New horizons in the pharmacologic management of peptic ulceration

Transendoscopic electrocautery-induced gastric ulcers as a model for gastric healing studies in ponies

The ponies were apparently healthy and 6-20 months of age. In Study 1, gastric lesions were created by transendoscopic electrocautery in the non-glandular gastric mucosa, adjacent to the margo plicatus in 9 ponies which were then treated with water, 12 mg cimetidine HCl/kg bwt or 18 mg cimetidine HCl/kg bwt per os every 12 h for 35 days. In Study 2, gastric lesions were similarly induced in 9 ponies in the non-glandular mucosa and also in the glandular mucosa just below the non-glandular lesion on the greater curvature of the stomach. The ponies were treated with water, 8 mg cimetidine/kg bwt or 16 mg cimetidine/kg bwt per os every 8 h for 21 days. In both studies gastric lesion healing was monitored twice weekly by video gastroscopy. There was no apparent difference in healing times between the water and cimetidine treatment groups in either study. These results indicate that uniform gastric ulcers can be created by transendoscopic electrocautery in the non-glandular mucosa of ponies and that these ulcers heal at a predictable rate which should be useful in studying compounds that might accelerate healing of gastric mucosal lesions. However, cimetidine was not effective in accelerating the rate of healing under the conditions of this study.

Effect of a Histamine H2Type Receptor Antagonist (WY 45, 727) on the Healing of Gastric Ulcers in Ponies

Using video gastroscopy, the efficacy of a Histamine-H2 type receptor antagonist (WY 45, 727) was investigated in young ponies with spontaneous and experimentally induced gastric ulcers. Oral administration of WY 45, 727 at 2 mg/kg and 10 mg/kg of body weight every 12 hours for 14 days resulted in complete healing of spontaneous gastric ulcers in the non-glandular portion of the stomach in 2/5 (40%) and 3/4 (75%) of the ponies, respectively, compared (P < 0.05) to 0/5 (0%) placebo-treated ponies. After intramuscular administration of flunixin meglumine at 1.5 mg/kg body weight every 8 hours for 6 days, 9/18 ponies had ulcers in the non-glandular portion of the stomach. Oral administration of WY 45, 727 at 10 mg/kg body weight every 12 hours for 14 days resulted in complete healing of the non-glandular gastric ulcers in 3/4 (75%) compared with (P < 0.05) 1/5 (20%) placebo-treated ponies. This study indicates that 1) the occurrence of subclinical ulcers may be common in young ponies; 2) flunixin meglumine at 1.5 mg/kg intramuscularly every 8 hours for 6 days may result in ulcers of the non-glandular stomach in ponies; and 3) WY 45, 727, a histaminergic H2 type receptor antagonist could be of value in the therapeutic management of ulcers in the non-glandular stomach of foals and adult horses.

Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic duodenal and gastric ulcer

During the past two decades, major advances have been made in our understanding of basic gastric physiology. Appreciation of cellular biology has contributed to rapid progress in gastric pharmacology. Clinicians may choose from a large and rapidly growing list of antiulcer drugs. The proper choice of medical or surgical therapy depends on knowledge of the pathophysiology of peptic ulceration and of the inherent limitations of each approach. Selective drug use, tailoring of medical regimens to individual clinical situations, and the combination of medical and surgical treatments will play prominent roles in the future management of peptic ulceration.