used in a decision analysis. Estimates of costs for the management of these events were derived from the Ontario Case Cost Project database and published economic evaluations; costs were adjusted to 1994 Canadian dollars. Incremental cost-effectiveness (from the viewpoint of the provincial health care plan in Canada) was calculated for the original trial population (risk of a serious GI complication 1%) and for the subsets of patients with medium (3%) and high (6%) risk. For the original study population, averting 1 serious GI complication by prescribing misoprostol would cost an additional $94,766 (Canadian; range $60,286-137,146). For patients with previous peptic ulcer disease (medium risk), the cost would be $14,943 (range $10,912-32,157), and for patients with previous peptic ulcer disease and age > 75 (high risk), the cost would be $4,101 (range $-220 to $18,146). Prescribing misoprostol for all patients with RA who are > or =52 years old costs $94,766 for each additional GI event averted. However, when patients at higher risk are specifically selected, the cost per averted GI complication is markedly reduced. These results, based on actual serious event rates and actual data on endoscopies and upper GI series, hospitalizations, and surgeries, provide a better estimate of the true cost-effectiveness of misoprostol than previous analyses based on endoscopic data and modeling of all resource utilizations.

Relation between gastric cancer and previous peptic ulcer disease.

It is presently not well understood to what extent peptic ulcer and gastric cancer represent related diseases. The objective of this study was to assess past occurrence of gastric and duodenal ulcers in patients with cancer of the gastric cardia or other parts of the stomach. The association between peptic ulcer and gastric cancer was studied among patients followed up at hospitals of the US Department of Veterans Affairs. Two populations of 1069 subjects with cancer of the cardia and 3078 subjects with cancer of other parts of the stomach were compared with a control population of 89082 subjects without gastric cancer. In multivariate logistic regressions, presence or absence of cancer served as the outcome variable, while age, sex, race, previous histories of gastric ulcer, duodenal ulcer, peptic ulcer site unspecified, gastric resection, or vagotomy served as modifier variables. Old age, non-white ethnicity, and male sex proved strong and independent risk factors for non-cardiac gastric cancer. A previous history of gastric, but not duodenal ulcer was associated with a significantly raised odd ratio of 1.53 (95% confidence interval: 1.24 to 1.87). Cancer of the cardia affected predominantly whites, and was relatively more common in men than non-cardiac gastric cancer. Past gastric ulcers exerted no significant influence (1.02, 0.67 to 1.56), while duodenal ulcers and peptic ulcer site unspecified were protective (duodenal ulcer: 0.68, 0.47 to 0.95; peptic ulcer disease: 0.66, 0.47 to 1.00). Partial gastrectomy was a risk factor for non-cardiac gastric cancer (1.86, 1.32 to 2.63), but not for cancer of the cardia (1.09, 0.54 to 2.20). These epidemiological patterns might stem from underlying differences in the influences of gastritis and acid secretion on the development of the two cancer types.

Antisecretory Therapy in 1017 Patients with Ulcerlike or Refluxlike Dyspepsia in General Practice

Objectives: The effect of omeprazole and H2-blockers in patients with ulcerlike and refluxlike dyspepsia is mainly studied in endoscoped patients. In general practice most patients are treated without endoscopy. We studied the effect of omeprazole versus H2-blockers and placebo in patients consulting the general practitioner because of dyspeptic complaints in which, based on symptom clusters, ulcerlike or refluxlike symptoms were predominant.Methods: Patients with ulcerlike or refluxlike dyspepsia according to a symptom-based classification were randomised to treatment with omeprazole 20 mg in the morning versus cimetidine 400 mg twice daily (n=469), if the patients had a verified medical history of peptic ulcer disease or reflux oesophagitis, or to a treatment with omeprazole 20 mg in the morning versus placebo (n=548), if no such history was present. The endpoint was a total relief of symptoms after two weeks of treatment.Results: In both groups treatment success was obtained in 50% of the patients treated with omeprazole versus 35% (p=0.002) of those treated with cimetidine, and 36% (p=0.009) of those treated with placebo, respectively.Conclusions: The response rates indicate that patient selection based on symptom clusters is insufficient for predicting the response to acid suppression, and that aspects other than acid-related factors contribute to symptom presentation. The lack of difference in the response to omeprazole treatment in the two groups indicates that recurrence of dyspeptic symptoms in patients with previous peptic ulcer disease or reflux oesophagitis does not necessarily reflect a relapse of the disease.

The Predictive Value of History in Dyspepsia

Symptomatic patients referred to an open-access upper gastrointestinal endoscopy completed a detailed, self-administered questionnaire aimed at assessing the predictive value of history in dyspepsia. Nine hundred and thirty patients were suitable for analysis. Of these, 29% were found to have organic dyspepsia. A substantial overlap of symptoms and demographic data was found among the various endoscopic diagnoses. Discriminating variables were identified by stepwise logistic regression analysis and included in predictive score models. Pain relieved by antacids, age above 40 years, previous peptic ulcer disease, male sex, symptoms provoked by berries, and night pain relieved by antacids and food were found to predict organic dyspepsia with a sensitivity and specificity of approximately 70%, when applied on the observed material. Similar probabilities were found for score models of peptic ulcer and esophagitis. In general, the low prevalence of organic diseases resulted in low positive and high negative predictive values. Accordingly, the main impact of the predictive models may be to reduce the number of negative endoscopies rather than to predict a precise diagnosis. Independent of disease category and age, 41% of the subjects expressed a fear of malignancy, emphasizing the value of reassurance from a negative endoscopy.

Prophylaxis of Upper Gastrointestinal Tract Bleeding in Mechanically Ventilated Patients

Sixty-two mechanically ventilated patients were randomized into three study groups to compare the efficacy of sucralfate vs cimetidine and antacid regimens for the prevention of upper gastrointestinal tract bleeding. Only five study patients (8%) developed bright-red blood per nasogastric tube; four patients received the antacid regimen and one received cimetidine. None of the patients receiving sucralfate developed acute upper gastrointestinal tract bleeding. Bleeding was not severe enough in any patient to require endoscopy or surgery. There were no significant differences in the three groups when several major risk factors for gastrointestinal tract bleeding were analyzed, including sepsis, hypotension, steroid use, adult respiratory distress syndrome, gastric pH of 4 or less, previous peptic ulcer disease, peritonitis, and jaundice. A significantly higher incidence of acute renal failure was noted in the antacid-treated group when compared with the cimetidine and sucralfate groups. We find preliminary evidence that sucralfate is as efficacious as and more cost-effective than either cimetidine or antacids for prophylaxis of stress-related gastrointestinal tract bleeding in the critically ill ventilator-dependent patient.

Gastric ulcer scars.

Gastric ulcer scars, which imply previous peptic ulcer disease, are visible with moderate frequency during double-contrast examinations. This article investigates the radiographic appearance of gastric ulcer scars and the frequency of their occurrence in two differing patient populations. Results with 35 gastric ulcers that were followed to healing indicate that most ulcer scars appear as folds converging toward the ulcer site, at times accompanied by a central depression and/or gross deformity of the stomach. Two series of 200 patients each who underwent double-contrast examinations suggest a 1 to 4% incidence of ulcer scars, dependent upon the population examined.

Letter: Pancreatitis--a rare complication?

To the Editor.— Numerous articles have been published on pancreatitis and some of the ensuing common complications. Recently, we saw a patient who had pancreatitis and a possible complication that may or may not have been associated with his primary disease process. Report of a Case. — This 47-year-old man was admitted to the hospital with a twoweek history of abdominal pain, primarily located in the left side of his abdomen, with some radiation to the left shoulder and down toward the left hip. The patient stated that the pain was not associated with eating and was not relieved with analgesics. There was history of previous peptic ulcer disease, but no gallbladder disease. The patient denied any change in his bowel habits. On admission, blood pressure was 120/80 mm Hg, hemoglobin value was 13.5 mg/100 ml, and white blood cell count was 9,000, with a normal differential cell count.