序贯疗法与四联疗法治疗幽门螺杆菌阳性消化性溃疡的疗效比较

目的比较序贯疗法与四联疗法治疗幽门螺杆菌（Hp）阳性消化性溃疡疗效及Hp根除率。方法采用前瞻性的方法,将120例消化性溃疡患者按单双号随机分为治疗组与对照组各60例,治疗组采用序贯疗法,对照组采用四联疗法。结果治疗组与对照组总有效率分别为86．7％和91．7％,两组比较差异无统计学意义（P〉0．05）。经检测,治疗组Hp根除率90．0％,对照组Hp根除率85．0％,两组Hp根除率差异无统计学意义（P〉0．05）。结论序贯疗法治疗消化性溃疡的有效率和Hp根除率较四联疗法无明显差异,可作为Hp感染初治患者的一线方案。     

幽门螺杆菌阳性十二指肠球部溃疡采用四联疗法治疗效果分析

目的采用四联疗法对于幽门螺杆菌阳性十二指畅球部溃疡进行治疗,对治疗效果进行分析。方法选择我院从2010年1月至2011年1月收治的幽门螺杆菌阳性十二指肠球部溃疡患者60例,随机分成两组,各30例,治疗组口服雷贝拉唑10mg,bid,雷尼替丁枸橼酸铋350mg,bid,阿莫西林1000mg,bid,呋喃唑酮100mg,hid,连续服药4d.对照组口服奥美拉唑20mg,bid．阿莫西林1000mg,bid,克拉霉素500mg,bid,连续服药7d．采取以上治疗后,两组患者均改用雷贝拉唑10mg,qd,连续服药14d。经过治疗后5周左有观察治疗效果,然后在1年以后进行随访。结果治疗组和对照组溃疡愈合率分别为96．67％,76．67％,Hp根除率分别为96．67％,86．67％,治疗组溃疡愈合率、Hp根除率明显高于对照组。随访发现治疗组溃疡复发率、Hp再感染率明显低于对照组,差异均有统计学意义（P〈0．05）。结论 采用四联疗法加上雷贝拉唑对于幽门螺杆菌阳性十二指肠球部溃疡进行治疗,治疗效果显著,值得临床推广。     

One-week triple therapy with esomeprazole provides effective eradication of Helicobacter pylori in duodenal ulcer disease

BACKGROUND: Esomeprazole is the first proton pump inhibitor to be developed as an optical isomer for the treatment of acid-related diseases. METHODS: Four hundred and forty eight duodenal ulcer patients with Helicobacter pylori infection, confirmed by 13C-urea breath test (UBT), and no current ulcer, were randomised to double-blind treatment with esomeprazole 20 mg twice daily (b.d.) (n=224) or omeprazole 20 mg b.d. (n=224), in combination with amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week (EAC and OAC, respectively). A negative UBT at both 4 and 8 weeks after completing therapy indicated successful H. pylori eradication. RESULTS: Intention-to-treat (ITT) analysis comprised 400 patients (EAC, n=204; OAC, n=196) and per protocol (PP) analysis 377 patients (EAC, n=192; OAC, n=185). Eradication rates (95% confidence intervals) for ITT and PP populations were: EAC, 90% (85-94%) and 91% (86-94%); OAC, 88% (82-92%) and 91% (86-95%). Between-group differences in eradication rates were not statistically significant. Both regimens were well tolerated, with an adverse event profile and frequency typical of proton pump inhibitor plus antibiotic combination therapy. CONCLUSIONS: Esomeprazole-based triple therapy for 1 week is highly effective in eradicating H. pylori infection in duodenal ulcer disease, offers comparable efficacy to omeprazole-based therapy, and is well tolerated.     

雷贝拉唑、阿莫西林和硫糖铝根除幽门螺杆菌的疗效观察

目的观察雷贝拉唑、阿莫西林和硫糖铝三联疗法对根除幽门螺杆菌(HP)的疗效。方法将95例经胃镜检查确诊为十二指肠溃疡活动期,并经快速尿素酶试验和14C-尿素呼气试验,确定为HP阳性的患者分为两组。A组以雷贝拉唑0.01 g(qd),阿莫西林1 g(bid)和硫糖铝1 g(qid)治疗2周;B组以雷贝拉唑0.01 g(qd),阿莫西林1 g(bid)和克拉霉素0.5 g(bid)治疗2周。于用药结束后,第28天复查胃镜,观察溃疡愈合情况并检查HP。结果A组的HP根除率为91.5%,B组为93.8%,两组无显著性差异(P>0.05);A组溃疡的愈合率(93.6%)稍高于B组(89.6%),但无显著性差异(P>0.05)。结论雷贝拉唑、阿莫西林和硫糖铝三联疗法能有效地根除HP,溃疡愈合率高,安全且耐受性好,是一种较理想的HP根除新方案。     

铋剂四联疗法根除幽门螺杆菌疗效研究

目的 比较不同疗程铋剂四联疗法与经典三联疗法根除幽门螺杆菌(Hp)的疗效.方法 选择403例符合条件的Hp阳性的消化性溃疡或慢性胃炎患者.随机分为三组,其中A组138例、B组142例、C组123例.A组采用果胶铋200 mg+雷贝拉唑10 mg+阿莫西林1000 mg+呋喃唑酮100 mg,2次/天,共10 d;B组采用果胶铋200 mg+雷贝拉唑10 mg+阿莫西林1000 mg+呋喃唑酮100 mg,2次/天,共14 d;C组采用雷贝拉唑10 mg+阿莫西林1000 mg+呋喃唑酮100 mg,2次/天,共14 d.观察三组患者Hp根除率、不良反应发生率及其成本-效果比.结果 A、B、C三组患者Hp根除率分别为83.33％、83.80％、71.54％,A组与B组Hp根除率比较差异无统计学意义(P>0.05),A组与C组、B组与C组Hp根除率比较均差异有统计学意义(P<0.05).A、B、C三组患者的不良反应发生率分别为1.45％、2.11％、0.81％,均差异无统计学意义(P>0.05).A、B、C三组成本-效果比分别为1.50、2.09、2.04.结论 三种治疗方案均未达到Hp根除率>90％的理想方案.但三种方案的比较中含铋剂10 d与14 d四联疗法Hp根除率较高,接近理想方案.含铋剂10 d四联疗法成本-效果比最好,建议临床使用.14 d三联疗法Hp根除率仅达71.54％,远低于理想标准,不建议临床使用.     

Ranitidine bismuth citrate versus omeprazole triple therapy for the eradication of Helicobacter pylori and healing of duodenal ulcer

Aim:

To compare the efficacy and safety of triple therapy with omeprazole plus amoxycillin and clarithromycin vs. ranitidine bismuth citrate plus amoxycillin and clarithromycin in the treatment of Helicobacter pylori-associated duodenal ulcers.

Methods:

Eighty-one patients with duodenal ulcers were randomized to the following treatments: 39 cases with amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 1 week plus omeprazole 20 mg b.d. for 2 weeks (omeprazole + amoxycillin + clarithromycin (OAC)), and 42 cases to the same regimen of amoxycillin and clarithromycin for 7 days plus ranitidine bismuth citrate 400 mg b.d. for 2 weeks (ranitidine bismuth citrate + amoxycillin + clarithromycin (RbAC)). Upper gastrointestinal endoscopy was performed together with a rapid urease test and histological examination of antral and corpus biopsy samples prior to treatment and 4 weeks after the end of therapy.

Results:

Thirty-four patients in the OAC group and 38 in the RbAC group completed the treatment and 4-week follow-up. H. pylori was eradicated in 30 of 34 patients (88%) in the OAC group and in 32 of 38 patients (84%) in the RbAC group according to a per-protocol analysis (P = N.S.). Thirty-three (97%) patients treated with OAC and 36 (95%) treated with RbAC presented healed duodenal ulcers at 4 weeks (P = N.S.). On an intention-to-treat basis there was no difference in H. pylori eradication between the OAC (77%) and RbAC groups (76%); duodenal ulcer healing was achieved in 85 and 86% of patients in the OAC and RbAC groups, re- spectively (P = N.S.).

Conclusion:

The OAC and RbAC triple therapy regimens proved equally effective in both H. pylori eradication and in duodenal ulcer healing.

     

clinical aspects of Helicobacter pylori eradication therapy in peptic ulcer disease

Background and aims : Although the role of H. pylori in peptic ulcer disease is no longer in dispute, certain aspects of eradication therapy in this condition have yet to be settled. Uncertainties still surround the relationship between Helicobacter pylori status and ulcer healing, the efficacy of eradication therapy in alleviating acute symptoms and healing ulcers, and the prognosis after eradication with respect to recurrence of symptoms, ulcers and complications. The present literature review, encompassing studies published up to October 1995, specifically addresses these issues.
Results : Pooled data show that eradication therapy heals 90% of duodenal ulcers and 85% of gastric ulcers, while individual studies repeatedly confirm that it is more effective at healing ulcers than conventional treatment with anti-secretory drugs. Recent reports indicate that triple therapy regimens for 1 week, provided they include an anti-secretory drug, are sufficient to achieve high rates of healing and rapid symptom relief. A detailed analysis of the data, particularly those from studies reporting healing rates in relation to H. pylori status after eradication therapy, provides strong evidence that eradication of H. pylori produces ulcer healing. Follow-up studies show that ulcer recurrence and complications are rare after eradication treatment in patients with either gastric or duodenal ulcer disease. However, while ulcer symptoms are infrequent during follow-up, a proportion of patients appear to develop gastrooesophageal reflux after eradication.
Conclusions : H. pylori eradication is highly effective in promoting ulcer healing and preventing subsequent ulcer recurrence. These beneficial effects of eradication therapy are observed in patients with either gastric or duodenal ulcers which are associated with H. pylori infection.     

Omeprazole, azithromycin and either amoxycillin or metronidazole in eradication of Helicobacter pylori in duodenal ulcer patients

Background

Azithromycin is a new generation, acid stable, macrolide antibiotic that achieves remarkably high concentrations in gastric tissue (above the minimal inhibitory concentration for Helicobacter pylori) after oral administration.

Aim

To establish whether azithromycin plus omeprazole in association with either amoxycillin or metronidazole are useful in curing H. pylori infection in patients with a duodenal ulcer.

Methods

One hundred patients with active duodenal ulcers and H. pylori infection were treated with omeprazole (days 1–10, 40 mg b.d.; days 11–24, 40 mg o.m.; days 25–42, 20 mg o.m.) plus azithromycin 500 mg o.m. for the first 6 days. Patients were randomly assigned to receive either amoxycillin 1 g b.d. (OAzA group; n = 50) or metronidazole 400 mg t.d.s. (OAzM group; n = 50) during the first 10 days of treatment. H. pylori status was determined by urease test and histology before the treatment and 6 weeks after completion of therapy.

Results

Ninety-seven patients completed the study. H. pylori infection was eradicated in 85% (41/48) of patients in the OAzA group (intention-to-treat analysis 82%) vs. 74% (36/49) of patients in the OAzM group (intention-to-treat analysis: 72%) (N.S.). All ulcers had healed after 6 weeks of omeprazole treatment. Side-effects, usually minor, were recorded in 13% (OAzA group) and 47% (OAzM group) of patients (P < 0.001), but therapy was discontinued for only one patient in the OAzA group (N.S.).

Conclusion

Ten days of treatment with omeprazole plus (for the first 6 days) azithromycin and either amoxycillin or metronidazole provides effective regimens to cure H. pylori infection in patients with duodenal ulcer disease.

     

Nitrofurantoin quadruple therapy for Helicobacter pylori infection: effect of metronidazole resistance

BACKGROUND: Antibiotic resistance has increasingly been recognized as the major cause of treatment failure for Helicobacter pylori infection. New therapies for patients with metronidazole- or clarithromycin-resistant H. pylori are needed. AIM: To investigate the role of nitrofurantoin quadruple therapy for the treatment of H. pylori. METHODS: Patients with confirmed H. pylori infection received nitrofurantoin (100 mg t.d.s.), omeprazole (20 mg b.d.), Pepto-Bismol (two tablets t.d.s.), and tetracycline (500 mg t.d.s.) for 14 days. Four or more weeks after the end of therapy, outcome was assessed by repeat endoscopy with histology and culture or urea breath testing. RESULTS: Thirty patients were entered, including 25 men and five women; the mean age was 54.9 years. The most common diagnoses were duodenal ulcer (23%) and GERD (18%). The intention-to-treat cure rate was 70% (95% CI: 50.6-85%). Nitrofurantoin quadruple therapy was more effective with metronidazole-sensitive strains (88%; 15 out of 17) than with metronidazole-resistant strains (33%; three out of nine; P=0.008). Two of the treatment failures had pre-treatment isolates susceptible to metronidazole, which were resistant after therapy. CONCLUSIONS: Because nitrofurantoin quadruple therapy performed inadequately in the presence of metronidazole resistance, we conclude that nitrofurantoin is unlikely to find clinical utility for the eradication of H. pylori.     

四联疗法一线治疗幽门螺杆菌感染疗效研究

目的 探讨含铋剂四联7 d疗法一线治疗幽门螺杆菌感染的临床疗效.方法 120例既往未接受过根除治疗的Hp 感染患者,随机分配至三联组和四联组,三联组给予兰索拉唑30 mg +阿莫西林1.0 g + 克拉霉素250 mg,(2次/d) 治疗7d,四联组给予兰索拉唑30 mg +阿莫西林1.0 g + 克拉霉素250 mg + 胶体果胶铋150 mg,(2次/d),治疗7 d.疗程结束4周后行13c-尿素呼气试验检查,结果阴性者判断为Hp根除,同时观察治疗过程中症状缓解率和不良反应.结果 四联组Hp的根除率均明显高于三联组,差异有统计学意义(P< 0.05).两组症状缓解率和不良反应发生率相似,差异无统计学意义(P>0.05).结论 含铋剂四联7 d疗法根除幽门螺杆菌初治疗效高于标准三联7 d疗法.     

Cost-effectiveness analysis of different strategies for treating duodenal ulcer. Helicobacter pylori eradication versus antisecretory treatment

Helicobacter pylori has recently been recognised as a causative agent for duodenal ulcer, and the efficacy of various combinations of antibacterials and antisecretory agents in eradicating this pathogen has been assessed. The objective of this study was to determine the efficiency of 2 treatment strategies for patients with H. pylori-positive duodenal ulcer. Cost effectiveness was analysed for antisecretory therapy (omeprazole 20 mg/day for 4 weeks), and eradication therapy (triple therapy: omeprazole 40 mg/day plus clarithromycin 1 g/day plus amoxicillin 2 g/day for 1 week). In a Markov model, a hypothetical cohort of 5000 patients was followed for 10 years through 6 disease states. Cyclic eradication therapy (i.e. in the first duodenal ulcer episode and in relapses) was the most cost effective [21 Spanish pesetas (Pta) per day free of symptoms (DFS); Pta128 = $US1 (October 1995)] of the eradication options evaluated [antisecretory in the first episode, then eradication for relapses (Pta22.3/DFS), and eradication therapy first, then antisecretory therapy (Pta27.3/DFS)]. Antisecretory therapy alone was less cost-effective (Pta39/DFS) than each of the 3 eradication options. Eradication treatment in the first episode of duodenal ulcer and relapses has savings in direct costs per patient of up to 56% compared with antisecretory therapy alone. Sensitivity analyses showed the model to be very robust. It is, therefore, advisable to treat initial episodes of H. pylori-positive duodenal ulcer and relapses with triple therapy. The improved cost-effectiveness ratio was largely explained by the long term reduction in relapses obtained with the eradication strategies.     

三九胃泰四联疗法治疗消化性溃疡及根除幽门螺杆菌的多中心临床研究

目的：观察含三九胃泰的四联疗法对消化性溃疡的治疗作用及根除幽门螺杆菌（Hp)的效果。方法：经胃镜确诊的102例消化性溃疡患者随机分成3组，试验组（A组，48例）给予三九胃2.5 雷尼替丁150mg 阿莫西林500mg 甲硝唑400mg,bid；对照组1（B1组，31例）给予铋剂220mg 雷尼替丁150mg 阿莫西林500mg 甲硝唑400mg,bid；对照组2（B2组，23例）给予雷尼替丁150mg 阿莫西林500mg 甲硝唑400mg,bid；以上药物除抗菌药只服用2周外，其余药物服至6周末疗程结束，第7周复查胃镜和／或^13C呼气试验。结果：溃疡总愈合率A组、B1组、B2组分别为90．9％，100％和86．4％，S2获得率分别为68．2％，73．1％和45．5％，Hp根除率分别为76．1％，73．3％，52．6％，症状缓解率大致相似，3组均无明显不良反应发生。结论：雷尼替丁三联疗法加用三九胃泰治疗消化性溃疡，可使S2获得率增加，同时Hp根除率上升，其效果与加用铋剂效果相近，临床观察无明显不良反应。     

含左氧氟沙星和铋剂的四联疗法根除幽门螺杆菌的疗效研究

目的评价含左氧氟沙星和铋剂的四联10d疗法作为一线方案根除治疗幽门螺杆菌感染的有效性和安全性。方法将150例幽门螺杆菌感染的初治患者,随机分配至三联组和四联组,三联组给予埃索美拉唑20mg(2次/d)+克拉霉素500mg,2次/d+阿莫西林1.0g(2次/d)治疗7d,四联组给予埃索美拉唑20mg(2次/d)+胶体果胶铋200mg(2次/d)+左氧氟沙星500mg(1次/d)+阿莫西林1.0g(2次/d)治疗10d。疗程结束6周后行13C-尿素呼气试验检查,判断幽门螺杆菌根除情况,同时观察治疗过程中的不良反应。结果三联组按意向治疗(ITT)分析和按方案(PP)分析H.pylori的根除率分别为73.3%和75.3%,四联组按ITT分析和按PP分析根除率分别为93.3%和95.9%,四联组的按ITT分析和按PP分析H.pylori的根除率均明显高于三联组(P<0.01)。两组不良反应发生率相似,无严重不良反应事件发生。结论含左氧氟沙星和铋剂的四联10d疗法用于幽门螺杆菌感染的初治,疗效高于标准三联7d疗法,是一种可供选择的一线治疗方案。     

Triple therapy with sucralfate, amoxycillin and metronidazole for healing duodenal ulcer and eradicating Helicobacter pylori infection

Methods: Seventy-seven chronic duodenal ulcer patients (50 male) were entered into this study. Treatment was started with sucralfate suspension (2 g b.d.) for 8 weeks. After 2 weeks the patients also received 750 mg amoxycillin t.d.s. plus 500 mg metronidazole t.d.s. for 12 days. Endoscopy with six antral biopsies (urease test, Gram staining, culture and histology) was performed before commencement of sucralfate therapy, 4 weeks after the end of antibiotic therapy, and during the follow-up examinations at 6 and 12 months.
Results: Seven patients were excluded prematurely from the study. Helicobacter pylori in five patients had primary resistance to metronidazole and these patients were also excluded. The ulcer healing rate 4 weeks after the end of antibiotic therapy was 92% and the H. pylori eradication rate was 82% (all per protocol). In all patients who were still H. pylori- positive, the bacterium became resistant to metronidazole and histologically the inflammatory state of the mucosa was the same as before treatment. All H. pylori- eradicated patients (n=53) were re-examined after 6 and 12 months; no ulcer recurrence was observed and each time only one reinfection was found.
Conclusions: In an open study, sucralfate with amoxycillin and metronidazole appeared to act together to eradicate H. pylori infection and to speed duodenal ulcer healing.     

Cost effectiveness of Helicobacter pylori eradication therapies in patients with duodenal ulcer. An analysis of triple therapy versus two dual therapy alternatives

OBJECTIVE: Recent research has focused on eradication therapy as the principal treatment of patients with duodenal ulcers and Helicobacter pylori infection. The aim of this study was to analyse the cost effectiveness of triple therapy versus 2 dual therapies. DESIGN: A health economic evaluation of triple therapy with lansoprazole, amoxicillin and clarithromycin versus 2 dual therapies (lansoprazole or omeprazole, each with amoxicillin) in the eradication of Helicobacter pylori in patients with duodenal ulcers was performed in parallel with a randomised clinical trial. Direct and indirect costs were estimated for 1 year using data elicited from patient questionnaires and from the clinical trial. MAIN OUTCOME MEASURES AND RESULTS: Despite the initial drug cost for triple therapy being 650 Swedish kronor (SEK; 1996 values) higher, the average total direct cost in this group was only SEK150 to SEK200 higher than in the dual therapy groups. This was a result of fewer outpatient visits and lower drug use after treatment failure in the triple therapy group. Triple therapy had a more favourable cost-effectiveness ratio than the dual therapies. CONCLUSION: In spite of higher initial antimicrobial costs, triple therapy with lansoprazole, amoxicillin and clarithromycin is more cost effective than dual therapy because of a higher eradication rate and greater symptom relief.     

H2-antagonist maintenance therapy versus Helicobacter pylori eradication in patients with chronic duodenal ulcer disease: a prospective study

Background:

Few outcome studies directly compare Helicobacter pylori eradication therapy with maintenance H₂-antagonist therapy in duodenal ulcer disease.

Aim:

To examine prospectively the efficacy of H. pylori eradication therapy with ranitidine maintenance therapy over 1 year in patients with confirmed chronic duodenal ulcer.

Methods:

One hundred and nineteen patients with active H. pylori infection were randomized to receive ranitidine, 150 mg/day initially (58 patients), or omeprazole, 40 mg/day, amoxycillin 2 g/day and metronidazole 1.2 g/day for 14 days, or omeprazole 40 mg/day and clarithromycin 1.5 g/day, for 14 days (if penicillin-allergic). Symptoms were assessed using the Gastro-intestinal System Rating Scale (GSRS) and SF36 quality of life index.

Results:

¹³C urea breath testing confirmed overall treatment success in 100% of patients (58/58) per protocol and 95.1% (58/61) on an intention-to-treat basis. At 4 and 12 months there were no differences in any GSRS symptoms between treatment groups. SF36 analysis showed a perceived health improvement at 4 and 12 months in patients who received H. pylori eradication. However, despite successful H. pylori eradication, one-fifth of patients still required antisecretory therapy.

Conclusion:

Following successful H. pylori eradication, chronic duodenal ulcer patients were at least as well symptomatically as when taking maintenance ranitidine. They perceived that their health had improved, but a subgroup was still acid-suppression dependent.

     

序贯疗法治疗十二指肠溃疡穿孔幽门螺杆菌感染的疗效

目的研究序贯疗法与标准三联药物疗法治疗幽门螺杆菌感染的根除率之间的差异。方法根据胃镜检查及尿素酶试验筛选幽门螺旋杆菌感染的十二指肠溃疡穿孔患者61例,随机分成两组,分别接受标准的三联药物疗法或序贯疗法。标准三联药物疗法包括奥美拉唑,克拉霉素和阿莫西林,疗程10d。序贯疗法包括奥美拉唑和阿莫西林或前5d口服奥美拉唑和阿莫西林,后5d改用克拉霉素。2个月后利用胃镜检查评估每个疗程的根除率及不良反应。结果标准三联疗法和序贯疗法的根除率分别为83.3%和90.3%(P=0.473)。序贯疗法的费用较低,两组的不良反应发生率相似。结论序贯疗法和标准三联疗法根除幽门螺旋杆菌的疗效相似,但序贯疗法比较经济可替代标准三联疗法。     

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.