Diet and duodenal ulcer

BACKGROUND: Despite the fact that the main cause of duodenal ulcer incidence and recurrence is the Helicobacter pylori bacterium, more than 80% of Helicobacter pylori-infected people never develop an ulcer. Diet may be one of the most important environmental factors contributing to duodenal ulcer. AIMS: To explore the role of diet in causation, treatment and prevention of duodenal ulcer recurrence. METHODS: All research papers published in English from 1966 to October 1999 present in Medline, involving human subjects, and having duodenal ulcer as outcome, entered the review. RESULTS AND CONCLUSIONS: Soluble fibre from fruit and vegetables seem to be protective against duodenal ulcer and refined sugars a risk factor. The role of fibre in the treatment and prevention of recurrence of duodenal ulcer is uncertain, as is that of essential fatty acids. However, none of the epidemiological studies on the relationship between diet and duodenal ulcer disease controlled for Helicobacter pylori.     

Perforated peptic ulcer in Hong Kong and New South Wales

Direct comparisons of ulcer perforation rates and trends between countries have not been made in the past. Data on hospital admissions for perforated peptic ulcer during 1 January 1979 to 31 December 1985 were collected in Hong Kong (5868 perforations) and New South Wales, Australia (1669 perforations). Age and sex specific rates per 100,000 population were calculated. In Hong Kong, annual duodenal ulcer and gastric ulcer perforation rates were 13-16 and under two per 100,000 population respectively. In New South Wales, the corresponding rates were between three and four and under two per 100,000 population, respectively. The male:female ratios for duodenal ulcer perforation were consistently about 5:1 in Hong Kong and 2:1 in New South Wales, and for gastric ulcer perforation about 2:1 and 1:1, respectively. The incidence of perforation increased with age, and there was a statistically significant rise, over time, in duodenal but not gastric ulcer perforation rates in persons aged over 60 years in New South Wales; similar trends were seen in Hong Kong. Thus duodenal ulcer perforation occurs five times more commonly in Hong Kong than in New South Wales and this is largely accountable for by the higher rates of duodenal ulcer perforation in Chinese than in Australian males. Such geographical differences can best be explained by the occurrence of multiple aetiological mechanisms in ulcer perforation. Furthermore, there appears to be an increased susceptibility and an appreciable rising trend for duodenal ulcer perforation to occur in the elderly.     

Discriminant factors of gastric ulcer healing by colloidal bismuth

One hundred and twelve patients with 49 corpus and 35 prepyloric gastric ulcers and 28 duodenal ulcers associated with gastric ulcers were entered into a stratified, controlled double-blind randomized study comparing the healing efficacy of colloidal bismuth suspension with placebo. Healing of corpus and prepyloric ulcers, but not duodenal-ulcer associated gastric ulcers, was significantly better with the bismuth compound than with placebo. The clinical, personal, ulcer and acid secretory data of these patients were prospectively collected and evaluated by stepwise discriminant analysis in two phases. In the first phase, the collected data of 91 consecutive patients were entered into computer analysis. The derived discriminant function classified patients into healed and unhealed categories with a sensitivity of 82%, specificity of 77%, positive diagnostic value of 73%, negative diagnostic value of 85% and diagnostic efficiency of 79%. In phase two, the discriminant function from phase 1 was applied prospectively to 21 patients to predict the outcome of treatment. Five out of five healed and 11/16 unhealed gastric ulcers were correctly predicted, giving a diagnostic efficiency of 76%. The present study shows that healing or non-healing of gastric ulcer can be predicted with reasonable accuracy by discriminant analysis. In addition, discriminant analysis identified, aside from the efficacious drug, ulcer size, young age, co-existing duodenal ulcer, and concomitant medical condition as adverse factors for gastric ulcer healing.     

Helicobacter pylori and gastric acid output in peptic ulcer disease

Helicobacter pylori is associated with peptic ulcer, and a causal relationship has been postulated. We investigated the association betweenHelicobacter pylori and gastric acid output. Two hundred forty-one patients were studied: 173 with duodenal ulcer, 51 with gastric ulcer (41 corpus, 10 prepyloric), and 17 with combined gastric and duodenal ulcer. In 194 patients (80%),Helicobacter pylori could be demonstrated histologically from gastric antral biopsies. The presence or absence ofHelicobacter pylori was not influenced by age, sex, or use of tobacco or analgesics. Patients with duodenal ulcer or combined gastric and duodenal ulcer had similar gastric acid outputs irrespective of the presence or absence ofHelicobacter pylori. However, gastric ulcer patients withHelicobacter had higher basal and maximal acid outputs when compared to patients withoutHelicobacter (mean basal output: 4.1 mmol/hr vs 2.4,P<0.05; mean maximal output 19.5 mmol/hr vs 14.4,P<0.05). AlthoughHelicobacter pylori is associated with both gastric ulcer and duodenal ulcer, its significance may be different in the two diseases.     

Society stress and peptic ulcer perforation

To examine the relationship between society stress and peptic ulcer perforation, time-trend analysis was performed on the annual incidence of perforated peptic ulcer per 100 000 population in Hong Kong during the years 1962–85, when Hong Kong, as a developing city, went through significant socio-economic and political changes, and the trend was correlated with specially designed and validated society stress scores estimated annually during the same period. The society stress scores were derived independently by two expert panels blinded to the purpose of the study, one selecting and categorizing negative news events for Hong Kong during this period, and the other weighing the categories and scoring the impact of the news on Hong Kong. The incidence of perforation increased significantly during the years and manifested three distinct peaks, which coincided with the worst economic recession in Hong Kong, the influx of mainlander Chinese and Vietnamese boat people, and the Sino-British negotiation on the sovereignty of Hong Kong after 1997. Both linear and autoregression analysis, the latter taking into consideration point fluctuations in rates, showed that perforation rates correlated significantly with the society stress scores (r= 0.57, P < 0.002). The peak effects and the significant correlations indicate that an association exists between society stress and peptic ulcer perforation, and suggest that chronic society stress plays an important role in the aetiology of this condition, although the relatively low r value also suggests the presence of other aetiological factors.     

Helicobacter pylori epidemiology in relation to peptic ulcer and gastric cancer in South and North China

Abstract Peptic ulcer disease is twice as common in people living in South China when compared with those in North China. However, the gastric cancer rate in North China is three times that of South China. The overall Helicobacter pylori prevalence rate is similar in North and South China populations and it is higher than Caucasians living in Western societies. However, there is a significantly higher prevalence of H. pylori seropositivity among those who live in the high gastric cancer areas of China. On the other hand, there is no significant difference in the H. pylori positive rate in the peptic ulcer disease patients between the two regions of China. Other permissive/associated co-factors in the development of peptic ulcer disease or gastric cancer remain unknown at this stage.     

Effect of smoking on gastric acid secretion in patients with duodenal ulcer

The effect of smoking on gastric secretion was studied in 15 consecutive patients with duodenal ulcer--six normosecretors (basal acid output less than or equal to 3 mEq/h), and nine hypersecretors (basal acid output greater than 3 mEq/h). The volume, acid output, acid concentration, and pH of the gastric juice measured before, during and after 1 h of smoking did not show any significant difference in these patients taken as a single group, or when the normosecretors and hypersecretors were analysed as separate groups (P greater than 0.05 for each parameter in each group). The higher acid output before and during smoking in hypersecretors than in normosecretors was due to the higher acid concentration in the gastric juice (P less than 0.01). Study of the pH curves of the gastric juice after acute smoking showed that hypersecretors had a lower pH for a longer duration compared with normosecretors. This could make the hypersecretors with a history of chronic smoking more prone to developing duodenal ulcer.     

Clinical significance of gastric juice viscosity in peptic ulcer patients

We developed a simple method of determining gastric juice viscosity using a cone plate viscometer and tested its clinical application in the staging of peptic ulcers. We found a significant positive correlation between viscosity and macromolecular glycoprotein concentration of gastric juice P<0.001).Gastric juice viscosity in active and healing gastric ulcer patients was significantly lower than that in the scarring stage or hospital control patients P<0.05 and P<0.01, respectively). In duodenal ulcer patients, a significant difference was found between the active and healing stages and hospital controls P<0.01). However, the difference between the active and healing stages and the scarring stage was not significant. Gastric juice viscosity is a simple, reliable, clinically useful measure.     

Somatostatin in gastric juice in normal subjects and patients with duodenal ulcer

Somatostatin in gastric juice was determined in normal subjects and patients with duodenal ulcer. Gel exclusion chromatography of gastric juice revealed that the main immunoreactivity existed at the position of somatostatin-14. A large amount of somatostatin was present in gastric juice, and the quantity increased following tetragastrin stimulation. Furthermore, there was a good inverse correlation between somatostatin concentration and acidity of gastric juice; however, there was no difference between normal subjects and patients with duodenal ulcer in the amount of somatostatin released into gastric juice.     

Observations on peptic ulcer in Shan Dong, China

The study consisted of 10 994 inpatients with peptic ulcer in Shan Dong province. The ratio of duodenal to gastric ulcer was 1.59 : 1. The ratio of males to females was 6.8 : 1 for duodenal ulcer and 4.6 : 1 for gastric ulcer. The highest incidence was in adolescence and young adults and the presentation occurred more commonly in winter. A study of blood groups revealed that there was no relationship between blood group and duodenal or gastric ulcer. The majority (71.9%) of patients with peptic ulcer had complications of upper gastrointestinal bleeding, perforation or gastric outlet obstruction. Bleeding and obstruction were equally common in gastric and duodenal ulcer, but perforation was more common in gastric ulcer.     

Racial differences in peptic ulcer frequency in Singapore

Several hospital series of peptic ulcer patients have suggested that ulcer prevalence may be different in the different races in Singapore. However, such studies may be biased because different races use hospital services differently and also because hospital catchment populations are difficult to define. In the present study the racial composition of a consecutive series of 1248 peptic ulcer patients seen in two medical units of a general hospital was compared to that of 2023 general medical patients attending the same units. For both sexes, the racial structure of the gastric ulcer as well as the duodenal ulcer patients was significantly different from that of the general medical group. There was an excess of Chinese patients of both sexes with gastric ulcer and duodenal ulcer. In contrast, the numbers of male Malay gastric ulcer, male Malay duodenal ulcer, female Malay duodenal ulcer as well as Indian gastric ulcer patients of both sexes were fewer than expected. These results cannot be accounted for by racial differences in either health-seeking behaviour or analgesic and tobacco usage. These observations confirm the probable occurrence of racial differences in peptic ulcer frequency in Singapore.     

Candida-associated gastric ulcer relapsing in a different position with a different appearance

An 87-year-old, Japanese woman was shown to have a submucosal tumor-like lesion with a deep, central ulceration covered with thick, whitish exudate in the stomach. Biopsy showed Candida tropicalis but not Helicobacter pylori (H. pylori). She had no predisposing factors or history of peptic ulcers nor had taken non-steroidal anti-inflammatory drugs (NSAIDs), diagnosed with Candida-associated gastric ulcer. Though cured of the lesion, she developed another ulcer in a different position, in which Candida was demonstrated but H. pylori was undetectable. This is the first case of recurrent Candida-associated gastric ulcer in the world. Detected in both the original and recurrent lesions in an H. pylori-negative patient with no antecedent ulcers who had not taken NSAIDs, Candida is considered, contrary to the prevailing opinion, to play an etiologic role in ulcer formation.     

Seasonal changes in symptomatic duodenal ulcer activity in Taiwan: a comparison between subjects with and without haemorrhage

Abstract. Tsai C-J, Lin C-Y (Chi Mei Foundation Hospital, Tainan, Taiwan). Seasonal changes in symptomatic duodenal ulcer activity in Taiwan: a comparison between subjects with and without haemorrhage. J Intern Med 1998; 244 : 405–10.

Objectives

To examine if climatic changes may influence the presentation of pain and haemorrhage in patients with duodenal ulcers.

Design

Cross-sectional study.

Setting

Tertiary referral centre.

Subjects

A total of 10 331 symptomatic duodenal ulcer diseases were diagnosed from 1989 to 1996. The patients who had any extrinsic factors that might influence the exacerbation of duodenal ulcer were not included. Patients were divided into those whose ulcer bled once or repeatedly as distinct from those whose ulcers caused pain without haemorrhagic complications. Patients with acute cholangitis diagnosed in the same period were studied as controls.

Results

During the 7-year period, 10 331 symptomatic duodenal ulcer diseases were diagnosed. Amongst these, 5328 showed active duodenal ulcer without haemorrhage, 2088 showed acute duodenal ulcer with stigmata of recent haemorrhage, and 2915 showed a deformed bulb. The incidence of total duodenal ulcers showed significant monthly variation and was found to be more common from November to March (P < 0.001). The monthly incidence of total episodes of upper gastrointestinal tract bleeding peaked from November to March (P < 0.001) with significant variation. The monthly incidence of bleeding episodes from duodenal ulcer only was the same (P < 0.001). In patients whose duodenal ulcers repeatedly caused pain without haemorrhage, there were significant monthly fluctuations, with peak months from December to March (P < 0.001). In the control diagnosis, there were no significant calendar variations (P = 0.85).

Conclusions

Our study has shown that both groups of patients demonstrated similar monthly fluctuations. The incidence is significantly higher during the cold seasons. These data suggest that climatic changes may influence the presentation of pain and haemorrhage in duodenal ulcer patients.

     

Hydroxyl radical formation in human gastric juice

The hydroxyl radical is the most potent free radical derived from oxygen, and has been implicated in damage caused to the gastroduodenal mucosa. The ability of human gastric juice to generate hydroxyl radicals has been investigated in 54 adults with endoscopically normal gastroduodenal mucosa and in 39 patients with chronic duodenal ulcer. Hydroxyl radical production was measured by the formation of formaldehyde from dimethylsulfoxide. Unlike other body fluids, this reaction could proceed without the extraneous addition of catalysts such as hydrogen peroxide (H2O2), ascorbate and iron. Measurement of H2O2, iron and ascorbate showed that these catalysts are already present in the gastric juice. There was no significant difference in the concentration of these components in gastric juice between normal subjects and patients with duodenal ulcer, except that H2O2 levels were slightly higher in duodenal ulcer patients. Although generation of free radicals has been investigated in other body fluids, this is the first reported case regarding the production of these active species in normal human gastric juice. Since hydroxyl production is not significantly enhanced in duodenal ulcer, we suggest that attention may be turned to mucosal antioxidant defences in this disease.     

Gastric adenocarcinoma masquerading endoscopically as benign gastric ulcer

The pathologic features and five-year survival of patients in whom gastric cancer masquerades at endoscopy as a benign gastric ulcer has been poorly characterized. We reviewed retrospectively all cases of gastric adenocarcinoma in three hospitals for a five-year period. Of 266 patients with gastric adenocarcinoma, 169 (63.5%) had endoscopy with biopsy prior to diagnosis of cancer. In 159 of these 169 patients (94.1%), the endoscopic findings suggested cancer, while in the remaining 10 patients (5.9%) the endoscopic appearance suggested benign ulcer. In six of these 10 patients, the initial endoscopic biopsies did not reveal cancer and correct diagnosis was delayed for as long as 14 months. Three of the 10 patients had early gastric cancer by pathologic criteria at gastrectomy, although one had lymph node metastasis. The other seven patients had pathologic criteria for advanced gastric cancer, and three had lymph node metastasis. In spite of advanced cancer and/or lymph node metastasis in eight of our 10 patients, five-year survival in these patients with benign-appearing ulcers was 70%, as compared to 17% in patients whose gastric lesions appeared malignant at endoscopy.This work was supported by grants from the National Institutes of Health (AM 16816 and AM 26794), the Veterans Administration, Southwestern Medical Foundation's Abbie K. Dreyfuss Fund, and the Berta M. and Cecil O. Patterson Endowment Fund in Digestive Disease.     

Peptic ulcer in hepatic cirrhosis and renal failure

Abstract The prevalence of peptic ulcer in cirrhotic patients is similar to that reported for the general population. Although gastric acid outputs ar normal or lower in cirrhotic subjects compared with non-cirrhotics, the frequency of non-response to histamine H₂-receptor antagonists is higher. Peptic ulcer disease in the cirrhotic seems to pursue a more virulent course compared with that in the non-cirrhotic subject.
Peptic ulcer prevalences in patients dying of uraemia or in uraemic patients on maintenance dialysis treatment are comparable with those in the general population. However, the frequency of peptic ulcer, especially complicated ulcer, is increased following renal transplantation. Ulcer complications in this context are associated with a high mortality rate. Pre-transplant risk factors for subsequent development of peptic ulcer remain to be identified and the value of histamine H₂-receptor antagonists in prophylaxis is as yet unproven.     

Somatostatin and gastrin content of gastric antral mucosa in ulcer disease

Gastrin and somatostatin containing cells are abundant in the gastric antral mucosa suggesting a role for these peptides in gastric physiology, presumably acid secretion. The concentration of these peptides in antral mucosa in ulcer disease is controversial, some finding normal levels, others decreased somatostatin levels. Biopsies of antral mucosa from patients with ulcer disease and non-ulcer dyspepsia were obtained at endoscopy, and somatostatin and gastrin concentration were measured by specific radioimmunoassay. Levels were similar in non-ulcer, duodenal and gastric ulcer patients but prior treatment with H₂-receptor antagonists in duodenal ulcer patients led to a fall in somatostatin and a rise in gastrin mucosal levels. It is thus unlikely that a lack of somatostatin or an increase in gastrin are factors in the pathogenesis of duodenal ulcer, but the cells may behave abnormally in ulcer disease.