What is an intractable duodenal ulcer and how should it be managed?

Prevention of duodenal ulcer relapse with omeprazole 20 mg daily: a randomized double-blind, placebo-controlled study

We report the first double-blind, placebo-controlled study that assesses the efficacy and safety of omeprazole 20 mg daily in the maintenance treatment of duodenal ulcer. For the healing phase, 128 patients with endoscopically proven active duodenal ulcer and a history of three or more relapses during the 2 years prior to the study were treated until healing with omeprazole 40 mg daily for 2 and up to 8 weeks. One hundred and twenty-three patients whose ulcers were healed were randomized to receive omeprazole 20 mg daily (n = 60) or placebo (n = 63) for 12 months as maintenance treatment. Patients were interviewed at 3, 6, 9 and 12 months, and endoscopy was performed at 3, 6 and 12 months and whenever symptoms recurred. The healing rates of the 124 patients completing the healing phase were 84, 98 and 100% at 2, 4 and 8 weeks, respectively. During the maintenance phase, eight and four patients discontinued treatment from the omeprazole and placebo groups, respectively. The proportion of patients in remission in the omeprazole group and placebo group after 12 months were 94 and 9% respectively (life table estimates, P < 0.0001). No significant clinical or laboratory changes were observed in patients on therapy with omeprazole. Patients with a history of frequent relapses thus continued to have a very high relapse rate without prophylactic treatment. Omeprazole 20 mg daily was effective and safe in maintaining such patients in remission.

Predictors of duodenal ulcer healing during treatment with cimetidine

A two phase study was performed to identify factors that influence the healing rate of duodenal ulcer. The study included an initial clinical trial in 145 patients and a second trial in a further 61 patients. All patients were prescribed cimetidine at a daily dose of 800 mg for six weeks. The factors examined were age, sex, inpatient or outpatient treatment, duration of present ulcer pain, past history of duodenal ulcer, smoking, drinking, the length of time it took for symptoms to resolve after beginning treatment, and the characteristics of the ulcers themselves. Eighty four per cent of the duodenal ulcers healed after six weeks. Using univariate and multivariate analyses, it was found that three factors indicated a significant delaying effect on healing: (1) symptoms that persisted two weeks after treatment had begun; (2) heavy smoking (20 or more cigarettes daily); and (3) severe narrowing of the duodenal bulb. Patients with none of the three unfavourable factors (n = 90) had a healing rate of 95.6% compared with patients with one (n = 45) or two or more (n = 10) factors, whose healing rates were 75.6% and 20.0% respectively (p less than 0.001). The corresponding figures in a second study were 88.9%, 55.0%, and 0%, respectively (p less than 0.001). A prognostic score based on these three factors represents the severity of duodenal ulcers with regard to healing in patients treated with cimetidine.

Omeprazole in the treatment of peptic ulcers resistant to H2-receptor antagonists

Thirty patients with peptic ulcers resistant to at least 8 weeks of continuous therapy with full-dose H2-receptor antagonists alone or followed by other anti-ulcer drugs, were treated with the gastric proton pump inhibitor omeprazole (40 mg), administered orally once daily for up to 8 weeks. The study design was non-comparative and open; healing was verified by endoscopy. After only 2 weeks of treatment, 21 out of 23 (91%) duodenal ulcer patients were healed, as well as 2 out of 2 patients with both duodenal and gastric ulcer and 1 out of 3 patients with prepyloric ulcer. After 4 weeks, all duodenal ulcers, 1 out of 2 gastric ulcers and 2 out of 3 pre-pyloric ulcers were healed. A further month of therapy healed the gastric ulcer to give an overall healing rate of 97% and leaving only one patient (pre-pyloric ulcer) unhealed at the end of the study. Of 19 patients suffering ulcer symptoms at entry, only two patients reported any symptoms at 2 weeks and one of these (who remained unhealed) continued to have symptoms throughout the study. One patient reported mild asthenia; otherwise, no clinical or biochemical side-effects were recorded. It is concluded that omeprazole is highly effective in healing refractory peptic ulcers.

Histamine H2-receptor antagonists

The first histamine H2-receptor antagonists were developed in the early 1970s, and they have a dominant role in today's management of peptic ulceration. The original regimens using either cimetidine or ranitidine attempted to control acidity across the 24 hours, but more 'modern' regimens use a large single dose of the H2-blocker in the evening, which produces a pulse of decreased intragastric acidity during the night with a normal acidity in the daytime. High-dose regimens using a new generation of extremely potent histamine H2-receptor antagonists may improve ulcer healing rates at 4 weeks, and may be particularly useful for the management of either severe oesophagitis or intractable duodenal ulceration.