Post-bulbar and coexisting ulceration: unique features of peptic ulcer in Hyderabad.

Post-bulbar ulceration is uncommon, but a pilot study in Hyderabad showed a high incidence. We therefore carried out a prospective endoscopic study of the distribution of peptic ulceration and its relation to symptoms and demography. Of the 360 consecutive patients referred for endoscopy, 113 (92 men, 21 women) had peptic ulceration. Median age 35 years, median duration one year. Five patients (4%) had gastric ulcer, 77 (68%) had duodenal ulcer, and 31 (28%) had coexisting gastric and duodenal ulcer. The duodenal ulcer was found in the pyloric canal in 14% of patients, in the bulb in 80%, and the post-bulbar region in 56% of patients. Sixty seven per cent of duodenal ulcers were located at more than one site. The incidence of post-bulbar v bulbar ulcer was 1:1.5. Deformed bulb was seen in 50% of duodenal ulcer patients, but haemorrhage and stenosis were uncommon. Except for nocturnal pain, there were no differences in symptoms between the groups. Forty two per cent of patients smoked, 15% chewed tobacco, and 18% drank alcohol; almost all were men. Sixty four per cent drank tea. The staple diet (85%) was rice, and 70% used tamarind and spices daily. Duodenal ulcer was three times more common than gastric ulcer with a high incidence of post-bulbar and coexisting ulcer. It affected a younger and predominantly male population, and was not associated with a higher rate of complication.     

Oral tripotassium-dicitratobismuthate in gastric and duodenal ulceration

One hundred ambulant outpatients with active, endoscopically proven peptic ulceration entered a double-blind trial of either tripotassium-dicitratobismuthate or placebo. Thirty-four patients had gastric ulceration, 56 had duodenal ulceration, three had both gastric and duodenal ulcers, and two had stomal ulceration. Five patients with gastric ulceration were withdrawn from the trial. Three patients with both gastric and duodenal ulceration and two patients with stomal ulceration were excluded from statistical analysis. After 28 days of tripotassium-dicitratobismuthate 94% of gastric ulcer patients had significant endoscopic healing (P less than 0.01). Although 75% of duodenal ulcers healed after 28 days of tripotassium-dicitratobismuthate, this was not statistically significant because of a 60% rate of healing with placebo. Tripotassium-dicitratobismuthate produced a significantly quicker symptomatic response in duodenal ulcer patients (P less than 0.01). No serious side effects were recorded, and patient acceptability was high. It is concluded that tripotassium-dicitratobismuthate is an effective agent for promoting gastric ulcer healing and for symptomatic relief in duodenal ulceration.     

Endoscopic and gastric acid studies in homozygous sickle cell disease and upper abdominal pain.

Upper endoscopic and gastric acid output studies were done in 51 patients with homozygous sickle cell (SS) disease and recurrent epigastric pain. Twenty (39%) had abnormalities in the upper gastrointestinal tract including 18 (35%) with peptic ulcers. Mean basal and maximum acid output were similar in patients with and without duodenal ulcer (DU). Because DU in SS disease does not appear to be associated with high acid outputs observed in other populations, it may reflect reduced mucosal resistance, possibly resulting from ischaemia. This hypothesis was supported by the significantly lower fetal haemoglobin level among SS-DU patients.     

Peptic ulcer in the very old patients

OBJECTIVE: To describe the clinical features of peptic ulcer in patients aged 80 years or over. DESIGN: The patient files of 73 ulcer patients were retrospectively analyzed. RESULTS: Peptic ulcer was found in 17% of the gastroscopies made on patients aged 80 years or over. Epigastric pain was the most common symptom (74%). Vomiting and nausea were also common symptoms. 48% of the ulcers were duodenal and 52% gastric. The majority (65%) of ulcers were Helicobacter pylori negative. H.-pylori-positive patients used acetylsalicylic acid more frequently than the H.-pylori-negative (57 vs. 43%) ones. Complications occured in 69% of the patients. Aspirin and nonsteroidal anti-inflammatory drug (NSAID) users had more often complications than the others. CONCLUSIONS: Peptic ulcer is a common clinical finding of gastroscopy in patients aged 80 years or over. Most ulcers are H.-pylori-negative and almost evenly divided between duodenal and gastric ulcers. Most of the elderly patients suffer from epigastric pain. Complications are frequent among the patients, especially in aspirin and NSAIDs users. H.-pylori-infected aspirin users are at increased risk of ulcer disease. Before starting long-term aspirin treatment in elderly patients, eradication of H. -pylori is recommended.     

Chronic upper abdominal pain: site and radiation in various structural and functional disorders and the effect of various foods.

Pain site and radiation and the effect of various foods were studied prospectively in a consecutive series of patients with chronic upper abdominal pain. Patients followed for less than one year were excluded unless peptic ulcer or abdominal malignancy had been diagnosed or laparotomy had been carried out. A total of 632 patients were eligible for the first study and 431 for the second. Gastric ulcer pain was more likely to be left hypochondrial (17%) compared with pain from duodenal ulcer (4%) or from all other conditions (5%). It was less likely to be epigastric (54%) compared with duodenal ulcer pain (75%). Oesophageal pain was more likely to be both retrosternal and epigastric (25%) compared with non-oesophageal pain (2%). Radiation to the back was more common in peptic ulcer (31%) and biliary pain (35%) compared with functional pain (20%). Pain precipitation by fatty foods was commoner in biliary disease (40%) than in duodenal ulcer (11%), peptic ulcer (9%), or non-ulcer dyspepsia (19%). Orange, alcohol, and coffee precipitated pain more frequently in duodenal ulcer (41%, 50%, and 43% respectively) than in biliary disease (17%, 0%, and 14% respectively). Chilli precipitated pain in one quarter to one half of subjects regardless of diagnosis. Approximately one tenth of all subjects avoided chilli, curry, coffee, and tea because of medical or other advice.     

Peptic ulceration in patients with chronic liver disease

A prospective study was undertaken to determine the frequency of peptic ulceration in different forms of chronic liver disease and the effect of corticosteroid treatment. One hundred sixty-three patients with chronic liver disease underwent upper gastrointestinal endoscopy, 106 for investigation of dyspeptic symptoms and the remaining 57 for assessment of the presence of varices. Twenty-four peptic ulcers were found (14.7%), 12 duodenal, 8 gastric, and 4 prepyloric. Ulcers were found in 5 of 15 patients with hepatitis B surface-antigen-positive chronic active liver disease (33%), 10 of 46 patients with alcoholic liver disease (22%), 5 of 35 with primary biliary cirrhosis (14%), 2 of 19 with miscellaneous chronic liver diseases (10%), and 2 of 25 with cryptogenic cirrhosis (8%). Ulcers were not demonstrated in any of the 23 patients with hepatitis B surface-antigen-negative chronic active hepatitis. Thirty-one patients were receiving prednisolone therapy, 5 had peptic ulcer compared with 19 of the remaining 132 patients. This difference was not significant. Fifty-nine patients presented with gastrointestinal bleeding on 88 separate occasions. Peptic ulcer was the cause in 6% of these. In chronic liver disease peptic ulcers occurred with differing frequencies in different forms of the disease. This was unaffected by corticosteroid therapy. Peptic ulcers were rarely the cause of gastrointestinal bleeding.     

Peptic ulcers and abdominal aortic aneurysms

Upper gastrointestinal endoscopy was performed in 106 of 204 Chinese patients with intact abdominal aortic aneurysms, ninety-seven for screening and nine for gastrointestinal bleeding or pain. Peptic disease was discovered in 38 patients: 12 duodenal ulcers, 12 gastric ulcers, four duodenal and gastric ulcers, three duodenitis, three gastritis and four previously operated for ulcers. The eight patients who bled before aneurysmectomy all had gastric ulcers; four required emergency operation and two died. Only two patients bled from duodenal ulcers, both after aneurysmectomy and one died. Excluding gastritis and duodenitis, peptic ulcer was found in 26.4% of patients with abdominal aortic aneurysms. Half of these ulcers were gastric ulcers and 50% of them bled before aneurysmectomy. Duodenal ulcers tend to remain asymptomatic before operation and two of 12 (16.7%) bled postoperatively. The risk of bleeding for ulcers associated with aneurysms was 10 of 28 (35.7%) ulcers. The result of this uncontrolled study suggests that routine endoscopic screening should be used in all patients with aortic aneurysms and early surgery should be offered for gastric ulcers.     

Risk factors and therapeutic response in Chinese patients with peptic ulcer disease

AIM:To assess the risk factors and the eff icacy of medications of patients with gastric and duodenal ulcers among Chinese patients in Taiwan.METHODS:Patients with peptic ulcers,diagnosed by upper endoscopy,were retrospectively collected between January 2008 and December 2008.The differences were compared.RESULTS:Among all 448 cases,254(56.6%) and 194(43.4%) patients had gastric ulcers and duodenal ulcers respectively.Patients with gastric ulcers were younger than those with duodenal ulcers.Although more me...     

Pain provocation test in peptic duodenitis

Controversy exists as to whether or not duodenitis alone can cause peptic ulcer symptoms. A modified provocation perfusion test has been performed in 10 symptomatic patients with duodenitis confirmed by endoscopy and histology. The test was conducted without the patient being aware of whether 0.1 N hydrocholoric acid, normal saline, or 8.5% sodium bicarbonate was being perfused directly on the area of duodenitis through the endoscopic irrigation cannula at a fixed rate of 10 ml/min for 10 min. The test was also performed in eight patients with dyspepsia alone and in five patients with chronic duodenal ulceration. Intraduodenal infusion of acid reproduced the epigastric pain in all patients with peptic duodenitis and duodenal ulcer patients, including the feeling of nausea in several which was partially relieved by bicarbonate infusion. In patients with dyspepsia but no peptic duodenitis, the symptoms were not reproduced. It would appear that "peptic duodenitis" can cause symptoms and that this "pain provocation test" may prove useful in its diagnosis.     

Campylobacter pyloridis in peptic ulcer disease: microbiology, pathology, and scanning electron microscopy.

After the recent successful isolation of spiral organisms from the stomach this paper presents the bacteriological and pathological correlation of gastric antral biopsies from 51 patients endoscopied for upper gastrointestinal symptoms. Campylobacter pyloridis was cultured from 29 patients and seen by either silver staining of the biopsy or scanning electron microscopy in an additional three. The organism was cultured from 23 of the 33 (69%) patients with peptic ulcer disease and from within this group 17 (80%) of the 21 patients with duodenal ulceration. It was cultured only once from the 12 normal biopsies in the series but from 27 of the 38 (71%) biopsies showing gastritis. C pyloridis was also cultured from five out of seven of the 14 endoscopically normal patients, who despite this had biopsy evidence of gastritis. It was the sole organism cultured from 65% of the positive biopsies and scanning electron microscopy invariably revealed it deep to the surface mucus layer. C pyloridis persisted in the three patients with duodenal ulcers after treatment and healing. The findings support the hypothesis that C pyloridis is aetiologically related to gastritis and peptic ulceration though its precise role still remains to be defined.     

Clinical picture of peptic ulceration diagnosed endoscopically.

Clinical features and laboratory data are presented for 100 patients with benign gastric ulceration and 150 patients with duodenal ulceration confirmed endoscopically in a district general hospital unit. Abdominal pain was the commonest indication for endoscopy, but one third of examinations were performed for acute gastrointestinal haemorrhage. Although the patients were selected by referral for endoscopy their clinical presentation, age, and sex distribution were similar to those reported in previous general surveys. There were no clinical features which clearly distinguished gastric from duodenal ulceration. However, of those with gastric ulceration younger patients more often had distal ulcers and presented with pain, while elderly subjects tended to have high lesser curve involvement and presented with haemorrhage. Moreover, all females presenting with haemorrhage were aged over 50 years, while 6% of males bleeding from gastric ulceration and 40% of males bleeding from duodenal ulceration were under this age. Anaemia when present, except in two premenopausal females, indicated either a recent acute gastrointestinal haemorrhage or a coexistent second diagnosis.     

Discriminant value of dyspeptic symptoms: a study of the clinical presentation of 221 patients with dyspepsia of unknown cause, peptic ulceration, and cholelithiasis.

This study aims to determine whether the features of dyspepsia can discriminate a subgroup of patients who present with non-ulcer dyspepsia from other diagnostic categories. The following groups were studied: One hundred and thirteen patients with endoscopically confirmed non-ulcer dyspepsia in the absence of clinical, biochemical or radiological evidence of other gastrointestinal diseases or disorders, termed essential dyspepsia; Fifty five patients with symptomatic and endoscopically proven peptic ulceration (32 duodenal ulcers, 23 gastric ulcers); Fifty three patients admitted to hospital with biliary pain and cholelithiasis without other lesion at laparotomy. All patients completed a structured history questionnaire at personal interview. Stepwise logistic regression analysis was done on 19 predefined variables to determine if one or more of these could discriminate between the diagnostic categories. The results suggest that certain groups of symptoms may be of diagnostic value, but many are not. Upper abdominal pain aggravated by food or milk, pain severity, night pain, vomiting, weight loss, and age significantly discriminated essential dyspepsia from the other diagnostic categories. A scoring system was established based on these discriminating symptoms. Using the weighted score, at a sensitivity of 57%, the specificity for a diagnosis of essential dyspepsia was 94%, but only prospective studies will determine if this scoring system is of actual clinical value.     

Serum positive cagA in patients with non-ulcer dyspepsia and peptic ulcer disease from two centers in different regions of Turkey

AIM: To investigate and compare frequencies of serum positive cagA in patients from two separate regions of Turkey who were grouped according to the presence of peptic ulcer disease or non-ulcer dyspepsia. METHODS: One hundred and eighty Helicobacter pylori-positive patients with peptic ulcer disease or non-ulcer dyspepsia were included in the study. One hundred and fourteen patients had non-ulcer dyspepsia and 66 had peptic ulcer disease (32 with gastric ulcers and/or erosions and 34 with duodenal ulcers). Each patient was tested for serum antibody to H. pylori cagA protein by enzyme immunoassay. RESULTS: The total frequency of serum positive cagA in the study group was 97.2 %. The rates in the patients with peptic ulcers and in those with non-ulcer dyspepsia were 100 % and 95.6 %, respectively. These results were similar to those reported in Asian studies, but higher than those that have been noted in other studies from Turkey and Western countries. CONCLUSION: The high rates of serum positive cagA in these patients with peptic ulcer disease and non-ulcer dyspepsia were similar to results reported in Asia. The fact that there was high seroum prevalence regardless of ulcer status suggests that factors other than cagA might be responsible for ulceration or other types of severe pathology in H. pylori-positive individuals.     

Gastrointestinal bleeding: dyspeptic symptoms and clinical course in relation to use of non-steroidal antiinflammatory drugs

To study the symptoms of NSAID-associated gastroduodenal bleeding, 94 patients (median age 71 years, range 19-90), were included in a prospective, clinical trial where hematemesis or melena from gastroduodenal ulceration or haemorrhagic/erosive gastritis were the inclusion criteria. NSAID use within one month was studied in relation to subjective symptoms prior to admission and to clinical course of the episode. Significantly fewer of the NSAID users (n = 54) than the non-users (n = 40) had experienced prior peptic ulceration or dyspeptic symptoms. Otherwise, no differences were seen between users and non-users, as regards pre-admission epigastric pain, heartburn or nausea. Also, the clinical course was similar in the two groups. We also found sporadic and regular NSAID use to be similar in this respect. These data do not support the alleged masking of ulcer symptoms by NSAIDs in bleeding ulcers.     

Helicobacter pylori, non-steroidal anti-inflammatory drugs and smoking in risk pattern of gastroduodenal ulcers

BACKGROUND: Helicobacter pylori, NSAID and cigarette smoking are major risk factors for gastroduodenal ulcers. However, the results of studies on the interaction between these factors on ulcerogenesis are controversial. This study was designed to examine the association between gastroduodenal ulcers and H. pylori infection, NSAID use, smoking and age. METHODS: 5967 dyspeptic patients underwent 13C-urea breath test (UBT) and upper endoscopy, while age and dyspeptic symptoms were reported. RESULTS: Out of 5967 patients, 31.8% were ulcerated; 9.2% had gastric, 17.2% duodenal and 5.4% both gastric and duodenal ulcers. H. pylori was found in 72.5% of gastric ulcer patients, in 83.6% of duodenal ulcer patients, in 76.9% of gastroduodenal ulcer patients and in 64.8% of dyspeptic patients. The gastric, duodenal and gastroduodenal ulcers were related to H. pylori significantly and the respective ORs were: 1.44, 2.77 and 1.81. NSAID alone was used by 6.2%-12.7% of ulcer patients, tending to raise only the risk of gastric ulcer but reducing that of duodenal and gastroduodenal ulcers. The H. pylori prevalence was significantly higher in smokers (76%) than in non-smokers (67%) and the ulcer risk was also significantly higher in smokers than in non-smokers. About 20% of ulcers were 'idiopathic', i.e. without NSAID and H. pylori and the ratio of these ulcers to all ulcers significantly increased during the 5 years of the study. CONCLUSIONS: Based on multivariable logistic regression analysis we conclude that: 1) H. pylori infection, NSAID use, smoking and age play major roles in the pathogenesis of peptic ulcerations; 2) there is a negative interaction between H. pylori and NSAID on duodenal ulcers, suggesting that H. pylori reduces the development of these ulcers in NSAID users, and 3) about 20% of peptic ulcers in the Polish population are unrelated to H. pylori and NSAID use (idiopathic ulcers).     

Multiple recurring gastric erosions/aphthous ulcers).

Five patients are described who had repeated endoscopy because of continuing dyspeptic symptoms associated with a negative barium meal. They were found to have multiple recurring gastric erosions (aphthous ulcers). No common aetiological factor could be found, although four of these patients did have a mild or moderatley active superficial chronic gastritis. Conventional peptic ulcer therapy failed to control either symptoms or ulceration. Two patients finally came to gastric surgery (highly selective vagotomy), which resulted in the relief of symptoms and healing of the gastric aphthous ulceration.     

Profound spatial clustering of simultaneous peptic ulcers.

In an endoscopic study of 90 consecutive patients with more than one peptic ulcer, the ulcers in an individual were profoundly spatially clustered. Clustering of ulcer locations was shown using a non-parametric test of clustering (Kruskal-Wallis statistic with 89 degrees of freedom = 151.31, probability of observing this extreme statistic with no clustering less than 0.0005) and a parametric test of clustering (F test statistic with 89 and 124 degrees of freedom = 5.41, probability of observing this extreme statistic with no clustering less than 0.0005). Patients having their largest ulcer in any given region had a much greater likelihood than other patients of having other ulcers in that same site. For example, the 26 patients with their largest ulcer in the proximal duodenal bulb had 20 of 33, or 61% (9) (standard error), of their other ulcers in the proximal duodenal bulb. In contrast, the 18 patients with their largest ulcer in the proximal stomach had four of 23, or 17% (8), of their other ulcers in the proximal duodenal bulb. Of the 59 patients who had two simultaneous ulcers, 28 patients had adjacent ulcers (distance between ulcers less than 4% of the distance from the gastric cardia to the apex of the duodenal bulb). These findings suggest that local factors may be important in the pathogenesis of simultaneous peptic ulcers, including infection caused by Campylobacter pylori or other microorganisms, ischaemia and mucosal barrier disruption.     

Crack-related perforated gastropyloric ulcer

Cocaine is a potent topical vasoconstrictor that causes nasal mucosal and dermal ulceration. Use of the purified cocaine derivative "crack" has reached epidemic proportions in large cities. In 18 months we operated on 24 patients with perforated peptic ulcers. Five of the patients were young (27-38 years) male crack users without prior history of gastric symptoms who presented with a perforated gastric ulcer related to smoking crack. Three had had symptoms for only 1-5 days before admission. All five were afebrile, had a rigid abdomen, normal leukocyte count, and free intraabdominal air upon radiography. Five other age-matched, non-crack-using patients served as case controls. Their duration of symptoms was 1-24 months, they had elevated leukocyte counts on admission, and, in contrast to the crack users, four of these patients had duodenal perforations. The clinical presentation of the crack smokers and the unusual localization of the perforations imply different pathogenetic mechanisms than are commonly seen in perforated ulcer disease. With increasing abuse of crack, greater numbers of patients with this new complication may be expected to present to emergency services in urban areas.     

Ulcer anamnesis and gastroduodenoscopic findings--a contribution to the symptomatology of gastroduodenal ulcers

513 patients who were gastroduodenoscopically examined on account of suspicion of ulcer were aimedly inquired for 18 typical ulcer complaints. Compared with patients with normal gastroduodenoscopic findings patients peptic ulcers of erosions of the gastric mucous membrane had significantly more frequently symptoms of the gastrointestinal haemorrhage, patients with ulcus ventriculi had, moreover, inappetence and vomiting, patients with duodenal ulcer a late pain in the centre of the epigastrium and in the right epigastrium. But these symptoms did not allow a significant differentiation between the patients with ventricular ulcer and duodenal ulcer. Patients without pathological gastroduodenoscopic findings had significantly more frequently an incompatibility of food and connected with this sensation of fullness. A typical symptomatology of ulcer may, indeed, be present in the individual case, but according to the results of the study it is no sufficient proof for the actual existence of a peptic ulcer and is thus of little differential-diagnostic value.     

"Campylobacter pyloridis" and epigastric pain: endoscopic, histological, and bacteriological correlations

Campylobacter pyloridis is a newly discovered bacterium which has been implicated in gastric pathology. C. pyloridis was looked for by hematoxylin and eosin staining and culture (chocolate and brucella blood agar) in gastric antral biopsies in 136 unselected patients suffering from epigastric pain. The distribution of C. pyloridis positive cases according to the endoscopic diagnosis was as follows: duodenal ulcer (19 positive/21 tested), duodenitis (6/10), gastric ulcer (9/21), gastritis (13/26), and normal endoscopy (21/58). The association was statistically significant for duodenal ulcers (p less than 0.001). All of the 68 C. pyloridis positive patients showed histologic signs of gastritis as compared to 29 of the 68 C. pyloridis negative patients. The two techniques detection were comparable in sensitivity: 57 were detected by culture only and 63 by microscopy only. We also looked for C. pyloridis in biopsies of the body of the stomach in 71 patients. Bacteria were found in 33 of 36 cases with C. pyloridis positive antral biopsies (15 had histologic lesions) but only in 2 of 35 C. pyloridis antrum negative cases. Therefore, C. pyloridis was tightly associated with histologic signs of antral gastritis and with duodenal ulcers when diagnosed by endoscopy.