Dyspepsia. The broad etiologic spectrum

Dyspepsia remains one of mankind's most common afflictions. It affects virtually everybody at one time or another, it is responsible for the hundreds of millions of dollars spent each year on antacids and H2 antagonists, and it ranks second only to the common cold as a cause of loss of time from work. The condition denotes widely different things to different people, but by definition, complaints of dyspepsia must bear some relation to food or drink. (The term "dyspepsia" derives from dys, meaning "bad," and pepsis, meaning "digestion.") A physician writing in the Lancet more than a hundred years ago referred to dyspepsia as "the remorse of a guilty stomach." Unfortunately, the problem often turns out to be more serious than the transient pangs emanating from overindulgence. "Dyspepsy," De Quincey wrote in 1823, "is the ruin of most things: empires, expeditions, and everything else." That may be an overstatement. Still, dyspepsia can certainly be the harbinger of disastrous illness, as the following case illustrates.

Gastroduodenal mucosal hemodynamics by endoscopic reflectance spectrophotometry

The reflectance spectrophotometric technique measures an index of mucosal hemoglobin concentration and an index of oxygen saturation by spectral analysis of light reflected from the mucosal surface. Using a commercially available unit, a technique for obtaining reproducible endoscopic measurements with acceptable intraobserver and interobserver variability was developed in the anesthetized dogs. The reflectance spectrophotometric finding that experimentally induced prehepatic portal hypertension did not affect gastric mucosal blood flow was confirmed by hydrogen gas clearance measurements. Endoscopic studies in patients with active duodenal ulcer disease revealed a higher index of mucosal hemoglobin concentration and a normal index of oxygen saturation (i.e., an increase in blood flow) at the margin of the ulcer compared with the adjacent normal appearing mucosa.

Duodenal ulceration: review of 110 cases

This paper describes 110 cases of childhood duodenal ulcer, which were diagnosed over 26 years: 63 were diagnosed by barium meal examination; 47 by upper gastrointestinal endoscopy. The mean age at diagnosis was 11.2 years, with symptoms reported in 46% before 10 years and in 15% before 6 years of age. There was often a considerable delay in diagnosis, particularly in the younger age group. Nocturnal pain (61%) and a close family history of duodenal ulcer disease (62%) were the most valuable pointers to the diagnosis. Fifteen children had required surgery for persistent symptoms. Thirty four had received treatment with an H2 receptor antagonist, and all but four had had a satisfactory initial response. Seventy per cent relapsed within six months of discontinuing treatment, and long term maintenance treatment may therefore be necessary.

Do symptoms of gastric ulcer become less frequent with time?

It has been claimed that gastric and duodenal ulcer (GU and DU) symptoms decrease in frequency with time, indicating 'burn out' of ulcer. The present study was undertaken to investigate further this phenomenon in GU. The prevalence of symptom experience during 1 year was examined in 447 medically treated patients with GU diagnosed 2-20 or more years previously. When ulcer history length was measured from either first symptom onset or first ulcer diagnosis, reporting of symptoms did not become less frequent as history length increased. This remained true after adjustment for GU location, sex, age, smoking, and analgesic and non-steroidal anti-inflammatory drug ingestion. It is concluded that GU symptoms do not decrease in frequency with time.

[Behavior in disability assessment of uncomplicated duodenal ulcer--a study]

There is internationally no standardized therapy of the uncomplicated duodenal ulcer, including the inability to work. In order to obtain a representative behaviour concerning the duration of the inability to work prescribed by specialists for general medicine, internal medicine and surgery, an interrogation was performed. An evaluation of 729 questionnaires shows the following tendency: 1. The younger the attending physician is the longer is the time of inability to work prescribed and the more frequent such a certificate is given. 2. General practitioners in rural districts on an average prescribe a longer time of inability to work. 3. The higher is the qualification of the specialist for internal medicine the shorter is the duration of inability to work attested. 4. In the assessment of the duration of the inability to work the attending physicians increasingly accommodate themselves rather to the symptoms than to the radiological or to the endoscopic control of healing.

Prognosis of chronic duodenal ulcer: a prospective study of the effects of demographic and environmental factors and ulcer healing

The aim of this prospective study of 370 community based duodenal ulcer patients was to define the effect on duodenal ulcer course (from the aspect of symptom occurrence) of demographic and environmental factors, and of proven healing of index ulcer within four months. Follow up was three monthly, for up to three years. By survival analysis, it was found that marriage breakup adversely affected duodenal ulcer course, that age 50 years and under, female sex, and aspirin use tended to do so, and that smoking, alcohol ingestion, and paracetamol use did not. Proven healing of index ulcer within four months was associated with a small and non-significant reduction in symptom occurrence over time.

Modified sham feeding test after parietal cell vagotomy for juxtapyloric ulcer disease in patients with and without recurrent ulcers

The mean of individual coefficients of variation of acid output after modified sham feeding was 39% in 22 patients operated on with parietal cell vagotomy. The reproducibility of the interpretation of the sham feeding test as 'positive' or 'negative' was good. An intragastric infusion of a marker to correct for pyloric loss did not increase the accuracy of the test. The prognostic value of the qualitative estimation of the sham feeding test 2 months after operation to predict recurrent ulcer after parietal cell vagotomy was poor in 39 patients studied prospectively over 3 years. With the criterion sham feeding minus basal acid output over 1.0 mmol/30 min as a positive test, 63% of patients with a positive and 24% with a negative test later had recurrent ulcers. The consistency of the interpretation as either positive or negative was low in annual tests during the 3 years of follow-up study. After parietal cell vagotomy the sham-feeding-stimulated acid output was higher in patients with duodenal than in those with prepyloric recurrent ulcers and also in those without recurrences. This indicates that the amount of vagal innervation left after parietal cell vagotomy is of special importance in the occurrence of duodenal ulcer relapse.

Choledochoduodenal fistula: a rare complication of peptic ulcer disease

Choledochoduodenal fistula is a rare complication of peptic ulcer disease. Many cases are asymptomatic and incidentally diagnosed. Treatment is controversial and ranges from medical treatment of peptic ulcer disease alone, to vagotomy with antrectomy or gastroenterostomy. Common bile duct exploration and reconstruction are reserved for cases with biliary stricture.

[Primary peptic ulcer in childhood: apropos of 16 cases]

We report a retrospective review of primary peptic ulcer disease in 16 children, 8 boys and 8 girls between 2 and 14 years of age, seen at our hospital over a 4 years and 4 months period. Endoscopy was realized in all children and revealed 7 duodenal ulcers (DU) and 11 gastric ulcers (GU) (two patients had both locations). At the initial diagnosis 5 patients were less than 6 years old with a ratio GU/DU of 4:1; in the other patients this ratio was 1:1. In children with duodenal ulcer 56.5% of them had positive family history. The commonest presenting symptoms were abdominal pain (87.5%) and acute gastrointestinal bleeding (68.7%). The follow-up period ranged from 2 to 52 months; in 13 cases follow-up was more than 1 year. Four patients (3 DU and 1 GU) older than 6 years recurred.

Relationship between gastric acid secretion and clinical outcome after parietal cell vagotomy

Results of insulin and pentagastrin tests 2 months after parietal cell vagotomy were compared with clinical outcome in six patients with subsequent duodenal recurrence of ulcer, ten with pyloric or gastric recurrence, 43 with dyspepsia and 75 persistently symptom-free controls. The insulin-stimulated peak acid output (IPAO) and the pentagastrin-stimulated peak acid output (PAO), but not the basal acid output (BAO), were significantly higher in the duodenal recurrence group than in the controls. In the pyloric/gastric recurrence and dyspepsia groups, BAO, IPAO and PAO were similar to the control values. In the duodenal group the postvagotomy reductions of IPAO and PAO were significantly less than in the controls, indicating incomplete vagotomy. In the pyloric/gastric recurrence and dyspepsia groups, the postvagotomy BAO fall was significantly less than in the controls, but IPAO and PAO fell similarly in all three groups, indicating that pyloric or gastric recurrence was related only to inadequately reduced BAO.

Office visit patterns in physician group practices

In summary, this study provides evidence that with as few as five diagnosis it is possible to identify some physician group practices that consistently treat patients with more or fewer visits, on average. However, even among group practices that vary considerably in size, location, and organizational structure, there is little deviation from the norm in terms of office visits. A study of more than 30 patients per site using data from both office records and insurance claims is needed, however, to examine the entire spectrum of treatment, including lab tests, special procedures, medications, and hospitalization. Such future studies may exploit the possibilities and avoid the pitfalls describes here to better characterize physicians' practice patterns.

Duodenal ulcer. Incidence, risk factors, and predictive value of plasma pepsinogen

In 1958 the Yale freshman class gave blood samples as part of a study intended to determine the predictive value of plasma pepsinogen (PP) for the subsequent development of duodenal ulcer (DU). We report a long-term follow-up of this cohort. A self-administered questionnaire designed to ascertain information about the development of peptic ulcers, and the presence of risk factors was mailed to 861 subjects with "active" addresses. A second questionnaire was mailed to each respondent's physician(s) to verify the diagnosis of DU. Completed questionnaires were returned, after three mailings, by 604 (70%) of the subjects. They reported 18 documented DUs, 15 since 1958, for an incidence of 1.1/1000 person years. Only smoking (P less than 0.05) and undergraduate physical inactivity (P less than 0.01) were identified as risk factors for DU. Family history; blood type; blood antigen secretor status; ingestion of coffee, alcohol, milk, salicylates, soda, or tea; and COPD were not identified as risk factors for DU. Patients with DU had higher mean PP values than those who did not (391.6 +/- 99.6 vs 346.6 +/- 106.7, mean +/- SD) but this was not statistically significant (P greater than 0.05). The predictive value of an elevated PP (greater than 450) for the development of DU was 7.9%, but a low or normal PP predicted the absence of a DU in 97.5% of subjects over a 22-year span.(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenal, prepyloric, and combined duodenal/prepyloric ulcer disease: three distinct entities of juxtapyloric ulcer disease?

One hundred and seven patients with long-standing and severe chronic juxtapyloric ulcer disease were classified in accordance with the location of the present ulcer and previous ulcers into 1) pure duodenal (DU), 2) pure prepyloric (PU), and 3) combined duodenal/prepyloric (DU/PU) or prepyloric/duodenal (PU/DU) ulcer disease. In a prospective follow-up study over a 3-year period after parietal cell vagotomy (n = 39) or during continuous treatment with cimetidine (n = 62) patients with DU had recurrent ulcers located exclusively to the duodenal bulb and patients with PU, exclusively to the prepyloric region. In patients with DU/PU and PU/DU recurrent ulcers occurred on either side of the pylorus. Basal acid and basal pepsin outputs were higher and bile acid in gastric juice was lower in patients with DU than in those with PU. There are a considerable number of patients who possess features of both duodenal and prepyloric ulcer disease. The clinical outcome of both continuous cimetidine treatment and vagotomy in these patients (DU/PU and PU/DU) was less satisfactory than in pure DU. All patients presenting with active DU should therefore be investigated for evidence of previous prepyloric ulceration.