RUDER--a prospective, two-year, multicenter study of risk factors for duodenal ulcer relapse during maintenance therapy with ranitidine. RUDER Study Group

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

AIM

To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy's lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS

Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: "alcoholic liver disease", "alcoholic hepatitis"," alcoholic cirrhosis", "cirrhosis", "liver disease", "upper gastrointestinal bleeding", "non-variceal upper gastrointestinal bleeding", "PUD", ''DL'', ''Mallory-Weiss tear", and "MWS''.

RESULTS

While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION

Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Antimicrobial therapy of peptic ulcers

It is now accepted that peptic ulcer disease, whether duodenal or gastric, is one manifestation of infection with the bacterium Helicobacter pylori. This realization has revolutionized the management of peptic ulcer disease and changed the dictum from no acid no ulcer, to no H. pylori, no ulcer. When confronted with a patient with peptic ulcer disease, the physician must now ask whether H. pylori infection is present and if so, attempt to cure it. The gastric milieu is a very difficult environment for effective antimicrobial therapy. Nevertheless, current multi-drug antimicrobial therapy can be expected to cure the infection in more than 80% of patients. Cure of the infection is associated with a very low rate of recurrence. The continued risk of serious disease or disease complications associated with treatment failure and the availability of the urea breath test to non-invasively assess the results of therapy suggest that post therapy assessment should be routine. Because H. pylori infection causes structural and functional damage to the stomach and is associated with a lifetime risk of peptic or gastric cancer of approximately 16 and 1%, respectively, the infection should be treated whenever it is diagnosed. This paper reviews the current approach to therapy of patients with H. pylori infection, the effective antimicrobial drug combinations end the factors that predict treatment failure. Emergence of antimicrobial resistance may soon undermine the effectiveness of current drug regimens and require pretreatment culture and sensitivity testing as well as development of new drugs and drug regimens.

[H2 blockers and antacids in gastrointestinal diseases]

Kaum ein gastroenterologisches Krankheitsbild hat in den vergangenen 30 Jahren einen derartigen Wandel hinsichtlich der medikamentösen Therapie erfahren wie das Ulcusleiden.

Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs

Helicobacter pylori (H. pylori) infection is widely accepted as the most important factor in the pathogenesis of duodenal ulcer. However, in parallel with more effective eradication of H. pylori, the prevalence of H. pylori is changing, and H. pylori-negative peptic ulcer disease appears to be increasing. When making a diagnosis of H. pylori-negative peptic ulcer disease, it is essential to avoid misclassification because of inaccurate diagnosis. In addition, secondary causes may need to be excluded with appropriate investigations. In the absence of H. pylori, nonsteroidal anti-inflammatory drug usage is the most common cause of peptic ulcer; surreptitious nonsteroidal anti-inflammatory drug usage is a cause of unexplained ulcer disease in up to 60% of patients. Hypersecretory syndromes such as Zollinger-Ellison syndrome, although rare, need to be excluded. Once all known etiological factors are excluded, there remains a group of patients with so-called "idiopathic ulcers." The interplay of etiological factors in the pathogenesis of idiopathic peptic ulcer disease is poorly defined but may include a genetic predisposition, altered acid secretion, rapid gastric emptying, defective mucosal defense mechanisms, psychological stress, and smoking. The management of idiopathic peptic ulcers is not defined; they appear to be more resistant to standard therapy, can be associated with more frequent complications, and those that relapse may require long-term maintenance therapy.

Psychosocial factors in peptic ulcer and inflammatory bowel disease

Over the past decade, while gastroenterologists' interest in mind-body interactions in organic disorders dwindled, stronger evidence has linked psychosocial factors with the incidence and recurrence of peptic ulcer and with the course of inflammatory bowel disease. Psychological-behavioral approaches to treatment continue to be disappointing. Psychosocial factors may affect ulcer by increasing duodenal acid load, altering local circulation or motility, intensifying Helicobacter pylori infection, stimulating corticosteroid secretion, and affecting health risk behaviors; possible mechanisms for inflammatory bowel disease include immune deregulation, gut permeability changes, and poor medication adherence. Both belong to the growing category of diseases thought to have an infectious component: for peptic ulcer the bacterium Helicobacter pylori, for inflammatory bowel disease an exaggerated immune response to gut bacteria. Peptic ulcer and inflammatory bowel disease, which present unique interactions among psychological, immunologic, endocrine, infectious, and behavioral factors, are splendid paradigms of the biopsychosocial model.

Atypical and aggressive upper gastrointestinal ulceration associated with aspirin abuse

BACKGROUND

Unusual resistance to treatment in 5% to 7% of 1,845 peptic ulcers examined under endoscopy from 1987 to 1996 prompted a search for unusual causes. Although some ulcers were caused by Zollinger-Ellison syndrome (ZES), an atypical clinical course in other patients, especially with those with multiple ulcers, suggested abuse of aspirin.

STUDY

Patients who did not have ZES were questioned closely regarding aspirin use and were tested for serum salicylate to detect surreptitious abuse.

RESULTS

The authors identified 37 patients with aspirin-related ulcers but otherwise intact upper gastrointestinal tracts. There were 12 men and 25 women aged 18 to 73 years; 18 admitted to current aspirin abuse (>1 g/d), but 19 denied it despite objective evidence from elevated serum salicylate (8.4 +/- 1.2 mg/dL). The clinical presentation was atypical, with only 10 patients having single ulcers, whereas 27 had 83 multiple or multiorgan ulcers. Overall, there were 32 duodenal, 57 gastric, and 4 esophageal ulcers. Omeprazole healed 64% of ulcers, but despite follow-up maintenance with H2 receptor antagonists, all ulcers recurred rapidly, often in a new location. Thirty of 37 patients had serious complications: 18 bled; 9 had pyloric and 2, duodenal stenosis; 2, esophageal strictures; and 2, perforation. Six patients who stopped using aspirin healed easily. The 80% who did not stop on advice after diagnosis were considered abusers.

CONCLUSION

Patients with aspirin abuse have atypical, often multiple, intractable ulcers with many complications. These ulcers differ from conventional Helicobacter pylori peptic ulcers and also from those found in patients with ZES. Unless aspirin use is stopped, these ulcers remain incurable and dangerous.

The very model of a modern etiology: a biopsychosocial view of peptic ulcer

OBJECTIVE

Research on ulcer psychosomatics has plummeted since the early 1970s, to the applause of many who argue that ulcer is simply an infectious disease. The purpose of this article is to discuss the relevance of ulcer psychogenesis in the age of Helicobacter pylori.

METHODS

A critical literature review was conducted.

RESULTS

There is a substantial and methodologically sound body of prospective studies linking stress with the onset and course of peptic ulcer. Psychosocial factors can be estimated to contribute to 30% to 65% of ulcers, whether related to nonsteroidal antiinflammatory drugs, H. pylori, or neither. The observed association between stress and ulcer is accounted for, in part, by recall bias, misreported diagnoses, and confounding by low socioeconomic status (a source of stress and of ulcer risk factors, such as H. pylori and on-the-job exertion) and by distressing medical conditions (which lead to use of nonsteroidal antiinflammatory drugs). Of the residual, true association, a substantial proportion is accounted for by mediation by health risk behaviors, such as smoking, sleeplessness, irregular meals, heavy drinking, and, again, nonsteroidal antiinflammatory drugs. The remainder results from psychophysiologic mechanisms that probably include increased duodenal acid load, the effects of hypothalamic-pituitary-adrenal axis activation on healing, altered blood flow, and impairment of gastroduodenal mucosal defenses.

CONCLUSIONS

Peptic ulcer is a valuable model for understanding the interactions among psychosocial, socioeconomic, behavioral, and infectious factors in causing disease. The discovery of H. pylori may serve, paradoxically, as a stimulus to researchers for whom the concepts of psychology and infection are not necessarily a contradiction in terms.

Cure with omeprazole plus amoxicillin versus long-term ranitidine therapy in Helicobacter pylori-associated peptic ulcer bleeding

BACKGROUND

Long-term prophylaxis with ranitidine reduces the risk of recurrent bleeding in patients with a history of bleeding peptic ulcers. To date, no randomized study has been performed to compare cure of Helicobacter pylori infection versus H2 blocker prophylaxis in patients with bleeding peptic ulcer.

METHODS

In a prospective randomized study, 95 consecutive patients with H. pylori-associated peptic ulcer bleeding were randomized to either ranitidine prophylaxis (150 mg at night) for 2 years or to H. pylori-eradication with omeprazole 60 mg twice daily plus amoxicillin 750 mg three times daily for 10 days.

RESULTS

(Intention-to-treat analysis). Forty-eight patients were enrolled in the ranitidine group; 47 in the omeprazole-plus-amoxicillin group. Mean follow-up was 576 days (77 to 730). Ulcer recurrence rate was 31.3% in the ranitidine group (group 1) versus 6.37% in the eradication group (group 2; p = 0.0018). More patients had recurrent bleeding in group 1 (8.3%) than in group 2 (4.2%) but we were not able to show a statistically significant difference with respect to recurrent bleeding between groups (p = 0.29). Definite cure of H. pylori infection was achieved in 89.3%.

CONCLUSIONS

Cure of H. pylori infection reduces recurrence of peptic ulcer and therefore rebleeding more effectively than does long-term maintenance therapy with an H2 blocker.

Long-term symptom patterns in duodenal ulcer: psychosocial factors

Seventy-five patients with recent-onset dyspepsia and endoscopically visible duodenal ulcer underwent psychological evaluation. Following ranitidine treatment, they were reinterviewed periodically for 12 to 76 months (mean 38.6). Ulcer symptoms were present during a mean of 14.9% of follow-up months. Patients did significantly worse if they had a low-status occupation, low education, depression, stressful life events, or abnormal Minnesota Multiphasic Personality Inventory at baseline. Of patients recalling premorbid life stress, those with a normal MMPI had a particularly benign course, whereas those with an abnormal MMPI did particularly poorly (6% versus 29% of months symptomatic: p < 0.04). Age, gender, smoking, drinking, antiinflammatory drugs, pepsinogen, Helicobacter pylori titers, and initial healing had no prognostic effect. Low socioeconomic status, life stress, depression, and psychopathology each predict a relatively poor symptom outcome for duodenal ulcer treated with antisecretory therapy, but psychologically stable individuals who develop an ulcer under stress have an excellent long-term prognosis.

A risk-benefit assessment of drugs used in the eradication of Helicobacter pylori infection

Helicobacter pylori is the cause of chronic active gastritis and predisposes to peptic ulcer disease (PUD). Furthermore, H. pylori is linked to the pathogenesis of gastric lymphoma and gastric cancer. However, treatment of this infection has proven difficult. In the last decade, many antimicrobial compounds have been studied extensively as monotherapy as well as in combination with bismuth or acid-suppressive drugs. The individual drugs and the most important eradication regimens are discussed with special regard to their risks. In the past, highly complex multidrug regimens, fear of adverse effects and frequent eradication failures have hampered the broad acceptance of H. pylori-eradication therapies. Recently, new 1-week, low-dose combination regimens of 2 antibacterials with a proton pump inhibitor have consistently achieved eradication rates of 90% and more with an acceptably low rate of adverse effects. One week's standard triple therapy [tripotassium dicitrato bismuthate (or bismuth salicylate plus metronidazole plus tetracycline or amoxicillin) has been shown to be highly effective and tolerated better in combination with a proton pump inhibitor. This regimen is, however, more complex and has more adverse effects. Therefore, it is not recommended as first-line therapy. Equipped with these therapies physicians can now be strongly encouraged to use H. pylori eradication as the therapy of choice for patients with PUD and even extend this treatment to other H. pylori-associated disease conditions.

The economic and quality-of-life benefits of Helicobacter pylori eradication in chronic duodenal ulcer disease--a community-based study

A policy of Helicobacter pylori eradication in patients with duodenal ulceration on long-term acid-suppressing therapy was evaluated in a prospective study amongst a general practice population, with particular reference to economic and quality-of-life benefits. One hundred and sixty-eight patients on long-term acid-suppressing therapy had chronic duodenal ulcer disease of whom 88 were eligible for the study; 45 patients attended for review, with 42 testing positive for H pylori (as assessed by 13C-urea breath test). The median duration of acid-suppressing therapy was six years (maximum 15 years); 47.6% of the patients were using additional antacids and 80.9% still experienced epigastric discomfort. Two-thirds (28/42) of the patients eradicated H pylori. Successful eradication was associated with a highly significant reduction in all symptoms. At 12 months follow-up, heartburn had decreased from 28.7% to 7.1%, epigastric discomfort from 75% to 3.6%, nausea from 32.1% to 0% and wind from 50% to 0%. Of the patients that eradicated H pylori 96.4% reported an improvement in their general health compared to none of those that remained H pylori positive. Successful H pylori eradication therapy scored higher on satisfaction ratings than long-term acid-suppressing therapy. Eradication of H pylori resulted in 27/28 patients being able to discontinue acid-suppressing therapy, representing a 5.8% reduction in the use of such drugs per year in the local general practice population. A policy of H pylori eradication in chronic duodenal ulcer disease reduces the use of long-term acid-suppression therapy in general practice. This has important financial implications as well as offering considerable symptomatic benefits to the patients and improving their quality of life.