A modification of the Visick grading for the evaluation of duodenal ulcer operations

A series of 150 patients with duodenal ulcer, treated by means of a highly selective vagotomy, is presented. The clinical follow-up of 100 patients, treated for more than three years, was assessed according to the Visick classification. A thirteen percent recurrence rate was noted in this series. Recurrences could either be cured easily by medical treatment or induce long lasting medication or operative intervention. A subdivision of the Visick 4 class of patients is proposed in this study, taking into account this quite different evolution of ulcer recurrences after highly selective vagotomy.

[Clinical relevance of sonography in acute diagnosis of perforated gastroduodenal ulcers]

In a prospective unselected series of 22 patients with perforated gastroduodenal ulcers the diagnostic efficacy of clinical and radiologic data was modest. In eight patients only (approximately 36%), clinical data yielded sufficient evidence; in 16 patients (approximately 73%), plain X-ray demonstrated subphrenic gas. Sonography was proven to be a major advance, especially rewarding in the diagnosis of perforations with negative plain X-ray. Gastric distention and stomach wall edema are unspecific sonographic criteria, whereas objectivation of a pathologic stomach "cockade" in the presence of free gas, extraluminary ingesta or echofree fluid in the peritoneal cavity are pathognomonic data. These criteria yielded a definite diagnosis in 16 patients (approximately 73%) including four patients with negative X-ray. The combined analysis of radiologic and sonographic findings yielded an immediate correct diagnosis in 20 patients (approximately 91%).

Statistical analysis of symptoms and signs in pediatric patients with peptic ulcer

It is not well known which symptoms or signs related to peptic ulcer are crucial for its diagnosis in children. In order to clarify this problem, we evaluated the sensitivity, specificity, and positive and negative predictability of 13 ulcer-related symptoms and signs. The data of 160 patients, who were suspected of having peptic ulcer and had undergone endoscopic examinations, were studied. It was significant that five symptoms, i.e., presence of pain in the epigastrium, relationship between the time of pain and that of eating, family history, vomiting, and bleeding, were frequently found in ulcer patients. There was, however, no symptom or sign that predicted by itself precisely the existence of a peptic ulcer. Thus, we computed a discriminant function by combining the data by multivariate analysis. With this score, we could predict the existence of ulcer more precisely. Finally, it was concluded that epigastric pain, food-related pain, vomiting, bleeding, and family history were crucial factors for the diagnosis of peptic ulcer in childhood and that an overall consideration of symptoms and signs was needed for the evaluation of these factors.

Peptic ulcer. A follow-up study

One hundred and ten patients who had been entered into an ulcer healing study 2 to 4 years previously were recalled during an 8-week period for clinical assessment and endoscopy. Fifty-five gastric ulcer patients were followed-up after an average period of 21.2 months. Nine of these had undergone gastric surgery; of the remaining 46 patients, recurrent ulceration was found in 16 (35%). Fifty-five patients with duodenal ulcer disease were also followed-up after an average of 35.6 months. Five of these patients had undergone surgery and of the remaining 50, 25 (50%) had a recurrent duodenal ulcer. About one-third of both gastric and duodenal ulcer recurrences were asymptomatic. Smoking had no effect on recurrence rates.

The efficacy of endoscopy in the evaluation of dyspepsia. A review of the literature and development of a sound strategy

Diagnostic approaches to the patient with dyspepsia include immediate evaluation with an upper gastrointestinal series, immediate study with esophagogastroduodenoscopy (EGD), or empiric medical treatment, reserving diagnostic evaluation for patients with complications and persistent symptoms after therapy. A literature review of dyspepsia as a symptom, and of duodenal ulcer, gastric ulcer, gastroduodenitis, and gastric cancer summarizes how the diagnostic approaches to the dyspeptic patient affect the precision of diagnostic information, efficacy, patient outcome, and cost. For patients without clinically obvious disease, an approach is developed which reduces cost and retains optimal patient management. The strategy proposes the use of empiric medical therapy while reserving EGD for those few dyspeptic patients who have no or minimal response to therapy after 7 to 10 days, and for the approximately 30% of patients whose symptoms persist, improved, but not resolved after a 6 to 8 week period.

Influence of the site of a duodenal ulcer on its mode of presentation

The aims of this study were to define the localization of duodenal ulcer and to determine whether the site influenced the initial presentation. Eight hundred eighty-four duodenal ulcer patients diagnosed by endoscopy in Singapore and Sydney were studied. The ulcer was situated on the anterior wall of the bulb in 49% and the posterior wall of the bulb in 23%. The distribution was not influenced by sex, age, or the center of diagnosis. Those situated posteriorly in the bulb were more likely to present with hemorrhage than those situated elsewhere.

Sensitivity, specificity and predictive values of the secretin infusion test in the diagnosis of gastrinoma

From 1974 to 1981, 55 patients, 18 with Zollinger-Ellison syndrome (ZES) histologically confirmed and 37 patients with duodenal ulcer (DU) without pylorostenosis were followed for a minimal period of 5 years. The diagnostic values of a) basal acid output (BAO mEq/h); b) 60 min acid output after secretin infusion, 3 CU-GIH/kg, (MAO-SE mEq/h); c) basal serum gastrin (BSG pg/ml: mean of 4 gastrin determinations) and d) serum gastrin after secretin (SG-SE pg/ml: mean of 4 gastrin determinations during secretin infusion) were calculated. Cut off point values of 100 p. 100 specificity (i. e. no DU patient reached these values) with a positive predictive value of 100 p. 100 (i. e. probability for gastrinoma when this cut off point was attained) were BAO greater than 26 mEq/h, MAO-SE greater than 18 mEq/h, BSG greater than 221 pg/ml, SG-SE greater than 186 pg/ml. The sensitivities of these parameters (i. e. percent of ZES which reached the given cut off point) were respectively (p. 100): 39, 78, 72 and 94. Ranking these parameters according to their own discriminative value expressed by R2 (square correlation coefficient) gave SG-SE, R2 = 0.559; BSG, R2 = 0.508; MAO-SE, R2 = 0.456; BAO, R2 = 0.414. The most discriminative association of 2 variables was SG-SE and MAO-SE (R2 = 0.650). Association of SG-SE, MAO-SE and BAO or BSG (or BAO and BSG) did not increase significantly the discrimination between ZES and DU (R2 = 0.672).

Nd:YAG laser in treatment of seriously ill patients with gastrointestinal bleeding

Nd:YAG (neodymium:yttrium aluminum garnet) laser coagulation was used to treat 30 seriously ill patients with massive or prolonged gastrointestinal bleeding. An average of 7.5 units of blood was given prior to Nd:YAG laser treatment. Twenty patients showed no evidence of continued or recurrent bleeding after laser therapy, four patients rebled after 48 hours, three patients rebled within 48 hours, one patient continued to bleed despite the laser treatment but died of an unrelated cause, one patient required immediate surgery because of inability to control bleeding, and one patient died several hours after control of the bleeding. Although six patients died within 10 weeks, no patient exsanguinated. Nd:YAG laser treatment is a useful modality for controlling severe gastrointestinal bleeding in the seriously ill patient.

Endoscopic detection of peptic ulcer disease in cystic fibrosis

Abdominal pain is common among cystic fibrosis (CF) patients and may be caused by a variety of conditions. Although peptic ulcer disease (PUD) has not been emphasized as a common cause of abdominal symptoms in CF, the risk for the development of PUD may be increased because of abnormal physiology. Contrast radiography appears to be an especially inaccurate method to document PUD in CF because the duodenal mucosa typically appears nodular and distorted with poor definition of the mucosal folds. These findings may obscure or mimic PUD. The first endoscopic diagnosis of PUD is reported in a CF patient. Based on this case and a review of the literature, endoscopy is the procedure of choice for evaluation of a CF patient who is suspected of having PUD.

The endoscopic diagnosis of duodenal ulcer disease. A randomized clinical trial of bias and of interobserver variation

In a randomized design we examined whether endoscopists are biased by knowledge of the radiologic diagnosis of duodenal ulcer and deformity of the duodenal bulb when recording the corresponding endoscopic diagnoses. A total of 156 patients had a barium meal and were subsequently randomized into 2 groups. In 74 of the cases the 2 endoscopists knew the result of the X-ray examination when doing the endoscopy; in 82 of the cases they did not. One endoscopist was significantly biased by his knowledge of the radiologic diagnosis of deformity of the duodenal bulb. Neither of the endoscopists was biased by his knowledge of the radiologic diagnosis of duodenal ulcer. In addition, the interobserver variation between the two endoscopists with regard to the endoscopic diagnoses of duodenal ulcer, deformity of the duodenal bulb, and duodenitis was examined. The interobserver variation was expressed by the overall agreement and by the kappa statistics, which adjusts the overall agreement for expected chance agreement. For duodenal ulcer, deformity of the duodenal bulb, and duodenitis, the overall agreements and kappa values were 0.91, 0.78, and 0.75, and 0.54, 0.42, and 0.33, respectively.

[Seasonal incidence of duodenal ulcer--a myth?]

A retrospective study was performed on 1091 acute duodenal ulcers found by endoscopy from 1973-1983. The chi 2-test verified statistically a maximum of ulcers in autumn. The vectorial analysis by means of the Rayleigh-Test showed a maximum of observed ulcers in November for all of the patients as well as for subjects with a duodenal ulcer seen only once, or with one relapse found endoscopically. Patients with three or more successive duodenal ulcers showed an individual pattern with or without seasonal periodicity. In chronic duodenal ulcer disease the individual long-time follow-up might be useful in prophylactic anti-ulcer therapy.

Upper gastrointestinal endoscopy in normal asymptomatic volunteers

In a prospective study, 355 healthy, asymptomatic, male volunteers, 18 to 45 years of age, were screened by esophagogastroduodenoscopy before admission to clinical trials. One hundred thirty-four volunteers (38%) showed abnormal endoscopic findings. Some volunteers had more than one site of involvement or more than one grade of lesion in each anatomic location. In 49 (14%) of these subjects the esophagus was a site of involvement, while in 86 (24%) the stomach was involved, and in 71 (20%) the duodenum was involved. The point prevalences in these asymptomatic subjects were 8.5% for erosive esophagitis, 12% for erosive gastritis, 10% for erosive duodenitis, 2% for gastric ulcer, and 2% for duodenal ulcer.