Ulcer epidemiology: an overview and proposed research framework

Gastroprotective effects of the nonsaponin fraction of Korean Red Ginseng through cyclooxygenase-1 upregulation

Background

Korean Red Ginseng is known to exhibit immune-enhancing and anti-inflammatory properties. The immune-enhancing effects of the nonsaponin fraction (NSF) of Korean Red Ginseng have been studied in many reports. However, the gastroprotective effect of this fraction is not fully understood. In this study, we demonstrate the activities of NSF for gastrointestinal protection and its related critical factor.

Methods

The in vitro and in vivo regulatory functions of NSF on cyclooxygenase-1 (COX-1) messenger RNA and protein levels were examined by reverse transcription polymerase chain reaction and immunoblotting analyses. Gastroprotective effects of NSF were investigated by histological score, gastric juice pH, and myeloperoxidase activity on indomethacin-induced, cold stress-induced, and acetylsalicylic acid-induced gastritis and dextran sulfate sodium-induced colitis in in vivo mouse models.

Results

NSF did not show cytotoxicity, and it increased COX-1 messenger RNA expression and protein levels in RAW264.7 cells. This upregulation was also observed in colitis and gastritis in vivo models. In addition, NSF treatment in mice ameliorated the symptoms of gastrointestinal inflammation, including histological score, colon length, gastric juice pH, gastric wall thickness, and myeloperoxidase activity.

Conclusion

These results suggest that NSF has gastroprotective effects on gastritis and colitis in in vivo mouse models through COX-1 upregulation.

Helicobacter pylori, úlcera péptica y cáncer gástrico

Introducción. Por lo general, se ha descrito que la localización duodenal de la úlcera es más frecuente que la localización gástrica; sin embargo, en áreas con alta incidencia de cáncer gástrico la úlcera péptica parece tener una distribución anatómica distinta, existiendo predominio de la localización gástrica.Objetivo. Realizar una revisión narrativa de la literatura acerca de la distribución anatómica de la úlcera péptica en áreas con alta y baja incidencia de cáncer gástrico.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip, SciELO y Cochrane Library con los términos “Peptic ulcer” AND “stomach neoplasm”; la búsqueda se hizo en inglés con sus equivalentes en español y se limitó a estudios observacionales, cohortes y casos y controles.Resultados. Se encontraron alrededor de 50 artículos con información relevante para la presente revisión.Conclusión. La literatura disponible sugiere que la úlcera péptica predomina en áreas donde el cáncer gástrico tiene alta incidencia, mientras que en zonas donde la incidencia de la neoplasia es baja predomina la localización duodenal.

Mechanism of apoptosis involved in gastric mucosal lesions in Tibetans with high-altitude polycythemia

The Tibetan high plateau is a low-oxygen environment, which may cause the pathogenesis of high-altitude polycythemia (HAPC). Gastric mucosal lesions (GML) are a common complication of HAPC. The molecular mechanisms involved in HAPC-induced GML have remained to be fully elucidated and were therefore investigated in the present study. Gastric tissues of patients with heavy, HAPC-induced GML and healthy controls were assessed by ultrastructural and histopathological analysis. In addition, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis were used to detect cell apoptosis in the gastric mucosa tissues. Moreover, the expression of genes associated with the phosphoinositide-3 kinase (PI3K) pathway was assessed by RT-qPCR to investigate the mechanism of cell apoptosis in HAPC-induced GML. The results revealed a significant increase in the number of red blood cells, gastric vessels and the diameter of gastric mucosal vessels in HAPC-induced GML patients compared with those in healthy controls. In addition, more red blood cells were distributed in gastric tissue not only at the vascular level but also in the tissue space. The number of vacuoles was increased in the gastric mucosal cells. Furthermore, a significant increase in apoptosis of the gastric mucosal cells was identified. The expression of phosphatase and tensin homolog was significantly higher in gastric mucosa from patients with HAPC-induced GML compared with that in the healthy controls. All of the pathologic changes suggested that significant cell apoptosis occurred in the HAPC-induced GML tissues, which may be associated with the PI3K pathway. These findings may provide novel insight for the treatment of gastric lesions caused by HAPC in the future.

Transcriptome reveals the overexpression of a kallikrein gene cluster (KLK1/3/7/8/12) in the Tibetans with high altitude-associated polycythemia

High altitude-associated polycythemia (HAPC) is a very common disease. However, it the disease is still unmanageable and the related molecular mechanisms remain largely unclear. In the present study, we aimed to explore the molecular mechanisms responsible for the development of HAPC using transcriptome analysis. Transcriptome analysis was conducted in 3 pairs of gastric mucosa tissues from patients with HAPC and healthy residents at a similar altitude. Endoscopy and histopathological analyses were used to examine the injury to gastric tissues. Molecular remodeling was performed for the interaction between different KLK members and cholesterol. HAPC was found to lead to morphological changes and pathological damage to the gastric mucosa of patients. A total of 10,304 differentially expressed genes (DEGs) were identified. Among these genes, 4,941 DEGs were upregulated, while 5,363 DEGs were downregulated in the patients with HAPC (fold change ≥2, P<0.01 and FDR <0.01). In particular, the kallikrein gene cluster (KLK1/3/7/8/12) was upregulated >17-fold. All the members had high-score binding cholesterol, particularly for the polymers of KLK7. The kallikrein gene cluster (KLK1/3/7/8/12) is on chromosome 19q13.3-13.4. The elevated levels of KLK1, KLK3, KLK7, KLK8 and KLK12 may be closely associated with the hypertension, inflammation, obesity and other gastric injuries associated with polycythemia. The interaction of KLKs and cholesterol maybe play an important role in the development of hypertension. The findings of the present study revealed that HAPC induces gastric injury by upregulating the kallikrein gene cluster (KLK1/3/7/8/12), which can bind cholesterol and result in kallikrein hypertension. These findings provide some basic information for understanding the molecular mechanisms responsible for HAPC and HAPC-related diseases.

Transcriptome Reveals 1400-Fold Upregulation of APOA4-APOC3 and 1100-Fold Downregulation of GIF in the Patients with Polycythemia-Induced Gastric Injury

High-altitude polycythemia (HAPC) inducing gastric mucosal lesion (GML) is still out of control and molecular mechanisms remain widely unknown. To address the issues, endoscopy and histopathological analyses were performed. Meanwhile, microarray-based transcriptome profiling was conducted in the gastric mucosa from 3 pairs of healthy subjects and HAPC-induced GML patients. HAPC caused morphological changes and pathological damages of the gastric mucosa of GML patients. A total of 10304 differentially expressed genes (DEGs) were identified, including 4941 up-regulated and 5363 down-regulated DEGs in gastric mucosa of GML patients compared with healthy controls (fold change ≥2, P<0.01 and FDR <0.01). Particularly, apolipoprotein genes APOA4 and APOC3 were 1473-fold and 1468-fold up-regulated in GML patients compared with the controls. In contrast, gastric intrinsic factor (GIF) was 1102-fold down-regulated in GML patients compared with the controls. APOA4 (chr11:116691770–116691711), APOC3 (chr11:116703530–116703589) and GIF (chr11:59603362–59603303) genes are all located on chromosome 11. APOA4 and APOC3 act as an inhibitor of gastric acid secretion while gastric acid promotes ulceration. GIF deficiency activates a program of acute anemia, which may antagonize polycythemia while polycythemia raises the risk of GML. Therefore, the present findings reveal that HAPC-induced GML inspires the protection responses by up-regulating APOA4 and APOC3, and down-regulating GIF. These results may offer the basic information for the treatment of HAPC-induced gastric lesion in the future.

Esomeprazole: a proton pump inhibitor

Proton pump inhibitors (PPIs) are the most potent inhibitors of gastric acid secretion available, and they are effective for treating all acid-related disorders. Esomeprazole is one of several most recent PPIs that became available to the market in 2001. Esomeprazole is indicated for the treatment of gastroesophageal reflux disease in adults and children, risk reduction of NSAIDs-associated gastric ulcer, Helicobacter pylori eradication and control of pathological hypersecretory conditions associated with Zollinger-Ellison syndrome. Esomeprazole is available in both oral and intravenous formulations. A number of studies have compared esomeprazole with other PPIs. While differences supporting esomeprazole have been reported, the magnitude of differences has been variable and of uncertain clinical importance. Cost plays a major role in prescribing patterns of PPIs.

Unanswered questions about Helicobacter pylori

There is general agreement that Helicobacter pylori eradication is indicated in all infected patients with duodenal ulcer disease and is probably indicated in all infected patients with gastric ulcer disease. However, translation of treatment recommendations into practice leads to some difficult clinical decisions. Three of the more perplexing questions are whether or not all patients with dyspepsia and H. pylori should be treated, whether or not a definitive diagnosis of ulcer should be established by an invasive method, and whether H. pylori eradication is sufficient to prevent recurrence of bleeding ulcers, especially in patient groups that have a high frequency of nonsteroidal anti-inflammatory drug (NSAID) use. Another common problem is the question of whether or not to establish the success of an eradication regimen in an individual patient and the choice of method to obtain this information. There is also an obvious need to develop better antimicrobial regimens aimed specifically at Helicobacter pylori. At the basic level, almost nothing is known about the mechanisms by which H. pylori produces peptic ulcer in 10-20% of infected patients while producing gastritis in all infected subjects. There is good evidence that host factors, including intrinsic rate of acid secretion, family history and smoking are independent additive risk factors for ulcer. Ingestion of NSAIDs appears to be an independent and separate risk factor. There is evidence that strains of H. pylori that lack certain genetic markers may have a reduced likelihood of causing ulcers, but the 'ulcer' marker is present in the majority of infected subjects without ulcer.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing rates of Helicobacter pylori testing and treatment in patients with peptic ulcer disease

OBJECTIVES

The aim of this study was to identify temporal trends in the rate of Helicobacter pylori (H. pylori) testing, prevalence, and treatment among patients with peptic ulcer disease in Olmsted County, MN, from 1984 through 1997.

METHODS

All 3317 Olmsted County residents with a clinical diagnosis of peptic ulcer disease at the Mayo Clinic from 1984 through 1997 were identified. The complete medical records of an age-, sex-, and calendar year-stratified random sample were reviewed (n = 720); 298 patients (41%) had confirmed peptic ulcer disease. Changes in proportions of H. pylori testing, infection, and treatment over time were analyzed by logistic regression.

RESULTS

Of the 298 patients with confirmed peptic ulcer disease, 32% were tested for H. pylori; 36% were positive for infection, of whom 66% received antibiotic therapy. The rate of testing for H. pylori increased from 0% in 1984 to 96% in 1997, but the prevalence of infection did not change (36.4% vs 36.5%). The rate of treatment of those infected increased from 0% to 95%. By logistic regression, calendar year was associated with H. pylori testing and treatment but not infection. Recent use of nonsteroidal anti-inflammatory drugs was reported by 58% of patients, and 44% presented with GI bleeding.

CONCLUSIONS

Physicians' practice of testing and treating for H. pylori in patients with confirmed peptic ulcer disease has steadily increased over the past 14 yr. However, in our study, only 36% of these patients were infected with H. pylori, whereas the majority used nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, testing seems to be more appropriate than empiric treatment in patients with peptic ulcer disease.

Pathogenesis and therapy of gastric and duodenal ulcer disease

Despite the decreasing frequency of Helicobacter pylori-induced peptic ulcers, peptic ulcer disease remains a major clinical problem partly because nonsteroidal anti-inflammatory drug ulcers have increased in frequency. The reduction in nonsteroidal anti-inflammatory drug ulcers by use of selective cyclooxygenase-2 inhibitors will not eliminate the problem because of increased use of aspirin for cardiovascular prophylaxis. This article reviews current concepts of peptic ulcer pathogenesis and therapy according to ulcer etiology; discusses potential interactions between etiologies; and considers the therapy for H pylori infection including the effects of antimicrobial resistance, and the role of bismuth quadruple therapy or furazolidone salvage therapy.

Acid peptic disease in the elderly

GERD and peptic ulcer disease are important diseases in the elderly. GERD presents similarly in the elderly and the young, although elderly patients may have less severe symptoms yet more severe mucosal disease and a higher prevalence of BE. Although the prevalence of H. pylori is falling, the elderly remain at risk for peptic ulcer because of the widespread use of NSAIDS. The presentation of peptic ulcer disease in the elderly can be subtle and atypical when compared with younger patients, leading to a delay in diagnosis. Because of comorbidity in the aged, peptic ulcer disease and its complications result in increased morbidity and mortality rates.

Double-blind comparison of lansoprazole 15 mg, lansoprazole 30 mg and placebo as maintenance therapy in patients with healed duodenal ulcers resistant to H2-receptor antagonists

BACKGROUND

Maintenance antisecretory therapy is often used to prevent duodenal ulcer recurrence and control symptoms. This study compared the efficacy and safety of lansoprazole 15 mg and 30 mg daily with placebo in preventing ulcer recurrence in patients with a recent history of duodenal ulcer disease.

METHODS

Fifty-six patients were treated with either lansoprazole 15 mg, 30 mg or placebo o.m.

RESULTS

Within 1 month of study initiation, 27% (four out of 15) of placebo-treated patients experienced ulcer recurrence as compared to 13% (two out of 15) and 6% (one out of 18) of lansoprazole 15 mg and 30 mg treated patients, respectively. Median time to first ulcer recurrence was > 12 months in lansoprazole patients. At Month 12, significantly (P < 0.001) more lansoprazole 15 mg patients (70%) and lansoprazole 30 mg patients (85%) remained healed. Eighty-two per cent of lansoprazole 15 mg and 76% of lansoprazole 30 mg patients remained asymptomatic during the entire study period. All placebo patients became symptomatic, experienced ulcer recurrence, or withdrew from the study by month six. The incidence of adverse events was comparable among the three treatment groups.

CONCLUSIONS

Lansoprazole safely and effectively reduces duodenal ulcer recurrence and ulcer-related symptoms.

Gastrointestinal diseases in women

Gastrointestinal disorders are among the most common disorders for which women seek medical attention. Most gastrointestinal diseases in women are not inherently different from those that occur in men. There are several disorders, however, that occur more frequently or manifest themselves differently in women. This article reviews common gastrointestinal disorders affecting women. The pathophysiology, clinical manifestations, management, and gender-specific issues of gastroesophageal reflux disease, peptic ulcer disease, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD) are discussed.

High prevalence of duodenal ulcer and gastric cancer in dyspeptic patients in Korea

BACKGROUND

Although gastric cancer and duodenal ulcer are both related to Helicobacter pylori infection, they are mutually exclusive diseases such that patients with a history of duodenal ulcer have a markedly reduced risk of developing gastric cancer. It has been hypothesized that different strains of H. pylori may be related to the different diseases. Our aim was to study the prevalence of duodenal ulcer disease and gastric cancer in dyspeptic patients in South Korea, a country with a high incidence of gastric cancer.

METHODS

The study population consisted of consecutive patients between the ages of 20 and 81 years referred to Guro Hospital's Endoscopic Unit for evaluation of dyspepsia. Patients with a history of peptic ulcer or gastric cancer were excluded. Each patient underwent endoscopy and completed a detailed questionnaire. Peptic ulcer was defined as the presence of an active ulcer, red scar, or white scar.

RESULTS

One thousand patients were evaluated, and 867 (43% men and 57% women) met the entry criteria. The prevalence of peptic ulcer and gastric cancer were 24% and 7%, respectively. Among peptic ulcer patients, duodenal ulcer was commoner (75%) than gastric ulcer or coexistent duodenal and gastric ulcer (21% and 4%, respectively). The mean age of duodenal and gastric ulcer patients (45 +/- 14 and 48 +/- 12 years, respectively) was significantly lower than that of gastric cancer patients (59 +/- 11 years) (P < 0.01). Only 44 (7%) of the 597 remaining patients had definite endoscopic abnormalities (for example, erosive esophagitis, duodenitis, or pyloric deformity).

CONCLUSION

Gastric cancer and duodenal ulcer were prevalent diagnoses among Korean patients undergoing endoscopy for evaluation of dyspepsia. Korea may be the ideal country to investigate the relation between specific H. pylori strains and different H. pylori diseases.

Quantitative noninvasive testing for Helicobacter pylori does not predict gastroduodenal ulcer disease

BACKGROUND

Helicobacter pylori is strongly associated with gastric and duodenal ulcer disease. However, the diagnosis of gastroduodenal ulcers requires an endoscopic or radiographic examination. In this study, we attempted to establish a relationship between the magnitude of [13C]urea breath test results or serum H. pylori IgG levels and endoscopic findings in H. pylori-infected individuals.

METHODS

Patients who had undergone endoscopy and had a positive [13C]urea breath test and/or positive H. pylori IgG serology were identified. Endoscopic diagnoses included duodenal ulcer, gastric ulcer, nonulcer dyspepsia, and others. Results of 6% or greater on the [13C]urea breath test was defined as positive for H. pylori infection. H. pylori IgG serology was determined by an enzyme linked immunosorbent assay with values of greater than or equal to 1.0 being seropositive.

RESULTS

One hundred seventy-five patients were seropositive (mean = 3.01 +/- 1.58). One hundred sixty-eight patients had a positive [13C]urea breath test (mean = 25.43 +/- 16.90). One hundred fifty-five patients were common to both the groups. Statistical analysis did not reveal any relationship between quantitative [13C]urea breath test results or H. pylori IgG values and endoscopic diagnoses.

CONCLUSION

The magnitude of [13C]urea breath test or H. pylori IgG serology cannot be used to predict the presence or absence of gastroduodenal ulcer disease.

Effect of liver cirrhosis and age on the glutathione concentration in the plasma, erythrocytes, and gastric mucosa of man

GSH and its related enzymes are one of the protective mechanisms vs. the oxidative damage, both in the circulation and in various tissues, including gastric mucosa. Patients with liver cirrhosis frequently suffer from a gastropathy caused by portal hypertension and they present low circulating levels of GSH. Aging processes cause an increase of gastric damage, of lipoperoxidative phenomenons, and a decrease of GSH in animals. The aim of this study was the evaluation, in humans, of the effect of both these factors, age and liver cirrhosis, on the global pool of GSH and on the antioxidant capability of the cells of gastric mucosa. Therefore, we evaluated the effect of liver cirrhosis and age on the circulating levels of GSH, both in the plasma and in the erythrocytes, and the GSH concentration and the activity of the total GSH-transferase (GSH-T) in gastric mucosa of healthy subjects and in patients affected by liver cirrhosis. Age, but not liver cirrhosis, induced a significant decrease of GSH and GSH-T activity in gastric mucosa; on the contrary, the plasma levels of GSH decreased in cirrhotics but not in elderly healthy subjects. In the erythrocytes, GSH was affected by both these factors (age and liver cirrhosis). These findings indicate that both in patients with liver disease and in elderly healthy subjects the GSH-related cellular defensive mechanisms are depressed and therefore susceptibility to oxidative damage may increase.

Prevalence and incidence of peptic ulcer disease in a Danish County--a prospective cohort study

Peptic ulcer prevalence and five year incidence were assessed in a sex and age stratified population sample of 3608 Danish subjects aged 30-60 years. Statements of peptic ulcer disease obtained from questionnaires were scrutinised by reviewing medical records. Life time ulcer prevalence (95% confidence intervals) was 5.6 (4.9-6.4) per cent. Male to female prevalence ratio was 2.2:1, and duodenal to gastric ulcer prevalence ratio was 3.8:1. Thirty two participants with no previous history of peptic ulceration developed an ulcer within the observation period resulting in a five year ulcer incidence of 11.3 (7.4-15.2) per 1000 persons at risk with no demonstrable sex difference. The prevalence of duodenal ulcer has declined in Denmark whereas gastric ulcer prevalence in men has increased slightly. A decline in male duodenal ulcer incidence has probably contributed to the low male to female ulcer incidence ratio, implying that women today incur the same risk of developing an ulcer as men. If such trends continue, they will bring about a new era in ulcer epidemiology characterised by equal incidence in men and women and an even distribution of lesions in the stomach and duodenum.

Disability and severe gastrointestinal hemorrhage. A prospective study of community-dwelling older persons

OBJECTIVE

To describe the occurrence of severe gastrointestinal bleeding in community-dwelling older persons and to examine whether disability is a risk factor for this life-threatening condition independent of other known predictors.

DESIGN

Prospective cohort survey.

SETTING

Three communities of the Established Populations for Epidemiologic Studies of the Elderly (EPESE).

PARTICIPANTS

8205 persons age > or = 68 years.

MEASUREMENTS

The hospital discharge diagnoses provided by the Medicare Provider Analysis and Review files and the death certificates were prospectively surveyed for 3 years. Those with at least 1 discharge diagnosis of gastrointestinal bleeding and who received a blood transfusion or died were identified as cases of severe gastrointestinal hemorrhage. Physical disability, cognitive function, smoking and alcohol intake habits, body mass index, blood pressure, chronic conditions, number of hospital admissions in past year and medications taken were assessed at baseline.

RESULTS

The occurrence rate of severe gastrointestinal bleeding was 10.8 per 1000 person-years (241 events/22,277 person-years). In proportional hazards regression models, compared with no disability, > or = 1 disabilities in the Rosow-Breslau scale (RR = 2.1, 95% CI = 1.5-2.9), and > or = 1 ADLs limitations (RR = 3.1, 95% CI = 2.1-4.6) independently predicted gastrointestinal hemorrhage after adjusting for age, gender, body mass index, comorbidity, number of hospital admissions, blood pressure, intake of coumarin, corticosteroids, aspirin and other nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

In this prospective analysis, disability is an independent predictor of gastrointestinal hemorrhage. Further studies are needed to explain the mechanisms by which disability may cause gastrointestinal hemorrhage. Because physical disability is potentially modifiable, strategies to lower the risk of gastrointestinal bleeding should be evaluated.

Nonsteroidal anti-inflammatory drugs and peptic ulcer hospitalization rates in New South Wales

BACKGROUND

Consumption of nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDS) increased substantially during the 1980s. The effects of this trend on hospitalization rates for peptic ulcer in different age groups in New South Wales, Australia, was investigated.

METHODS

A population model based on sales of NANSAIDS and aspirin, age specific estimates of the relative risk of ulcer complications with these drugs, and hospitalization data for 1979 through 1988 was created.

RESULTS

All age groups increased consumption of NANSAIDS. The increases were greatest in elderly subjects, with women over age 65 years increasing the prevalence of their use of the drugs from 11.9% in 1979 to 22.5% in 1988 and males over age 65 increasing use from 9.7% to 20%. Aspirin use remained relatively unchanged in all age groups. Hospitalization rates for peptic ulcer decreased in both sexes under age 64 despite increasing use of NANSAIDs. Hospitalization increased in males and females over age 65, but in females the increase was substantially greater than predicted by the computer model. In women and men over age 75 the increases in hospitalization rates predicted by the model were only 18% and 33%, respectively, of the observed rises.

CONCLUSIONS

The increasing hospitalization rate for peptic ulcer among elderly subjects was only partly explained by the increasing consumption of NANSAIDS. Further research is needed.

Dyspepsia, Helicobacter pylori, and peptic ulcer in a randomly selected population in India

There seems to be a worldwide geographic variation in the prevalence of peptic ulcer disease, although there are few reliable population based studies. This study aimed to determine the prevalence of peptic ulcer disease in a community in southern India and to evaluate the relationship between dyspeptic symptoms, Helicobacter pylori infection, gastritis, and peptic ulcer disease. A sample population was selected randomly from a rural monastic settlement in southern India. Subjects were interviewed using a standardised symptom and demography questionnaire then underwent upper endoscopy and antral biopsy for histology and CLO rapid urease test. Altogether 197 subjects from a population of 1499 (13.1%) were studied. All were male monks and ethnically Tibetan. The median age was 28 years (range: 21-81). None smoked or took NSAIDs. The six month period prevalence of dyspeptic symptoms was 68.5%. Current symptoms were present in 58.9% of subjects. Dyspepsia was more common in subjects aged 40 years or younger (p < 0.0001). H pylori was detected in 77.2% subjects. There was no association between dyspepsia and the presence of H pylori or histological gastritis, although there was a strong correlation between symptoms and ulcer (p < 0.003). The point prevalence of active peptic ulcer was 6.6% (13/197). All ulcers detected were either prepyloric or pyloroduodenal in location. A further 6.6% of subjects had definite evidence of scarring or deformity indicative of ulceration in the past. Subjects with past or present ulcers comprised 17.8% of dyspeptic subjects. H pylori was present in all subjects with active ulcers and in 12/13 of those with scarring. Dyspepsia, H pylori infection, gastritis, and peptic ulcer are all more common in this population than in those from developed countries. Ulcer disease, however, accounts for only a small proportion of subjects with symptoms and neither H pylori infection nor gastritis are significantly associated with the presence of dyspepsia.

Implications of sustained suppression of gastric acid secretion

The implications of profound and sustained suppression of acid secretion are of increasing concern. Short-term inhibition of acid secretion by H2-receptor blockade or proton pump inhibition alters the gastric luminal flora and increases the risk of nosocomial pneumonia in critically ill patients who are receiving prophylaxis for stress gastritis. Long-term suppression alters gut flora, carcinogen levels in the gastric lumen, and the hormonal milieu, leading to proliferative changes in the fundic mucosa. Previous reports have noted a significant incidence of gastric malignancies in the achlorhydric environment of atrophic gastritis and pernicious anemia. Concern has also been expressed regarding the possibility of gastric neoplasia that arises after vagotomy and distal gastrectomy. The exact risk of gastric epithelial and endocrine hyperplasia or neoplasia in patients receiving potent antisecretory agents is not yet known, but such risks cannot be dismissed until long-term follow-up studies are available. The relationship between sustained suppression of acid secretion and the proliferation of epithelial and endocrine elements may provide insight into processes that regulate replication and growth of cells in the gastric mucosa.

Current surgical management of duodenal ulcers

The optimal treatment of duodenal ulcer disease today requires familiarity with a variety of operative approaches. Experience and judgment are needed to select the best procedure for the individual patient presenting with a specific ulcer complication. Improved medical therapy has relegated surgery largely to the role of emergency life-saving intervention. Nonetheless, the goal of surgery remains cure of the ulcer diathesis with avoidance of postoperative side effects. Toward this end, proximal gastric vagotomy has proved itself to be the operation of choice, not only for intractable pain, but also for perforation and perhaps for bleeding in selected good-risk patients. Its efficacy in the treatment of obstructing duodenal ulcer has not been demonstrated. Modifications of proximal gastric vagotomy, including the use of laparoscopic techniques, are currently being evaluated in patients with intractable duodenal ulcer pain.

Management of gastroduodenopathy associated with use of nonsteroidal anti-inflammatory drugs

Adverse events associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are reported more frequently to the Food and Drug Administration than are those associated with any other group of drugs. The absolute risk for serious gastrointestinal events--in particular, ulcer bleeding, perforation, and death--is controversial; some investigators believe that an epidemic of NSAID-related complications is being experienced, whereas others suggest that the risks are being overemphasized. The management of patients who take NSAIDs regularly also remains controversial. Key unresolved issues include how best to identify those patients at particularly high risk for the development of ulcer complications and whether such patients should receive prophylactic therapy in an attempt to prevent such problems. In this review, we critically evaluate the currently available literature and present a management algorithm for the treatment and prevention of NSAID-associated gastroduodenopathy.

The course of peptic ulcer disease

Peptic ulcer disease usually has periodic exacerbations and remissions. Pain can disappear without total healing of the ulcer crater and can be absent when an ulcer is present. Changes in the incidence of ulcer disease have been noted in recent years. Genetic predisposition, infection with H. pylori, and the use of anti-inflammatory drugs are involved in causation. Stress; the use of alcohol, tobacco and caffeine; and other diseases have been implicated as etiologic factors. Ulcer pain has a recognizable pattern, but the symptoms can be variable, particularly in older people and in patients taking ulcerogenic medications. The familiar complications of hemorrhage, perforation, and obstruction still occur, and nonulcer dyspepsia has not been fully explained. Duodenal ulcers have a disturbing tendency to return; new therapeutic approaches offer hope.

Acute upper gastrointestinal bleeding in elderly persons

We have seen that UGI bleeding is a serious and apparently growing problem for seniors. Of special concern in the older patient are the frequency with which serious peptic disease presents silently, the limitation frequently imposed on adequate pain relief from NSAIDs, and the higher complication rates from most of the causes of UGI bleeding. Care of the elderly would be enhanced by research focused on defining those older patients most at risk of experiencing NSAID-induced peptic complications, improved methods for preventing or treating NSAID-induced ulceration that are well tolerated and cost-effective, and better regimens for preventing the recurrence of ulcers and UGI bleeding in these patients. In regard to the last, future investigation of the role of H. pylori, methods for successfully eliminating the organism, and the effect of eradication on patients' subsequent course may be particularly helpful.

Young onset peptic ulcer disease and non-ulcer dyspepsia are separate entities

The characteristics of peptic ulcer and non-ulcer dyspepsia in young men were studied in 202 consecutive conscripts who attended Central Military Hospital in Helsinki because of long-standing upper abdominal complaints. Active peptic ulceration (APU) was found in 48 patients, inactive peptic ulcer disease (IPU) was diagnosed in 77 patients, non-ulcer dyspepsia (NUD) was diagnosed in 52 patients. In 25 cases the reason for symptoms was another disease, and these patients were excluded from the study. A control series (CON) consisted of 30 symptomless healthy young male volunteers. The likelihood of discriminating between peptic ulcer disease and non-ulcer dyspepsia in a young male patient with dyspepsia are indicated by odds ratios (OR) and its 95% confidence limits (CL 95). Active peptic ulcer disease differs from NUD, e.g., by 1) presence of antrum gastritis, OR 41.5 (CL 95: 10.1-171), 2) Helicobacter pylori in the gastric mucosa, OR 31.0 (7.4-130), 3) Lewisa+ phenotype, OR 8.9 (1.7-45.4), 4) serum pepsinogen I (S-PGI) greater than 100 micrograms/l, OR 4.6 (1.7-12.4), 5) non-secretor status, OR 4.3 (1.6-11.6), and 6) O-blood group, OR 3.0 (1.2-7.7). In conclusion, the status of gastroduodenal mucosa, gastric secretion pattern and distribution of some genetic markers in patient series indicate that young onset peptic ulcer and non-ulcer dyspepsia are two separate entities. Helicobacter-positive antrum gastritis is the best determinant of ulcer risk, but also high S-PGI, Lewisa+ phenotype, non-secretor status and O-blood group are signs of increased risk of peptic ulcer.

Effects of aging on duodenal bicarbonate secretion

The incidence of duodenal ulcer increases with age, but acid secretion does not. We have investigated the effects of aging on a mechanism of duodenal mucosal defense. Basal and acid-stimulated bicarbonate secretions were measured in the proximal duodenum in anesthetized rats of three different age groups (3 months, 1 year, and 2 years). The proximal duodenum was cannulated in situ between two plastic tubes that extend downward from a titrating chamber, and bicarbonate secretion was measured by the method of Flemström et al. Although there was no significant difference in basal secretion among three groups, bicarbonate secretion in response to luminal acid (100 mmol/L [millimolar] HCl) was diminished in 1-year-old and 2-year-old rats (1-hour integrated bicarbonate secretions; 3 months = 5.8 +/- 0.7; 1 year = 3.1 +/- 1.0*; 2 years = 2.0 +/- 0.7*). We also studied the effects of two mediators for acid-stimulated duodenal bicarbonate secretion, vasoactive intestinal polypeptide (VIP), and prostaglandin E2 (PGE2). Intravenous infusion of VIP (0.4, 4, 40 nmol/kg/hr) and intraluminal administration of PGE2 (10(-5) mol/L [molar] and 10(-4) mol/L) induced duodenal bicarbonate secretion in a dose-dependent manner in all three groups, without significant difference between groups. These findings suggest that the release of mediator(s) in response to acid is decreased in the duodenum of the aging rats. The progressive breakdown in mucosal defense mechanisms with increasing age may explain, at least in part, the age-related increase of incidence of duodenal ulcer disease.