A meta-analysis of randomized controlled trials assessing efficacy and safety of acupuncture and moxibustion in the treatment of peptic ulcer

AIM: To evaluate the efficacy and safety of acupuncture and moxibustion in the treatment of peptic ulcer (gastric and duodenal ulcers).

METHODS: The Wan Fang, VIP, CNKI and PubMed databases were searched to retrieve randomized controlled trials RCTs assessing the efficacy and safety of acupuncture and moxibustion versus conventional therapy in the treatment of peptic ulcer. The quality of the included studies was evaluated using the Jadad score. Statistical analysis was carried out using RevMan 4.2.

RESULTS: Ten studies involving a total of 1 122 patients were included. The results of meta-analysis showed significant differences between patients undergoing acupuncture and moxibustion and those undergoing conventional therapy in terms of total response rate [total RR = 1.10, 95%CI (1.05, 1.16), Z = 4.02, P < 0.0001], conversion rate from H. pylori positive to negative status [total RR = 1.12, 95%CI (1.03, 1.21), Z = 2.71, P = 0.007], and recurrence rate [total OR = 0.42, 95%CI (0.24,0.74), Z = 3.05, P = 0.002], but demonstrated no significant difference in the healing efficiency between the two groups [total RR = 1.02, 95%CI (0.97, 1.08), Z = 0.75, P = 0.45].

CONCLUSION: Acupuncture and moxibustion are effective in the treatment of peptic ulcer in the immediate and long term.

Antiulcer effect of the methanolic extract of Tamarindus indica seeds in different experimental models

Background:

Peptic ulcer is a global health problem of the gastrointestinal tract characterized by mucosal damage secondary to pepsin and gastric acid secretion which occurs due to due to an imbalance between offensive and defensive factors.

Objective:

The present study was carried out with methanolic extract of the seed coat of Tamarindus indica Linn. to evaluate its antiulcer potential on ibuprofen, alcohol and pyloric ligation induced gastric lesions.

Materials and Methods:

Doses of 100 mg/kg & 200 mg/kg of methanolic extract wre administered orally to rats of different groups. Ranitidine at a dose of 50 mg/kg was used as a standard drug for these gastric ulcer models. The gastric content was collected and the volume was measured. The ulceration index was determined by examining the inner lining of each stomach. Furthermore, the effect was assessed by free acidity, pepsin activity, total carbohydrate (TC), protein content (PK).

Result:

The result showed that the methanolic extract of seed coats of Tamarindus indica significantly reduce the total volume of gastric juice, free and total acidity of gastric secretion (P < 0.01) in pylorus ligation induced ulcer model as is comparable with the standard drug ranitidine. There was also a significant reduction in ulcer index (P < 0.01) as compared to control group.

Conclusion:

The methanolic extracts of seed coat of Tamarindus indica can be used as a new source of antiulcer agent in animals.

A multi-center clinical trial to evaluate the efficacy and safety of intravenous nizatidine in the management of peptic ulcer bleeding

AIM: To evaluate the safety and safety of intravenous nizatidine in the management of peptic ulcer bleeding.

METHODS: A muti-center, randomized, parallel-controlled clinical trial was conducted in 205 patients with endoscopically proved peptic ulcer bleeding. The patients were randomly divided into nizatidine group (n = 102) and control group (n = 103). Patients in the nizatidine group were intravenously given nizatidine 0.1 g three times daily for 5 days, while those in the control group were intravenously given famotidine 20 mg twice daily for 5 days.

RESULTS: There were 201 cases evaluable for efficacy and safety. The effective rate and response rate were comparable between the nizatidine group and the control group (85.0% vs 82.2%; 99.0% vs 98.0%; both P > 0.05). Major adverse events include leucopenia, slightly elevated transaminase and anaemia.

CONCLUSION: Intravenous nizatidine is a safe and effective drug for treatment of peptic ulcer bleeding.

Advances in understanding relationship between Helicobacter pylori infection and peptic ulcer bleeding

Helicobacter pylori (H.pylori) is a definite causative factor for peptic ulcer; however, its role in peptic ulcer bleeding is not very clear. Detection of H.pylori infection in patients with peptic ulcer bleeding is often affected by methods and drugs used. H.pylori infection increases, to some extent, the risk of peptic ulcer bleeding. Eradication of H.pylori may reduce the risk of peptic ulcer bleeding and promote ulcer healing.

Risk factors for peptic ulcer bleeding

Bleeding is the most common complication of peptic ulcer. Recent studies have suggested that male sex, blood type O, smoking, ulcer size and location, use of nonsteroidal anti-inflammatory drugs, and meteorological factors were risk factors for peptic ulcer bleeding, while age, Helicobacter pylori infection, psychological-social factors, and economic and educational levels were controversial risk factors for peptic ulcer bleeding.

Gastric juice acidity in upper gastrointestinal diseases

AIM: To search the independent factors determining gastric juice acidity and to investigate the acidity of gastric juices in various benign and malignant upper gastrointestinal diseases.

METHODS: Fasting gastric juice acidity of 165 healthy subjects and 346 patients with esophageal ulcer (n = 21), gastric ulcer (n = 136), duodenal ulcer (n = 100) or gastric cancer (n = 89) were measured and compared. Additionally, gastric specimens were taken from the antrum and body for rapid urease test and histological examination.

RESULTS: Multivariate analysis revealed that bile stain of gastric juice, high acute inflammatory score of the corpus, and atrophy of the corpus were independent risk factors for the development of gastric hypoacidity with odds ratios of 3.1 (95% CI: 1.3-7.3), 3.1 (95% CI: 1.2-7.9) and 3.5 (95% CI: 1.3-9.2). Esophageal ulcer and duodenal ulcer patients had a lower pH level (1.9 and 2.1 vs 2.9, both P < 0.05) of gastric juices than healthy subjects. In contrast, gastric ulcer and gastric cancer patients had a higher pH level (3.4 and 6.6 vs 2.9, both P < 0.001) than healthy controls. Hypoacidity existed in 22%, 5%, 29%, 5% and 88% of healthy subjects, esophageal ulcer, gastric ulcer, duodenal ulcer and gastric cancer patients, respectively.

CONCLUSION: Bile reflux, atrophy and dense neutrophil infiltrate of the corpus are three independent factors determining the acidity of gastric juice.

Gender differences of low-dose aspirin-associated gastroduodenal ulcer in Japanese patients

AIM: To clarify the gender differences about the clinical features and risk factors of low-dose aspirin (LDA) (81-100 mg daily)-associated peptic ulcer in Japanese patients.

METHODS: There were 453 patients under treatment with LDA (298 males, 155 females) who underwent esophagogastroduodenoscopy at the Department of Gastroenterology and Hepatology of Hiratsuka City Hospital between January 2003 and December 2007. They had kept taking the LDA or started treatment during the study period and kept taking LDA during the whole period of observation. Of these, 119 patients (87 males, 32 females) were diagnosed as having LDA-associated peptic ulcer. We examined the clinical factors associated with LDA-associated peptic ulcer in both sexes.

RESULTS: A history of peptic ulcer was found to be the risk factor for LDA-associated peptic ulcer common to both sexes. In female patients, age greater than 70 years (prevalence ORs 8.441, 95% CI: 1.797-33.649, P = 0.0069) was found to be another significant risk factor, and the time to diagnosis as having LDA-associated peptic ulcer by endoscopy was significantly shorter than that in the male patients (P = 0.0050).

CONCLUSION: We demonstrated gender differences about the clinical features and risk factors of LDA-associated peptic ulcer. Special attention should be paid to aged female patients taking LDA.

Influence of interleukin polymorphisms on development of gastric cancer and peptic ulcer

Pro-inflammatory cytokines are produced in the gastric mucosa by inflammatory cells activated by chronic Helicobacter pylori (H. pylori) infection. Polymorphisms of these cytokine genes are associated with individual differences in gastric mucosal cytokine mRNA level, which result in differences in gastric mucosal inflammation, acid inhibition and gastroduodenal disease risk in response to H. pylori infection. Although polymorphisms of interleukin (IL)-1B, IL-1RN and TNF-A have been reported to relate well with gastric cancer and peptic ulcer risk, those of IL-2, IL-4, IL-6 and IL-8 genes are unclear. In combined analyses using data from previous studies, we found that the risk of gastric non-cardia cancer development was significantly associated with IL-4-168 C allele (OR: 0.81, 95% CI: 0.69-1.00) and IL-4-590 T allele carrier status (0.61, 0.53-0.73), and IL-6-174 G/G genotype (2.02, 1.31-3.10). In peptic ulcer development, IL-2-330 G and IL-4-590 T allele carriers had a significantly decreased risk (0.37, 0.27-0.50 and 0.58, 0.34-0.99, respectively). Moreover, IL-2, IL-4, IL-6 and IL-8 gene genotypes prevalence differs among populations. The inflammatory cytokine gene polymorphisms (e.g. IL-4-590 and IL-6-572 for gastric cancer, and IL-4-590, IL-6-572 and IL-8-251 for peptic ulcer) have a more potent influence on development of gastroduodenal diseases in Western than East Asian populations. These cytokine gene polymorphisms, as well as those of IL-1B, IL-1RN and TNF-A, may be used to identify groups at higher risk of gastric cancer and peptic ulcer, and those suitable for their prevention by H. pylori eradication therapy in Western populations.

How evidence-based are current guidelines for managing patients with peptic ulcer bleeding?

Current guidelines for managing ulcer bleeding state that patients with major stigmata should be managed by dual endoscopic therapy (injection with epinephrine plus a thermal or mechanical modality) followed by a high dose intravenous infusion of proton pump inhibitors (PPIs). This paper aims to review and critically evaluate evidence supporting the purported superiority of a continuous infusion over less intensive regimens of PPIs administration and the need for adding a second hemostatic endoscopic procedure to epinephrine injection. Systematic searches of PubMed, EMBASE and the Cochrane library were performed. There is strong evidence for an incremental benefit of PPIs over H2-receptor antagonists or placebo for the outcome of patients with peptic ulcer bleeding following endoscopic hemostasis. However, the benefit of PPIs is unrelated to either the dosage (intensive vs standard regimen) or the route of administration (intravenous vs oral). There is significant heterogeneity among the 15 studies that compared epinephrine with epinephrine plus a second modality, which might preclude the validity of reported summary estimates. Studies without second look endoscopy plus re-treatment of re-bleeding lesions showed a significant benefit of adding a second endoscopic modality for hemostasis, while studies with second-look and re-treatment showed equal efficacy between endoscopic mono and dual therapy. Inconclusive experimental evidence supports the current recommendation of the use of dual endoscopic hemostatic means and infusion of high-dose PPIs as standard therapy for patients with bleeding peptic ulcers. Presently, the combination of epinephrine monotherapy with standard doses of PPIs constitutes an appropriate treatment for the majority of patients.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.

Therapeutic effects of colloidal bismuth subcitrate in rabeprazole-based quadruple therapy

AIM: To evaluate the therapeutic effects of colloidal bismuth subcitrate in rabeprazole-based quadruple therapy in peptic ulcer patients positive for Helicobacter pylori (H pylori).

METHODS: Seventy-six peptic ulcer patients with H pylori infection were randomly divided into two groups: control group and experimental group. The control group received rabeprazole plus amoxicillin and levofloxacin, while the experimental group received rabeprazole plus amoxicillin, levofloxacin and colloidal bismuth pectin. After a 7-day treatment course, the therapy for peptic ulcer was carried out. The eradication rate of H pylori infection, the ulcer healing rate and side-effects were compared between the two groups.

RESULTS: The eradication rate of H pylori infection was significantly lower in the control group than in the experimental group (71.05% vs 92.10%, P < 0.05). No significant difference was noted in the ulcer healing rate between the two groups (92.11% vs 94.74%, P > 0.05).

CONCLUSION: Colloidal bismuth subcitrate in rabeprazole-based quadruple therapy is effective and safe in peptic ulcer patients positive for H pylori.

Relationship between common duct stones and Helicobacter pylori infection

AIM: To investigate the rate of Helicobacter pylori (H. pylori) infection in patients with common duct stones and analyze the relationship between common duct stones and H. pylori infection.

METHODS: One hundred and five patients with common duct stones (experiment group) and 132 control subjects (control group) were included in the study. All the patients underwent electronic gastroscopy, rapid urease test and 14C urea breath test (¹⁴C-UBT).

RESULTS: Sixty-eight patients in the experiment group were positive for H. pylori, while 51 subjects in the control group were positive for H. pylori. The rate of H. pylori infection in the experiment group was significantly higher (64.8% vs 38.6%, P < 0.01) than that in the control group.

CONCLUSION: The rate of H. pylori infection is high in patients with common duct stones, and H. pylori infection may be related to the morbidity of common duct stones.

Peptic ulcer and childhood adversities experienced by working-aged people

AIM: To study the association between self-reported peptic ulcer and childhood adversities.

METHODS: The Health and Social Support Study (HeSSup) population consisted of a stratified random sample drawn from the Finnish Population Register in four age groups: 20-24, 30-34, 40-44 and 50-54. The survey was carried out by postal questionnaire during 1998, with a response rate of 40.0%. A follow-up questionnaire was sent during 2003 to all those who responded to the first. Altogether 19 626 individuals returned the follow-up questionnaire; a response rate of 75.8%. The subjects were asked whether a doctor had told them that they have or have had peptic ulcer. The analyses covered those who responded affirmatively to both the baseline and the follow-up enquiries (n = 718). Those not reporting a peptic ulcer in either of the two questionnaires (n = 17 677) were taken as controls. The subjects were further requested (through six questions) to think about their childhood adversities.

RESULTS: The most common adversities mentioned were long-lasting financial difficulties in the family, serious conflicts in the family, and a family member seriously or chronically ill. All the adversities reported, except parental divorce, were more common among peptic ulcer patients than among controls (P values varied between < 0.001 and 0.003). Age- and sex-adjusted odds ratios (OR) of childhood adversities in the multivariate logistic analysis for self-reported peptic ulcer varied between 1.45 and 2.01. Adjusting for smoking, heavy drinking, stress and nonsteroidal anti-inflammatory drug use had no further influence (ORs between 1.22 and 1.73).

CONCLUSION: Our findings suggest that childhood adversities maintain a connection with and have a predictive role in the development of peptic ulcer.

Detection and evaluation of antibodies against neutrophil-activating protein of Helicobacter pylori in patients with gastric cancer

AIM: To detect and evaluate the antibodies against Helicobacter pylori (H pylori) neutrophil-activating protein (HP-NAP) in patients with gastric cancer and other gastroduodenal diseases.

METHODS: Recombinant HP-NAP was prepared from a prokaryotic expression system in Escherichia coli. Serum positivity and level of HP-NAP-specific antibodies in sera from 43 patients with gastric cancer, 28 with chronic gastritis, 28 with peptic ulcer, and 89 healthy controls were measured by rHP-NAP-based ELISA. rHP-NAP-stimulated production of interleukin-8 (IL-8) and growth-related oncogene (GRO_α) cytokines in the culture supernatant of SGC7901 gastric epithelial cells was also detected.

RESULTS: The serum positivity and mean absorbance value of HP-NAP-specific antibodies in the gastric cancer group (97.7% and 1.01 ± 0.24) were significantly higher than those in the chronic gastritis group (85.7% and 0.89 ± 0.14, P < 0.005) and healthy control group (27.7% and 0.65 ± 0.18, P < 0.001). The sensitivity and specificity of ELISA for the detection of HP-NAP-specific antibodies were 95.5% and 91.5%, respectively. HP-NAP could slightly up-regulate IL-8 production in gastric epithelial cell lines but had no effect on GRO_α production.

CONCLUSION: Infection with virulent H pylori strains secreting HP-NAP is associated with severe gastroduodenal diseases, and HP-NAP may play a role in the development of gastric carcinoma. rHP-NAP-based ELISA can be used as a new method to detect H pylori infection. The direct effect of HP-NAP on gastric epithelial cells may be limited, but HP-NAP may contribute to inflammatory response or carcinogenesis by activating neutrophils.

Usefulness of anti-ulcer drugs for the prevention and treatment of peptic ulcers induced by low doses of aspirin

AIM: To investigate the usefulness of anti-ulcer drugs for the prevention and treatment of low-dose aspirin-induced peptic ulcer.

METHODS: Upper gastrointestinal endoscopy was performed in 68 patients receiving daily low-dose aspirin (81 or 100 mg/day). The endoscopic findings were classified according to the Lanza score, and the scores were compared between groups categorized according to the concomitant use of anti-ulcer drugs and the types of drugs used. In another study, 31 hemorrhagic peptic ulcer patients who had been receiving low-dose aspirin were enrolled. The patients were randomly classified into the proton pump inhibitor (PPI)-treated group and the H2 receptor antagonist (H2RA)-treated group. The administration of low-dose aspirin was continued concomitantly, and endoscopic examinations were performed 8 wk later.

RESULTS: The Lanza scores (mean ± SD) of the gastro-mucosal lesions were 1.0 ± 1.9 and 1.9 ± 2.3 in 8 and 16 patients receiving prevention therapy with a PPI and an H2RA, respectively. Both scores were significantly smaller than the scores in 34 patients who were not receiving prevention therapy (4.7 ± 1.0) and in 10 patients receiving cytoprotective anti-ulcer drugs (4.3 ± 1.6). In the prospective study, 18 and 13 patients received a PPI and an H2RA, respectively. Endoscopic examinations revealed that the tissue in the region of the gastro-mucosal lesions had reverted to normal in all patients in the PPI-treated group and in 12 patients (92%) in the H2RA-treated group; no significant differences were observed between the groups.

CONCLUSION: H2RA therapy was effective for both the prevention and treatment of low-dose aspirin-induced peptic ulcer, similar to the effects of PPIs, while cytoprotective anti-ulcer drugs were ineffective in preventing ulceration.

Analysis of 124 cases with senile peptic ulcer detected by gastroscopy

AIM: To analyze clinical characteristics of senile peptic ulcer.

METHODS: Patients with senile peptic ulcer confirmed by gastroscopy in our hospital from Jan 2007 to Oct 2008 were retrospectively analyzed and compared with those <60 years old with peptic ulcer detected contemporarily.

RESULTS: There were 124 peptic ulcer cases, including 61 cases of gastric ulcer, 51 cases of duodenal ulcer and 12 cases of complex ulcer in the aged group, and 100 peptic ulcer cases < 60 years old, including 29 cases of gastric ulcer, 64 cases of duodenal ulcer, and 7 cases of complex ulcer. Significant difference was detected between the two groups (P < 0.01). For senile gastric ulcer, gastric body ulcer was the dominant, accounting for 36.1%, D > 2 cm was 29.5%. Upper gastrointestinal hemorrhage was the most common complication, accounting for 43.5%.

CONCLUSION: Symptoms of senile peptic ulcer are not typical. The incidence rate of superior position is higher. The morbidity of gastric ulcer is high, and the involved area is bigger for aged people. More and severe complications are seen.

Endoscopic findings in patients with upper gastrointestinal bleeding clinically classified into three risk groups prior to endoscopy

AIM: To investigate in a prospective study whether a simplified clinical score prior to endoscopy in upper gastrointestinal bleeding (UGIB) patients was able to predict endoscopic findings at urgent endoscopy.

METHODS: All consecutive UGIB patients referred to a single endoscopic center during a 16 mo period were enrolled. Before endoscopy patients were stratified according to a simple clinical score (T-score), including T1 (high-risk), T2 (intermediate-risk) and T3 (low-risk). Endoscopy was performed in all cases within 2 h, and high-risk stigmata were considered for further analysis.

RESULTS: Out of the 436 patients included into the study, 126 (29%) resulted to be T1, 135 (31%) T2, and 175 (40%) T3. Overall, stigmata of recent haemorrhage (SRH) were detected in 118 cases (27%). SRH occurred more frequently in T1 patients than in T2/T3 cases (85% vs 3.2%; χ² = 304.5309, P < 0.001). Older age (t = 3.311; P < 0.01) and presence of comorbidities (χ² = 14.7458; P < 0.01) were more frequently detected in T1 than in T2/T3 patients.

CONCLUSION: Our simplified clinical score appeared to be associated with the detection of endoscopic findings which may deserve urgent endoscopy. A further, randomised study is needed to assess its accuracy in safely scheduling endoscopy in UGIB patients.

Proton pump inhibitors in cirrhosis: Tradition or evidence based practice?

Proton Pump Inhibitors (PPI) are very effective in inhibiting acid secretion and are extensively used in many acid related diseases. They are also often used in patients with cirrhosis sometimes in the absence of a specific acid related disease, with the aim of preventing peptic complications in patients with variceal or hypertensive gastropathic bleeding receiving multidrug treatment. Contradicting reports support their use in cirrhosis and evidence of their efficacy in this condition is poor. Moreover there are convincing papers suggesting that acid secretion is reduced in patients with liver cirrhosis. With regard to Helicobacter pylori (H pylori) infection, its prevalence in patients with cirrhosis is largely variable among different studies, and it seems that H pylori eradication does not prevent gastro-duodenal ulcer formation and bleeding. With regard to the prevention and treatment of oesophageal complications after banding or sclerotherapy of oesophageal varices, there is little evidence for a protective role of PPI. Moreover, due to liver metabolism of PPI, the dose of most available PPIs should be reduced in cirrhotics. In conclusion, the use of this class of drugs seems more habit related than evidence-based eventually leading to an increase in health costs.

Advance in research of genes associated with peptic ulcer

At present, studies about peptic ulcer have developed from cellular level to molecular level. More and more genes associated with peptic ulcer have been discovered, including human leukocyte antigen (HLA) genes, epidermal growth factor (EGF) genes, apoptosis-associated genes, calcitonin genes and trefoil peptide genes. These genes play important roles in the development and healing of peptic ulcer, providing theoretical basis for clinical diagnosis and cure of peptic ulcer.

Epidemiology of peptic ulcer in the Beijing area

AIM: To investigate the epidemiological characteristics of peptic ulcer in the Beijing area and its relationship with Helicobacter pylori, and to provide a theoretical basis for the treatment and prevention of peptic ulcer.

METHODS: To analyze the clinical data for active or healing peptic ulcer, diagnosed by gastroscopy in 29 hospitals in the Beijing area in 1999. This was a retrospective study using a standard questionnaire. The following associations were analyzed: sex, age, blood type, occupation, living habits, drug use and H. pylori status. The diagnosis of H. pylori infection was reached by using one of the methods as follows: rapid urea test, pathology, ¹³C-urea breath test and culture.

RESULTS: The detection rate of peptic ulcer was 13.83% by endogastroscopy in 58 546 patients. 3182 patients (2328 male, aged 17 - 86 years) were included in the final analysis. The ratio between duodenal and gastric ulcer was 2.81. The highest prevalence rate was in the 40-60 years group. The average age of patients with gastric ulcer was about 6.4 years higher than that of those with duodenal ulcer. Prevalence of peptic ulcer was significantly higher in patients with blood type O than in those with other blood types. Prevalence in smokers was significantly higher than that in non-smokers (P = 0.012). 1644 (54.9%) patients were found positive among the 2992 who were tested for H. pylori infection in 1999. There was no significant difference in rate of H. pylori infection among patients with different types of peptic ulcer(P = 0.72). 1660 (81.3%) patients were found positive among the 2042 patients who were tested for H. pylori infection when they were first diagnosed with peptic ulcer. It was found that the recurrence of PU associated with H. pylori infecting status and the selecting therapy, after the Logistic regression analysis.

CONCLUSION: Detection rate of peptic ulcer has decreased in the Beijing area. Detection of H. pylori infection in patients diagnosed for the first time with peptic ulcer is very high, but detection was lower in patients diagnosed in 1999. Age, blood type O, smoking and H. pylori infection are risk factors for peptic ulcer. Non-standard therapy and H. pylori infection are associated with peptic ulcer recurrence.

Peptic ulcer disease not related to Helicobacter pylori or non-steroidal anti-inflammatory drugs

Helicobacter pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs) are widely accepted as the most important factors in the pathogenesis of peptic ulcers. However, the proportion of H. pylori-negative peptic ulcers without intake of NSAIDs appears to have increased in recent years. The reason is partly related to a decreased prevalence of H. pylori among the population and more effective eradication of the bacterium, and it is also related to the defense measures for NSAIDs. The etiological factors involved in peptic ulcer disease not caused by H. pylori or NSAIDs include altered acid secretion, abnormal gastric emptying, defective mucosal defense mechanisms, psychological stress, smoking, genetic predisposition and other chronic diseases. The main therapeutic measures include anti-secretory drugs and mucosal protectants.

A low prevalence of H pylori and endoscopic findings in HIV-positive Chinese patients with gastrointestinal symptoms

AIM: To compare the prevalence of H pylori infection, peptic ulcer, cytomegalovirus (CMV) infection and Candida esophagitis in human immunodeficiency virus (HIV)-positive and HIV-negative patients, and evaluate the impact of CD4 lymphocyte on H pylori and opportunistic infections.

METHODS: A total of 151 patients (122 HIV-positive and 29 HIV-negative) with gastrointestinal symptoms were examined by upper endoscopy and biopsy. Samples were assessed to determine the prevalence of H pylori infection, CMV, candida esophagitis and histologic chronic gastritis.

RESULTS: The prevalence of H pylori was less common in HIV-positive patients (22.1%) than in HIV-negative controls (44.8%; P < 0.05), and the prevalence of H pylori displayed a direct correlation with CD4 count stratification in HIV-positive patients. In comparison with HIV-negative group, HIV-positive patients had a lower incidence of peptic ulcer (20.7% vs 4.1%; P < 0.01), but a higher prevalence of chronic atrophy gastritis (6.9% vs 24.6%; P < 0.05)，Candida esophagitis and CMV infection. Unlike HIV-negative group, H pylori infection had a close relationship to chronic active gastritis (P < 0.05). In HIV-positive patients, chronic active gastritis was not significantly different between those with H pylori infection and those without.

CONCLUSION: The lower prevalence of H pylori infection and peptic ulcer in HIV-positive patients with gastrointestinal symptoms suggests a different mechanism of peptic ulcerogenesis and a different role of H pylori infection in chronic active gastritis and peptic ulcer. The pathogen of chronic active gastritis in HIV-positive patients may be different from the general population that is closely related to H pylori infection.

Peptic ulcer perforation as the first manifestation of previously unknown primary hyperparathyroidism

A patient admitted for acute abdomen was incidentally found with elevated serum calcium level. In surgery, under conservative treatment of the hypercalcemia, a perforated duodenal ulcer was found and simple closure was performed. Postoperatively, calcium level continued to rise, parathyroid hormone was elevated and ultrasonographic examination showed a lesion in the right anterior neck, while serum gastrin level was normal, thus documenting the diagnosis of primary hyperparathyroidism. Conservative treatment had no effect on calcium level and the patient was subjected to emergency neck exploration, where a large parathyroid adenoma was removed. After surgery, calcium and PTH levels were normalized and the patient was discharged on the 5th postoperative day. Peptic ulcer and its complications are usual manifestations of primary hyperparathyroidism, with or without increased gastrin level. On the other hand, cases of a perforation of peptic ulcer as the first clinical manifestation of primary hyperparathyroidism are extremely rare.

Analysis of foreign literatures on peptic ulcer research

AIM: To present the hot topics on peptic ulcer research by analyzing the related literatures.

METHODS: PubMed database was searched to select the articles related to peptic ulcer and published during the year 2004 to 2006, and the subject heading (MeSH) terms of all articles were downloaded. Subsequently all the MeSH terms that appeared over 20 times were selected and co-word analysis was used to cluster these medical MeSHs. After statistically analyzing the contents of each cluster, the research focuses were obtained.

RESULTS: A total of 1559 articles associated with peptic ulcer were searched from PubMed database, and 64 MeSH terms appeared over 20 times. The MeSH term "application of anti-ulcer drugs" was found with the most occurrence frequency (181 times). The 64 terms were clustered into 7 groups according to their co-occurrence strengths.

CONCLUSION: The 7 hot topics are as follow: the drug therapy of peptic ulcer, the etiology study of chemical-induced peptic ulcer, surgery on peptic ulcer, the drug therapy of H. pylori infection, laboratory diagnosis of peptic ulcer and epidemiology and genetic research on peptic ulcer.

A head to head comparison of oral vs intravenous omeprazole for patients with bleeding peptic ulcers with a clean base, flat spots and adherent clots

AIM: To compare the effect of intravenous and oral omeprazole in patients with bleeding peptic ulcers without high-risk stigmata.

METHODS: This randomized study included 211 patients [112 receiving iv omeprazole protocol (Group 1), 99 receiving po omeprazole 40 mg every 12 h (Group 2)] with a mean age of 52.7. In 144 patients the ulcers showed a clean base, and in 46 the ulcers showed flat spots and in 21 old adherent clots. The endpoints were re-bleeding, surgery, hospital stay, blood transfusion and death. After discharge, re-bleeding and death were re-evaluated within 30 d.

RESULTS: The study groups were similar with respect to baseline characteristics. Re-bleeding was recorded in 5 patients of Group 1 and in 4 patients of Group 2 (P = 0.879). Three patients in Group 1 and 2 in Group 2 underwent surgery (P = 0.773). The mean length of hospital stay was 4.6 ± 1.6 d in Group 1 vs 4.5 ± 2.6 d in Group 2 (P = 0.710); the mean amounts of blood transfusion were 1.9 ± 1.1 units in Group 1 vs 2.1 ± 1.7 units in Group 2 (P = 0.350). Four patients, two in each group died (P = 0.981). After discharge, a new bleeding occurred in 2 patients of Group 1 and in 1 patient of Group 2, and one patient from Group 1 died.

CONCLUSION: We demonstrate that the effect of oral omeprazole is as effective as intravenous therapy in terms of re-bleeding, surgery, transfusion requirements, hospitalization and mortality in patients with bleeding ulcers with low risk stigmata. These patients can be treated effectively with oral omeprazole.