Current diagnosis and selection of patients for treatment of peptic ulcer disease

The introduction of fiberoptic endoscopy has altered the relative importance of ulcer symptoms in the diagnosis of peptic ulcer disease. Interestingly, we now realize that 50% of ulcer patients do not have the classical ulcer symptoms and that 25% of peptic ulcers are asymptomatic. Modern forward-viewing endoscopes of small diameter enable precise diagnosis with little discomfort in 95% of all duodenal ulcer patients. A biopsy is only recommended in rare cases (giant ulcers) because the malignancy rate is only 0.024% in duodenal ulcers. The diagnostic accuracy of endoscopy in detecting gastric ulcer is as high as that for duodenal ulcer, but for this ulcer type it is absolutely necessary to exclude malignancy by obtaining a minimum of six biopsies (four from the ulcer margin and two from the ulcer base), since approximately 10% of all gastric ulcers are actually carcinomas. Whereas in duodenal ulcer repeat endoscopy is seldom necessary, it is mandatory in gastric ulcer since ulcer healing is not proof of a benign ulcer. In experienced hands endoscopy is superior to radiography in duodenal and in gastric ulcer, although there is still a place for radiography as a supplementary investigation or if the patient rejects endoscopy. When selecting patients for treatment of peptic ulcer the following aspects must be considered: natural history of the disease, effectiveness of treatment, and risks and costs of treatment. Treatment goals (relief of symptoms, ulcer healing) can be achieved as far as the acute ulcer is concerned but as yet we have no evidence that we can cure chronic ulcer disease.     

Epidemiology of peptic ulcer disease

In the United States about four million people have active peptic ulcers and about 350,000 new cases are diagnosed each year. Four times as many duodenal ulcers as gastric ulcers are diagnosed. Approximately 3000 deaths per year in the United States are due to duodenal ulcer and 3000 to gastric ulcer. There has been a marked decrease in reported hospitalization and mortality rates for peptic ulcer in the United States. Changes in criteria for selecting the underlying cause of death might account for some of the apparent decrease in ulcer mortality rates. Hospitalization rates for duodenal ulcers decreased nearly 50 per cent from 1970 to 1978, but hospitalization rates for gastric ulcers did not decrease. Although this decrease in hospitalization rates may reflect a decrease in duodenal ulcer disease incidence, it appears that changes in coding practices, hospitalization criteria, and diagnostic procedures have contributed to the reported declines in peptic ulcer hospitalization and mortality rates. There is no good evidence to support the popular belief that peptic ulcer is most common in the spring and autumn. The most consistent pattern appears to be low ulcer rates in the summer. There is strong evidence that cigarette smoking, regular use of aspirin, and prolonged use of steroids are associated with the development of peptic ulcer. There is some evidence that coffee and aspirin substitutes may affect ulcers, but most studies do not implicate alcohol, food, or psychological stress as causes of ulcer disease. Genetic factors play a role in both duodenal and gastric ulcer. The first-degree relatives of patients with duodenal ulcer have a two- to threefold increase in risk of getting duodenal ulcer and relatives of gastric ulcer patients have a similarly increased risk of getting a gastric ulcer. About half of the patients with duodenal ulcer have elevated plasma pepsinogen I. A small increase in risk of duodenal ulcer is found in persons with blood group O and in subjects who fail to secrete blood group antigens into the saliva. In most Western countries, morbidity from duodenal ulcer is more common than from gastric ulcer, even though deaths from gastric ulcer exceed or equal those from duodenal ulcer. In Japan, both morbidity and mortality are higher for gastric ulcer than for duodenal ulcer.     

消化性溃疡2 387例胃镜分析

目的 了解地区性溃疡病发病学特点。方法 对10年间经胃镜检查诊断为消化性溃疡的病例进行统计分析。结果 （1）共检出2387例溃疡,十二指肠球部溃疡（DU）1295例,胃溃疡（GU）960例,复合性溃疡（CU）132例。（2）溃疡患者男女之比为4.96:1。（3）溃疡患者平均年龄42.3岁,球溃疡以30岁以下居多,胃溃疡以50岁以上居多,复合溃疡以50岁以上居多。结论 （1）病变好发部位以球溃疡最多见。胃次之,复合溃疡最少。（2）溃疡发病男性明显高于女性,与不良生活习惯有关。     

21310例十二指肠溃疡流行病学分析

目的探讨十二指肠溃疡的流行病学特点。方法对南宁市17家医院1992—1997年经胃镜检查诊断为十二指肠溃疡的21310例患者资料进行回顾性分析。结果①从行胃镜检查的104121例患者中检出十二指肠溃疡21310例,检出率为20．47％,占检出的消化性溃疡87．87％。②十二指肠溃疡中,男16002例、女5308例,男性发病人数多于女性（P〈0．01）。③中青年是十二指肠溃疡的高发年龄,30～39岁年龄段是检出的高峰。④十二指肠球部溃疡的易发部位依次为前壁（47．16％,11662处）、大弯（24．90％,6159处）、小弯（16．67％,4123处）、后壁（11．27％,2787处）。霜斑样溃疡在十二指肠球后发生率较高。⑤十二指肠溃疡发病与季节有一定关系,检出率最高的是冬春季。结论十二指肠溃疡患者男性多于女性;中青年为十二指肠溃疡高发人群,球部溃疡以前壁最多见;霜斑样溃疡在十二指肠球后较常见;十二指肠溃疡冬春季检出率高于夏秋季。     

Ventilatory function in chronic peptic ulcer. A controlled study of ventilatory function in patients with gastric and duodenal ulcer

The aim of this study was to determine if a defect in ventilatory function is present in patients with chronic peptic ulcer and if so, is it present in both gastric and duodenal ulcer and is it related to smoking. Fifty-six patients with peptic ulceration (27 gastric ulcer, 29 duodenal ulcer), together with 56 healthy controls matched for age, sex, and smoking status, were studied. Ventilatory function was measured and the ABH blood group antigen secretor status was determined. Vital capacity and forced expiratory volume in 1 s were significantly reduced in both smokers and nonsmokers with gastric ulcer when compared with controls; total lung capacity was lower than controls only in smokers with gastric ulcer. In duodenal ulcer patients, a trend similar to that observed in gastric ulcer patients was present. It is concluded that a defect in ventilatory function is present in patients with chronic gastric ulcer; a lesser defect is present in patients with duodenal ulcer.     

消化性溃疡患者非甾体类抗炎药服用史和幽门螺杆菌感染的协同致病性分析

目的了解服用非甾体类抗炎药(NSAIDs)和幽门螺杆菌(H.pylori)感染在消化性溃疡及合并上消化道出血发病中是否具有协同作用。方法应用病例对照研究,于1999年7月至2004年12月选取吉林大学中日联谊医院的803例消化性溃疡患者(其中208例溃疡合并上消化道出血者)与同一时期就诊的2061例非胃十二指肠疾病患者,进行NSAIDs服用史的调查和H.pylori感染的检测。结果服用NSAIDs合并H.pylori感染者患胃溃疡的OR值明显高于单纯服用NSAIDs者和单纯H.pylori感染者患胃溃疡的OR值之和;服用NSAIDs合并H.pylori感染的胃溃疡及十二指肠溃疡患者发生上消化道出血的OR值均低于单纯服用NSAIDs和单纯H.pylori感染的胃溃疡患者和十二指肠溃疡患者发生上消化道出血的OR值之和;与无溃疡未服NSAIDs者比较,偶尔服药者溃疡出血与短期服药者及长期服药者比较,差异无统计学意义。结论NSAIDs和H.pylori感染在胃溃疡的形成中具有协同作用;在溃疡合并上消化道出血的发病中无协同作用;溃疡合并上消化道出血与服用NSAIDs的时间长短无关。     

成都区域性老年性消化性溃疡内镜特点

目的 根据我院老年性消化性溃疡的检出情况及内镜下特征,探讨老年性消化性溃疡的特点。方法总结我院2004．8—2008．7间经胃镜确诊的4554例消化性溃疡患者,比较老年组和中青年组消化性溃疡的检出率、大小、部位、并发症、Hp阳性率及老年性胃溃疡与溃疡型胃癌的发生部位和大小。结果 老年组和中青年组消化性溃疡的检出率分别为5．98％和4．86％（P〈0．01）,且胃溃疡、十二指肠溃疡和复合性溃疡在两组的检出率均有差别（P〈0．01）;两组胃溃疡的发生部位没有差别（P〉0．05）,平均溃疡面积分别为1．479±3．737和3．209士7．914（P=0．015）;两组并发症的发生率分别为2．3％和0．89％（P〈0．005）,不同类型溃疡的Hp的检出率差异无统计学意义。老年性溃疡型胃癌在胃底的发生率高于胃溃疡（P=0．0005）,面积大于胃溃疡（P〈0．005）。结论老年性消化性溃疡的发病随年龄的增加而增加,胃溃疡多好发于胃窦和胃角,并发症发生率高。溃疡性胃癌则好发于胃底,且溃疡的面积大。     

Thickness of Brunner's glands and its clinical significance in peptic ulcer diseases

The thickness of Brunner's glands was measured using an ocular micrometer in 297 cases of surgically resected peptic ulcer and in 120 autopsy cases (control group). The mean maximum thickness of Brunner's glands in the control group was 1.55 +/- 0.37mm (mean +/- SD) and no difference in thickness was noted for each decade of age. The mean maximum thickness of Brunner's glands in patients with gastric ulcer, duodenal ulcer and gastroduodenal ulcer was 2.34 +/- 1.06, 3.18 +/- 1.07 and 3.24 +/- 1.05mm, respectively. When an ulcer is within the duodenum, Brunner's glands near the ulcer were thicker than those contralateral to it. In patients with gastric ulcer, Brunner's glands were the thickest in the pyloric ulcer group and negative correlation was noted between the thickness of Brunner's glands and the distance to the ulcer from the pyloric ring. Since gastric acidity is supposed to be lower when an ulcer is located more proximally, these results suggest that Brunner's glands become hyperplastic not only with the presence of an ulcer in the duodenum but also by acid hypersecretion of the stomach.     

Epidemiology of peptic ulcer disease in Wuhan area of China from 1997 to 2002

AIM: To describe the epidemiological features of peptic ulcer disease in Wuhan area during 1997-2002, to analyze the sex, age and occupation characteristics, as well as the geographic distribution of peptic ulcer disease, and to determine the effective methods of preventing and controlling peptic ulcer disease. METHODS: In the early 1980s, the peptic ulcer disease registry system was established to collect the data of peptic ulcer disease in Wuhan area. Here we performed a statistically detailed analysis of 4876 cases of peptic ulcer disease during 1997-2002. RESULTS: The morbidity of peptic ulcer disease between males and females was significantly different (chi(2) = 337.9, P<0.001). The majority of peptic ulcer diseases were found at the age of 20 to 50 years. Because of different occupations, the incidence of peptic ulcer disease was different in different areas. CONCLUSION: The incidence of peptic ulcer disease is highly associated with sex, age, occupation and geographic environmental factors. By analyzing the epidemiological features of peptic ulcer disease, we can provide the scientific data for prevention and control of peptic ulcer disease.     

Changes in the pattern of peptic ulcer disease in the northern part of Norway between 1946 and 1981

The unique pattern of peptic ulcer disease in arctic areas has long been of interest. Results from a retrospective study on the occurrences of gastric and duodenal ulcer for the period between 1962 and 1964 in the northern part of Norway are presented. These results are compared with preliminary data from an ongoing investigation of peptic ulcer in the radiological department at the University Hospital of Troms? and with those presented by others from the same area in the 1940s. It is shown that the relation between gastric ulcer and duodenal ulcer has changed markedly both for women and men. However, there is still a higher incidence rate of gastric ulcer than of duodenal ulcer in women, whereas the ratio of gastric to duodenal ulcer in men is 1:1. These results contrast sharply with those reported elsewhere in Europe and in the United States.     

Clinical investigation of perforated duodenal ulcer--with special reference to the presence of Helicobacter pylori infection and rate of recurrence]

Perforated duodenal ulcer was clinically evaluated with respect to Helicobacter pylori infection and rate of recurrence in 38 ulcer patients perforated and 154 patients with non-perforated duodenal ulcer who visited our hospital in past 5 years and 6 months. The frequency of occurrence of H. pylori-positivity was 42.1% in patients with perforated duodenal ulcer, significantly lower than that of 92.9% in patients with non-perforated lesions. This result suggests that H. pylori is hardly involved in the development of perforated duodenal ulcer. The rate of recurrence was significantly lower for perforated duodenal ulcer than for non-perforated ulcer. In particular, perforated duodenal ulcer did not recur in the group on maintenance therapy with H2-recepter antagonists. Maintenance therapy using inhibitors of gastric acid secretion seems effective for the prevention of recurrence of perforated duodenal ulcer.     

Aetiological factors of peptic ulcer: Perspectives of epidemiological observations this century

Abstract There are five known environmental, causative factors for peptic ulcer, namely, non-steroidal anti-inflammatory drugs (NSAID), Helicobacter pylori infection, cigarette smoking, environmental stress and dietary habit. There have been six factual, epidemiological observations on peptic ulcer this century: the rise and fall of ulcer frequency in Western societies; geographical variations in ulcer rates; in sex ratios; in duodenal: gastric ulcer ratios; and in placebo healing rates; and seasonal variation in ulcer frequencies. This report examines each of these epidemiological observations to see if each of the environmental factors can explain the observations. The secular trends and the variation in ulcer rates can be related to all the environmental factors. The sex ratios can be explained on the basis of cigarette smoking and environmental stress, whereas the duodenal: gastric ulcer ratios may be ascribed to NSAID use. Placebo healing and seasonal occurrence of ulcer is probably more related to environmental stress. Helicobacter pylori infection alone cannot explain the sex ratios, the duodenal: gastric ulcer ratios, the placebo healing and the seasonal occurrence of ulcer. Cigarette smoking or NSAID use alone does not tally with the seasonal variation of ulcer frequencies. Environmental stress alone does not fit into the recent fall of ulcer rates in Western countries. This report supports the concept of heterogeneity in peptic ulceration.     

不同病因所致食管溃疡临床特征的研究进展

食管溃疡是由不同病因引起的食管各段黏膜层、黏膜下层甚至肌层破坏而形成的坏死性病变,其在临床上相比于胃溃疡及十二指肠溃疡较为少见,且不同病因所致食管溃疡临床特征复杂多样,容易引起诊治延误,并严重的影响着患者的生活质量及日常工作。基于此,本文就不同病因所致的食管溃疡临床特征做一综述,从而为临床医师更好地诊治不同病因所致食管溃疡提供理论依据。     

Changes in Gastric Mucosal Blood Flow during Healing of EMR-Induced Ulcer

Abstract: We used the laser Doppler method to study the difference in gastric mucosal blood flow changes between peptic ulcer (65 cases) and artificial ulcer caused by endoscopic mucosal resection (35 cases) during their respective healing processes. At each endoscopic ulcer stage, blood flow at the ulcer margin and that in the surrounding mucosa were measured. In the artificial ulcer, which heals easily, blood flow at the ulcer margin was still high at the scarring stage as compared with that in the corresponding area of a peptic ulcer, which is prone to relapse. Moreover, the blood flow ratio (blood flow at the ulcer margin/blood flow in the surrounding mucosa) at the S1 stage in artificial ulcers was significantly higher than that in peptic ulcers (p<0.05). These results suggest that blood flow in the SI stage is an important aspect of ulcer healing and relapse.     

Thickness of Brunner’s glands and its clinical significance in peptic ulcer diseases

The thickness of Brunner’s glands was measured using an ocular micrometer in 297 cases of surgically resected peptic ulcer and in 120 autopsy cases (control group). The mean maximum thickness of Brunner’s glands in the control group was 1.55±0.37mm (mean±SD) and no difference in thickness was noted for each decade of age. The mean maximum thickness of Brunner’s glands in patients with gastric ulcer, duodenal ulcer and gastroduodenal ulcer was 2.34±1.06, 3.18±1.07 and 3.24±1.05mm, respectively. When an ulcer is within the duodenum, Brunner’s glands near the ulcer were thicker than those contralateral to it. In patients with gastric ulcer, Brunner’s glands were the thickest in the pyloric ulcer group and negative correlation was noted between the thickness of Brunner’s glands and the distance to the ulcer from the pyloric ring. Since gastric acidity is supposed to be lower when an ulcer is located more proximally, these results suggest that Brunner’s glands become hyperplastic not only with the presence of an ulcer in the duodenum but also by acid hypersecretion of the stomach.     

16例直肠孤立性溃疡的诊断

直肠孤立性溃疡综合征是一种少见的直肠良性病变。我院进行1万例纤维结肠镜检查中发现直肠孤立性溃疡综合征16例,其中溃疡型6例(单发溃疡5例,多发溃疡1例),隆起型6例,混合1例,平坦型3例。本文结合文献复习,重点讨论了直肠孤立性溃疡综合征的表现、病理及该病的鉴别诊断。     

The treatment of duodenal and gastric ulcer with ranitidine--a controlled, multicentre clinical trial

One hundred and seventy seven duodenal ulcer and eighty-one gastric ulcer patients were treated with either ranitidine or placebo in a prospective double-blind study. Groups treated with active drug and placebo were comparable and ulcer healing was assessed by weekly endoscopic examinations. Ranitidine was shown to accelerate the rate of spontaneous ulcer healing in both duodenal and gastric ulcer. This acceleration is significant after one week of treatment in duodenal ulcer and from three weeks onwards in gastric ulcer. The ulcer healing rate after three weeks treatment with ranitidine was 85.5% in duodenal ulcer, and 72.5% in gastric ulcer which was significantly higher than in the placebo group where it was 51.7% and 41.5% respectively (P less than 0.005 and P less than 0.01). Treatment with ranitidine for a maximum of six weeks healed 97.1% of duodenal ulcer patients (172 out of 177) and 96.5% of gastric ulcer patients (77 out of 81). Out of total of 258 patients only 9 failed to heal. No adverse events were seen with ranitidine and it would appear free of the side effects that have been seen with cimetidine. In addition there were no significant changes in blood haematology or clinical chemistry parameters. Ranitidine is also given in a more convenient regimen, 150 mg daily as compared to 200 mg three times daily and 400 mg nocte with cimetidine.     

Epidemiological aspects of peptic ulcer disease on the Faroe Islands. An interim report

A prospective epidemiological study was carried out from 1981 to 1983 to determine the incidence of peptic ulcer on the Faroe Islands. The annual incidence of first-time-diagnosed peptic ulcer was on the average 3.3 per 1000 inhabitants aged 15 years and older. No significant changes in incidence were observed during the 3-year period. The male to female ratio of peptic ulcer was 2.1:1. The annual incidences of duodenal and gastric ulcer were 2.3 per 1000 and 1.0 per 1000, respectively. The duodenal to gastric ulcer ratio was approximately 2:1 in both male and female patients. The incidence of peptic ulcer observed in the Faroe Islands is very high compared with other countries. The incidence of duodenal ulcer is of the same high magnitude as observed in Scotland, whereas the incidence of gastric ulcer is twice as high as generally found in Western countries and in accordance with the rates found in Arctic areas.     

Epidemiological Aspects of Peptic Ulcer Disease on the Faroe Islands: An Interim Report

A prospective epidemiological study was carried out from 1981 to 1983 to determine the incidence of peptic ulcer on the Faroe Islands. The annual incidence of first-time-diagnosed peptic ulcer was on the average 3.3 per 1000 inhabitants aged 15 years and older. No significant changes in incidence were observed during the 3-year period. The male to female ratio of peptic ulcer was 2.1:1. The annual incidences of duodenal and gastric ulcer were 2.3 per 1000 and 1.0 per 1000, respectively. The duodenal to gastric ulcer ratio was approximately 2:1 in both male and female patients. The incidence of peptic ulcer observed in the Faroe Islands is very high compared with other countries. The incidence of duodenal ulcer is of the same high magnitude as observed in Scotland, whereas the incidence of gastric ulcer is twice as high as generally found in Western countries and in accordance with the rates found in Arctic areas.     

Gastric cancer among peptic ulcer patients: Retrospective, long-term follow-up

BACKGROUND: Patients with duodenal ulcer are not at high risk although Helicobacter pylori infection is no doubt associated with gastric cancer development. However, little is known about the risk after long-term follow-up. AIMS: We investigated the incidence for gastric cancer development in peptic ulcer patients in a long term. PATIENTS AND METHODS: Between 1965 and 2004, endoscopic follow-up of more than 1 year was conducted on 1504 peptic ulcer patients in our hospital. They consisted of 978 gastric ulcer patients, 444 duodenal ulcer patients and 82 gastric and duodenal ulcer patients. Gastric and duodenal ulcer patients were excluded from the analysis because of their limited number. RESULTS: Gastric cancers developed in 32 (3.3%) of gastric ulcer patients and 3 (0.68%) of duodenal ulcer patients. Kaplan-Meier analysis showed that the incidence of gastric cancer in duodenal ulcer patients was significantly lower than that in gastric ulcer patients (log-rank test, p=0.0059). Cox's proportional hazard model denoted the relative risk for duodenal ulcer against gastric ulcer adjusted by sex and age as 0.23 (95% CI: 0.072-0.77, p=0.016). CONCLUSION: The risk for patients with duodenal ulcer to develop gastric cancer over the long term is significantly less than in those with gastric ulcer.