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Iijima K, Kanno T, Koike T, Shimosegawa T. Helicobacter pylori-negative, non-steroidal anti-inflammatory drug: Negative idiopathic ulcers in Asia. World J Gastroenterol 2014; 20:706-713. [PMID: 24574744 PMCID: PMC3921480 DOI: 10.3748/wjg.v20.i3.706] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/07/2013] [Accepted: 12/04/2013] [Indexed: 02/06/2023] Open
Abstract
Since the discovery of Helicobacter pylori (H. pylori) infection in the stomach, the bacteria infection and non-steroidal anti-inflammatory drugs (NSAIDs) use had been considered to be the 2 main causes of peptic ulcers. However, there have been recent reports of an increase in the proportion of peptic ulcers without these known risk factors; these are termed idiopathic peptic ulcers. Such trend was firstly indicated in 1990s from some reports in North America. In Asia, numerous studies reported that idiopathic ulcers accounted for a small percentage of all ulcers in the 1990s, but in the 2000s, multiple studies reported that the proportion of idiopathic ulcers had reached 10%-30%, indicating that the incidence of idiopathic ulcers in Asia has also been rising in recent years. While a decline in H. pylori infection rates of general population in Asia is seen as the main reason for the increased incidence of idiopathic ulcers, it is also possible that the absolute number of idiopathic ulcer cases has increased. Advanced age, serious systemic complication, and psychological stress are considered to be the potential risk factors for idiopathic ulcers. Management of idiopathic ulcers is challenging, at present, because there is no effective preventative measure against recurrence in contrast with cases of H. pylori-positive ulcers and NSAIDs-induced ulcers. As it is expected that H. pylori infection rates in Asia will decline further in the future, measures to treat idiopathic ulcers will also likely become more important.
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Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans. J Gastroenterol 2013; 48:483-90. [PMID: 23053423 DOI: 10.1007/s00535-012-0681-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 09/03/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Societal stress derived from an event that affects the whole society, e. g., a natural disaster, provides a unique, indirect way of determining the relationship between psychological stress and peptic ulcer disease in humans. In this study, we investigated the changing patterns of the incidence of peptic ulcers before and after the Great East Japan earthquake, which occurred on 11 March, 2011. METHODS Clinical data of patients with peptic ulcers were retrospectively collected during the 3 months after the earthquake (2011) from 7 major hospitals in the middle of the stricken area, and were compared with the data for the same period of the previous year (2010). The eligible subjects were classified into four groups according to Helicobacter pylori infection status and intake of nonsteroidal anti-inflammatory drugs (NSAIDs). RESULTS The incidence of all types of peptic ulcers was 1.5-fold increased after the earthquake, and in particular, the incidence of hemorrhagic ulcers was 2.2-fold increased; the gastric ulcer/duodenal ulcer ratio in hemorrhagic ulcers was also significantly increased (p < 0.05). Regarding the etiology of the peptic ulcers, the proportion of non-H. pylori and non-NSAID ulcers was significantly increased, from 13 % in 2010 to 24 % in 2011 after the earthquake (p < 0.05). CONCLUSION In addition to the increased incidence of peptic ulcers, compositional changes in the disease were observed after the Great East Japan earthquake. The significant increase in the proportion of non-H. pylori and non-NSAID ulcers after the earthquake indicated that psychological stress alone induced peptic ulcers in humans independently of H. pylori infection and NSAID intake.
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Osman D, Djibré M, Da Silva D, Goulenok C. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care 2012; 2:46. [PMID: 23140348 PMCID: PMC3526517 DOI: 10.1186/2110-5820-2-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 10/05/2012] [Indexed: 12/12/2022] Open
Abstract
Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.
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Affiliation(s)
- David Osman
- AP-HP, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service de réanimation médicale, Le Kremlin-Bicêtre, F-94270, France.
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Prise en charge par le réanimateur des hémorragies digestives de l’adulte et de l’enfant. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0489-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Moriya M, Uehara A, Okumura T, Miyamoto M, Kohgo Y. Stress-induced hemorrhagic gastric ulcer after successful Helicobacter pylori eradication: two case reports. J Med Case Rep 2011; 5:252. [PMID: 21714884 PMCID: PMC3141705 DOI: 10.1186/1752-1947-5-252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 06/29/2011] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Helicobacter pylori infection is a major cause of gastric ulcers, and Helicobacter pylori eradication drastically reduces ulcer recurrence. It has been reported, however, that severe physical stress is closely associated with gastric ulceration even in Helicobacter pylori -negative patients. CASE PRESENTATION We report the cases of a 47-year-old Japanese man and a 69-year-old Japanese man who developed psychological stress-induced hemorrhagic gastric ulcers, in both of whom Helicobacter pylori had been successfully eradicated. CONCLUSION Our cases strongly suggest that not only physical but also psychological stress is still an important pathogenic factor for peptic ulceration and accordingly that physicians should pay attention to the possible presence of psychological stress in the management of patients with peptic ulcers.
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Affiliation(s)
- Mitsuru Moriya
- Department of Psychosomatic Internal Medicine, Health Sciences University of Hokkaido, Japan
| | | | - Toshikatsu Okumura
- Department of General Medicine, Asahikawa Medical College, Asahikawa, Japan
| | - Mitsuaki Miyamoto
- Department of Psychosomatic Internal Medicine, Health Sciences University of Hokkaido, Japan
| | - Yutaka Kohgo
- Department of Internal Medicine, Asahikawa Medical College, Asahikawa, Japan
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Andersson E, Ansari D, Andersson R. Major haemorrhagic complications of acute pancreatitis. Br J Surg 2010; 97:1379-84. [PMID: 20564308 DOI: 10.1002/bjs.7113] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Haemorrhage is a rare, potentially fatal complication in acute pancreatitis (AP). The aim was to investigate the incidence, management and outcome related to this complication.
Methods
The medical records of all patients with AP who presented to a single hospital between January 1994 and July 2009 were reviewed retrospectively. Patients who developed at least one in-hospital episode of major haemorrhage were selected. The aetiology, patient characteristics, occurrence of sentinel bleeding, clinical management and outcome were recorded.
Results
Fourteen (1·0 per cent) of 1356 patients diagnosed with AP developed major haemorrhage. Angiography established the diagnosis in four of six patients. Embolization was successful in one patient. Surgery was performed in two patients. Sentinel bleeding occurred in three of four patients with major postoperative bleeding. The overall mortality rate was 36 per cent (5 of 14 patients). Haemorrhage presenting after more than 7 days was associated with a higher mortality rate of 80 per cent (4 of 5 patients). A fatal outcome was at least three times more likely in patients with severe AP and haemorrhagic complications than in those with severe AP but no bleeding.
Conclusion
Major haemorrhagic complications of AP are rare, but clinically important. Major postoperative bleeding is often preceded by sentinel bleeding. Intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication.
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Affiliation(s)
- E Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
| | - D Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
| | - R Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
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Abstract
Increased knowledge of risk factors and improved ICU care has decreased the incidence of stress-related bleeding. Not all critically ill patients need prophylaxis for SRMD and withholding such prophylaxis in suitable low-risk candidates is a reasonable and cost-effective approach. Mechanical ventilation for more than 48 hours and coagulopathy are the main risk factors for stress-induced upper GI bleeding. Although intravenous H2RAs can prevent clinically important bleeding, their benefits seem to be limited by the rapid development of tolerance. The availability of intravenous formulations of PPIs makes it possible to critically compare their prophylactic efficacy and safety to different classes of acid-suppressive agents, such as H2RAs, in critically ill patients. The appropriate dose of PPI and the role of newer PPI formulations need to be further defined along with proposed guidelines for the use of intravenous and oral/enteral formulations of PPIs in patients at risk for stress-related mucosal damage.
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Affiliation(s)
- Tauseef Ali
- Section of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Oklahoma Health Sciences Center, 1360 WP, 920 SL Young Boulevard, Oklahoma City, OK 73104, USA
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Lansdale N, Hill R, Hancock SW, Thomson M, Marven S. Stress-related mucosal disease in childhood appendicitis. Pediatr Surg Int 2008; 24:1219-22. [PMID: 18437395 DOI: 10.1007/s00383-008-2166-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2008] [Indexed: 11/30/2022]
Abstract
Stress-related mucosal disease (SRMD) is known to occur in critically ill patients both in the adult and paediatric population. Acute appendicitis is the most common surgical emergency in childhood and can precipitate SRMD. This possibility should be kept in mind, particularly in prolonged, complicated episodes. Although clinical complications of SRMD are rare, they may be highly significant in terms of haemorrhage or perforation and result in considerable morbidity or mortality. We provide a thorough review of the incidence, aetiology, role of Helicobacter pylori, risk factors, prophylaxis and management of this condition and describe a series of three cases of ulcerative SRMD in children with complicated appendicitis.
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Affiliation(s)
- Nick Lansdale
- Paediatric Surgical Unit, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.
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Abstract
Hemorrhage from stress ulceration in acutely ill children is seen in association with acute respiratory failure, coagulopathy and Pediatric Risk of Mortality Score of 10 or higher. We report an unusual association of clinically significant hemorrhagic stress ulcer with appendicitis in a pediatric patient.
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Affiliation(s)
- Hemant Shyam Agarwal
- Department of Pediatrics, Division of Pediatric Critical Care, Vanderbilt University School of Medicine, Nashville, TN 37232-9075, USA.
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Robert R, Gissot V, Pierrot M, Laksiri L, Mercier E, Prat G, Villers D, Vincent JF, Hira M, Vignon P, Charlot P, Burucoa C. Helicobacter pylori infection is not associated with an increased hemorrhagic risk in patients in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R77. [PMID: 16704741 PMCID: PMC1550927 DOI: 10.1186/cc4920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Revised: 04/11/2006] [Accepted: 04/18/2006] [Indexed: 02/08/2023]
Abstract
Introduction The potential role of Helicobacter pylori in acute stress ulcer in patients in an intensive care unit (ICU) is controversial. The aim of this study was to determine the frequency of H. pylori infection in ICU patients by antigen detection on rectal swabs, and to analyze the potential relationship between the presence of H. pylori and the risk of digestive gastrointestinal bleeding. Methods In this prospective, multicenter, epidemiological study, the inclusion criteria were as follows: patients admitted to the 12 participating ICU for at least two days, who were free of hemorrhagic shock and did not receive more than four units of red blood cells during the day before or the first 48 hours after admission to the ICU. Rectal swabs were obtained within the first 24 hours of admission to the ICU and were tested for H. pylori antigens with the ImmunoCard STAT! HpSA kit. The following events were analyzed according to H. pylori status: gastrointestinal bleeding, unexplained decline in hematocrit, and the number of red cell transfusions. Results The study involved 1,776 patients. Forty-nine patients (2.8%) had clinical evidence of upper digestive bleeding. Esophagogastroduodenoscopy was performed in 7.6% of patients. Five hundred patients (28.2%) required blood transfusion. H. pylori antigen was detected in 6.3% of patients (95% confidence interval 5.2 to 7.5). H. pylori antigen positivity was associated with female sex (p < 0.05) and with a higher Simplified Acute Physiology Score II (SAPS II; p < 0.05). H. pylori antigen status was not associated with the use of fiber-optic gastroscopy, the need for red cell transfusions, or the number of red cell units infused. Conclusion This large study reported a small percentage of H. pylori infection detected with rectal swab sampling in ICU patients and showed that the patients infected with H. pylori had no additional risk of gastrointestinal bleeding. Thus H. pylori does not seem to have a major role in the pathogenesis of acute stress ulcer in ICU patients.
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Affiliation(s)
- René Robert
- Réanimation Médicale, CHU Poitiers, 2 rue de la milèterie, BP 577 86021 Poitiers cedex France
| | - Valérie Gissot
- Réanimation Polyvalente, Hopital Girac 16140 Saint Michel France
| | - Marc Pierrot
- Réanimation Médicale, CHU Angers 4 rue Larrey 49100 Angers France
| | - Leila Laksiri
- Réanimation Chirurgicale, CHU Poitiers, 2 rue de la milèterie, BP 577, 86021 Poitiers cedex France
| | - Emmanuelle Mercier
- Réanimation Médicale, CHU Bretonneau, 2 Boulevard Tonnelé 37044 Tours, France
| | - Gwenael Prat
- Réanimation Médicale, CHU de la Cavale Blanche rue Tanguy Pringent 29200 Brest, France
| | - Daniel Villers
- Réanimation Médicale, CHU Nantes, 1 place Alexis Ricordeau 44093 Nantes cedex, France
| | - Jean-François Vincent
- Réanimation Polyvalente, Centre hospitalier de Saintes, 9 place du 11 novembre BP 326, 17108 Saintes cedex, France
| | - Michel Hira
- Réanimation Polyvalente Chateauroux, Centre hospitalier de Chateauroux 216 avenue de verdun 36000 Chateauroux, France
| | - Philippe Vignon
- Réanimation Polyvalente Limoges, CHU Dupuytren 2 avenue Martin Luther King 87042 Limoges cedex, France
| | - Patrick Charlot
- Réanimation Polyvalente Niort, 40 avenue du général de Gaulle 79000 Niort, France
| | - Christophe Burucoa
- Laboratoire de Microbiologie A EA 3807, CHU Poitiers, 2 rue de la milèterie, BP 577, 86021 Poitiers cedex France
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Maury E, Tankovic J, Ebel A, Offenstadt G. An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med 2005; 33:1513-8. [PMID: 16003056 DOI: 10.1097/01.ccm.0000168043.60624.3e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection. DESIGN A prospective observational study followed by a case-control study. SETTING Seven ICUs in the Paris area, five of them located in teaching hospitals. PATIENTS All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04). CONCLUSIONS Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.
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Affiliation(s)
- Eric Maury
- Service de Réanimation Médicale, Unité Inserm U444, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
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Robertson MS, Clancy RL, Cade JF. Helicobacter pylori in intensive care: why we should be interested. Intensive Care Med 2003; 29:1881-8. [PMID: 14608460 DOI: 10.1007/s00134-003-1838-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2002] [Accepted: 05/05/2003] [Indexed: 12/20/2022]
Abstract
Helicobacter pylori is estimated to infect over 50% of the world's population, the majority of whom are asymptomatic. Although most research to date has focused on local gastroduodenal disease manifestations, the potential impact of H. pylori infection and the associated chronic active inflammation on systemic disease processes is now being explored. This review addresses three aspects of emerging importance regarding H. pylori in intensive care medicine: acute gastric stress ulceration, nosocomial infection, and the potential modulatory effect on the systemic stress response. The role of H. pylori in acute stress ulceration remains uncertain, but it is unlikely to have the same major aetiological role as in peptic ulcer disease. The pathogenesis of both acute stress ulceration and H. pylori gastritis suggest overlapping mechanisms of gastric mucosal damage and H. pylori may augment stress ulceration incidence and severity. Nosocomial infection of both staff and patients with H. pylori has been suggested by serological studies, and increased H. pylori infection has been reported in intensive care staff. This has significant short- and long-term health implications and also raises questions regarding the efficacy and implementation of routine infection control precautions in intensive care. Finally, H. pylori infection has been linked with the pathogenesis of many extra-intestinal diseases, but the evidence is weak and the relationship between H. pylori and systemic diseases remains controversial. However, the potential for H. pylori to modulate systemic disease processes, particularly the systemic stress response in critical illness, is both theoretically plausible and therapeutically tantalising and requires further investigation.
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Affiliation(s)
- Megan S Robertson
- Intensive Care Unit, The Royal Melbourne Hospital, 3050, Parkville, VIC, Australia.
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Abstract
Stress-related mucosal disease is common in critically ill patients and can result in significant morbidity. The pathophysiology of this condition is multifactorial but mucosal ischaemia and gastric acid have pivotal roles. The major risk factors for developing stress-related mucosal bleeding are prolonged mechanical ventilation and coagulopathy. The mainstay of clinical management is prevention with acid-suppressing medications and cytoprotective agents. This chapter discusses medications used to prevent this condition and suggests an approach for management. Recent developments in gastroenterology include the development and use of proton pump inhibitors and the discovery of the association Helicobacter pylori with gastritis. The role of each of these in stress-related mucosal disease is discussed. Finally, an approach to the bleeding critically ill patient is presented.
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Affiliation(s)
- Donald R Duerksen
- Division of Gastroenterology, Department of Medicine, St Bonfaice Hospital, C5 120 409 Tache Avenue, Winnipeg, Man., Canada R2H 2A6.
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Gabry KE, Chrousos GP, Rice KC, Mostafa RM, Sternberg E, Negrao AB, Webster EL, McCann SM, Gold PW. Marked suppression of gastric ulcerogenesis and intestinal responses to stress by a novel class of drugs. Mol Psychiatry 2002; 7:474-83, 433. [PMID: 12082565 DOI: 10.1038/sj.mp.4001031] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2001] [Revised: 09/24/2001] [Accepted: 10/13/2001] [Indexed: 01/23/2023]
Abstract
When exposed to prolonged stress, rats develop gastric ulceration, enhanced colon motility with depletion of its mucin content and signs of physiological and behavioral arousal. In this model, we tested whether antidepressants (fluoxetine and bupropion), anxiolytics (diazepam and buspirone) or the novel nonpeptide corticotropin-releasing hormone (CRH) type-1 receptor (CRH-R1) antagonist, antalarmin, modify these responses. Fluoxetine, bupropion, diazepam and antalarmin all suppressed stress-induced gastric ulceration in male Sprague-Dawley rats exposed to four hours of plain immobilization. Antalarmin produced the most pronounced anti-ulcer effect and additionally suppressed the stress-induced colonic hypermotility, mucin depletion, autonomic hyperarousal and struggling behavior. Intraperitoneal CRH administration reproduced the intestinal but not the gastric responses to stress while vagotomy antagonized the stress-induced gastric ulceration but not the intestinal responses. We conclude that brain CRH-R1 and vagal pathways are essential for gastric ulceration to occur in response to stress and that peripheral CRH-R1 mediates colonic hypermotility and mucin depletion in this model. Nonpeptide CRH-R1 antagonists may therefore be prophylactic against stress ulcer in the critically ill and therapeutic for other pathogenetically related gastrointestinal disorders such as peptic ulcer disease and irritable bowel syndrome.
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Affiliation(s)
- K E Gabry
- Clinical Neuroendocrinology Branch, National Institute of Mental Health, Intramural Research Program, National Institutes of Health, Bethesda, MD 20892-11284, USA
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Gregor J. Helicobacter pylori suppression: one more reason to consider selective gut decontamination? J Crit Care 2001; 16:188. [PMID: 11815905 DOI: 10.1053/jcrc.2001.31436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J Gregor
- Victoria Campus Site, Department of Medicine, London Health Sciences Centre, South Street Campus, London, Ontario, Canada
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