Incompletely and completely healed duodenal ulcers' outcome in maintenance treatment: a double blind controlled study

The need for long-term treatment of peptic ulcer

Some 10% of the population in Western countries will suffer a duodenal ulcer or gastric ulcer at some time in their lives. Although there has been an improvement in the survival rate of patients with peptic ulcer haemorrhage, the mortality is still approximately 10%. There is evidence to suggest that peptic ulcer disease is a life-long condition and that ulcers remain active with an unchanged potential for complications such as haemorrhage and perforation. Over the past 15 years anti-ulcer drugs with different mechanisms of action have been developed, and their use results in complete healing of an ulcer in four to eight weeks. However, most patients experience recurrence of their peptic ulcer after discontinuation of the healing therapy. Studies of continuous H2-receptor antagonist therapy have shown that recurrence occurs less frequently than in untreated patients, is largely asymptomatic, and is rarely characterized by haemorrhagic complications. Limited data on therapy for the eradication of Helicobacter pylori suggest that this may be an alternative approach for selected patients. As protection afforded by H2-receptor antagonists remains undiminished over the course of several years and is also observed in ulcers which have bled in the past, the implementation of long-term management with these agents constitutes a rational policy.

Maintenance therapy for peptic ulcer disease

Peptic ulcers tend to recur; recurrence may be associated with an increased risk of potentially lethal complications, such as haemorrhage or perforation. Therapy aims to keep ulcers in remission. Currently, the optimal maintenance therapy is long-term, continuous administration of antisecretory drugs. More than 80% of patients remain in remission during maintenance therapy. Maintenance therapy may be required for the life of the patient, but it is acceptable to patients and is safe.

Effect of Helicobacter pylori eradication on duodenal ulcer scar in patients with no clinical history of duodenal ulcer

BACKGROUND

Helicobacter pylori eradication has become the standard treatment for duodenal ulcer. However, there is no relevant evidence for antibacterial treatment of the white scar stage of duodenal ulcer (duodenal ulcer scar) in patients with no past history of duodenal ulcer.

AIM

To investigate whether H. pylori eradication could decrease duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

PATIENTS AND METHODS

We prospectively enrolled 66 patients with duodenal ulcer scar: 53 were H. pylori-positive and 13 were H. pylori-negative. H. pylori-positive patients were randomly assigned into two groups (two-to-one allocation): 36 patients were assigned to the treatment group and 17 to the follow-up group. Thirteen H. pylori-negative patients were followed up according to the study protocol. Follow-up endoscopy was performed to evaluate ulcer scar changes and H. pylori status 6 weeks after anti-H. pylori treatment and then every 6 months for up to 30 months.

RESULTS

Active duodenal ulcer recurrence was identified in seven of 23 H. pylori-positive/non-cured patients (30%). There was no duodenal ulcer recurrence in 43 H. pylori-negative/cured patients (0%), which was significantly different in terms of duodenal ulcer recurrence (P=0.001).

CONCLUSIONS

H. pylori eradication is effective at preventing active duodenal ulcer recurrence in patients with duodenal ulcer scar and no past history of duodenal ulcer.

Effect of the eradication of Helicobacter pylori on duodenal ulcer healing and ulcer relapse: randomized controlled study in Japan

To investigate the effect of the eradication of Helicobacter pylori on the healing and relapse of duodenal ulcers. 50 patients with active duodenal ulcer and H. pylori infection were randomly allocated to two treatment groups. One group (cimetidine group) received cimetidine 400 mg twice daily for 6 weeks and the other group (double-therapy group) received 300 mg amoxicillin granules and 250 mg metronidazole thrice daily for 2 weeks, in addition to the same regimen of cimetidine as the cimetidine group. Forty-two patients completed the study. After confirmation of ulcer scar, all patients were followed up for 6 months while receiving treatment with teprenone, an agent that does not affect acid secretion or the eradication of H. pylori. The healing rates at 6 weeks were 90% in the cimetidine group and 95.5% in the double-therapy group. H. pylori eradication occurred in 0% of the cimetidine group and in 73.7% of the double-therapy group (P = 0.004). The cumulative relapse rates in the two groups at 6 months were 64.3% and 11.1%, respectively (P = 0.0007). In the double-therapy group, the cumulative relapse rate at 6 months in the patients in whom H. pylori persisted was 50% (2/4); the rate was 0% (0/14) in the patients in whom H. pylori had been eradicated (P = 0.005). Histological gastritis significantly improved compared with the baseline in the double-therapy group, but no such improvement was seen in the cimetidine group. White scarring was found in 7.1% of the cimetidine group and in 83.3% of the double-therapy group after 6 months (P < 0.0001). The eradication of H. pylori markedly decreased the relapse rate in duodenal ulcer patients, and it significantly improved both the grade of gastritis and the quality of the ulcer scar.

Omeprazole versus famotidine in the short-term treatment of duodenal ulcer disease

The efficacy and safety of omeprazole, in 241 patients with active recurrent duodenal ulcer from 21 Italian centres, was studied in a multicentre double-blind randomized trial comparing 20 mg omeprazole o.m. or 40 mg famotidine nocte with endoscopic examination, symptom recording, laboratory screening and gastrin assay. In a per protocol analysis, the duodenal ulcer healing rates for omeprazole and famotidine, documented by endoscopy, were 62% (68/109) and 33% (39/117) after 2 weeks of treatment (P less than 0.001), 92% (96/104) and 80% (86/108) cumulative after 4 weeks (P less than 0.05), and 99% (102/103) and 92% (96/104) after 6 weeks (P less than 0.05), respectively. The results of this trial demonstrate that 20 mg omeprazole o.m. is superior to 40 mg famotidine nocte in duodenal ulcer healing.

Long term treatment of duodenal ulcer. A review of management options

Duodenal ulcer is a chronic disease characterised by remission and relapses. The duration of this relapsing tendency is unpredictable for the individual patient, but in most cases it lasts for many years and perhaps the entire lifetime. Various therapeutic strategies have been suggested to maintain the disease in remission: continuous, intermittent and on-demand treatment with H2-antagonists, or surgery. Continuous maintenance treatment with the currently available H2-blockers has proved to be superior to all the other strategies in terms of efficacy, and should therefore be regarded as the long term treatment of choice for duodenal ulcer patients. The duration of maintenance treatment is still uncertain, but probably it should not be less than a few years. Intermittent treatment or surgery could be proposed to patients unsuitable for continuous maintenance, depending on whether they have mild or aggressive disease, respectively.

Maintenance ranitidine treatment after haemorrhage from a duodenal ulcer. A 3-year study

Forty patients with a recently healed duodenal ulcer (DU) that presented with haemorrhage were entered into a blind, randomized study of maintenance ranitidine therapy (150 mg at night) versus a placebo preparation, to determine whether prolonged ranitidine therapy could influence the natural history of the ulcer diathesis. Duodenal ulceration or duodenal cap erosions of Lanza grade 3 recurred in 24 of the 40 patients studied during the 2-year trial period but was associated with further bleeding in only 2 cases. Maintenance ranitidine therapy significantly reduced the incidence and symptoms of DU/erosion recurrence at all time intervals beyond 3 months, the maximum protective effect being observed after 12 to 15 months of treatment (incidence, p less than 0.001; symptoms, p less than 0.03). The DU/erosion recurrence rate without treatment after 2 years of successful maintenance ranitidine therapy was significantly less than for patients randomized to the placebo group at entry to the study (p less than 0.03). Two years of maintenance ranitidine therapy appear to be beneficial for patients who have a healed DU that presented with haemorrhage. This treatment, however, cannot be recommended without reservation until the implications of the associated high incidence of asymptomatic duodenal ulceration have been fully evaluated.

Over the counter sales of histamine-2 receptor antagonists

Self treatment with H2 antagonists may have a positive impact on quality of life and costs. It may, however, also lead to incomplete peptic ulcer healing with frequent relapse and complications, inadequate long term treatment, neglectance of the life style type treatment for gastroesophageal reflux disease and a delay in the diagnosis of gastric malignancy. More research needs to be focused on the consequences of a more unrestricted and symptom guided use of H2 antagonists.

Factors which influence the incidence and course of peptic ulcer

The present review concentrates on environmental factors which influence the outcome of peptic ulcer disease by acting from the outside. Endogenous risk factors, such as acid output, pepsin secretion and serum pepsinogen, gastritis and mucosal defense, blood group, and secretor status, are only dealt with when they help to explain the mechanism by which exogenous risk factors affect the upper gastrointestinal mucosa. After outlining the wax and wane of peptic ulcer, it is concluded that these changes resulted from similar temporal patterns of occupational workload in the general population. Cross sectional studies also support the contention of occupational workload being a risk factor in peptic ulcer, explaining several characteristic features of peptic ulcer, such as its sex, race, and social class distribution, increased incidence in immigrant workers, seasonal variation, healing by bed rest, and urban versus rural distribution. Susceptible subjects may react to a rise in occupational workload and acute exposure to stressful life events by increased gastric secretion which, in turn, leads to ulceration and symptoms. Cigarette smoking, intake of aspirin and related drugs, dietary salt, and alcohol abuse represent additional environmental risk factors, which form the etiologic link of the association of peptic ulcer with chronic lung disease, rheumatoid arthritis, hypertensive disease, and liver cirrhosis, respectively.

Duodenal ulcer healing after presentation with haemorrhage

Forty patients who were managed conservatively after haemorrhage from an endoscopically verified duodenal ulcer were randomised at discharge from hospital to enter a blind study of ranitidine therapy (150 mg bd) versus a placebo tablet. The patients were re-endoscoped after four weeks, ulcer status defined and the trial code broken revealing that five of 20 placebo patients had healed their duodenal ulcer compared with 16 of 20 ranitidine patients (p = 0.001). Lifestyle parameters of both groups improved during the study period but no directly related benefit in duodenal ulcer healing could be shown. We conclude that effective anti-ulcer therapy, such as ranitidine, is required to heal a duodenal ulcer which presents with haemorrhage.

Outcome of ulcer-associated duodenitis after short-term medical treatment

The relationship between duodenitis and the outcome of duodenal ulcers was prospectively investigated by evaluating the frequency and extent of bulbar duodenitis before and after short-term medical treatment of the ulcer. Duodenitis appeared to be more frequent and more severe in the bulbar area close to the ulcer and was more widespread in the bulb of patients whose ulcer did not respond to treatment. After medical treatment, duodenitis improved only in the ulcer area and only in patients with complete ulcer healing. While confirming that, in some patients, duodenitis may well be an inflammatory reaction to the presence of the ulcer, data from the present study indicate that, in other patients, duodenitis, throughout the bulb, does not seem to be influenced by the outcome of the ulcer or the treatment. These findings suggest that there are subpopulations of duodenal ulcer patients who differ according to the pattern of bulbar duodenitis.

Drugs for the prevention of peptic ulcer recurrence

The treatment of chronic peptic ulcer involves the treatment of acute exacerbations and the complications, and the prevention of ulcer recurrence. Several drugs accelerate the initial healing of ulcer and include the H2-receptor antagonists (cimetidine and ranitidine), colloidal bismuth, sucralfate, pirenzepine, carbenoxolone sodium, prostaglandins, high dose antacids and trimipramine. The long term management of ulcer involves the use of drugs and, in selected patients, surgery. Drugs used in this context include H2-receptor antagonists, pirenzepine, sucralfate and probably prostaglandins when further trial evidence is available. Regimens of long term drug treatment include intermittent treatment and maintenance treatment. The former consists of no active treatment after the ulcer is healed and the treatment of each acute exacerbation when it occurs, this treatment involving any one of the several drug routines mentioned above. If exacerbations are frequent (i.e. more than 2 to 3 years), maintenance therapy with H2-receptor antagonists, pirenzepine or sucralfate is advised. If the ulcer recurs despite long term treatment, it may be healed again using the healing dose of the above agents, and maintenance therapy recommenced if the remission induced by maintenance therapy was several years. If the remission was short, surgery should be advised.