Nonhealing duodenal ulceration due to candida

History in our lifetime: the changing nature of refractory duodenal ulcer in the era of histamine H2 receptor antagonists

BACKGROUND AND AIM

This prospective cohort observational study, set in a district hospital, presents our experience (1976-1993) of duodenal ulcer refractory to histamine H2 receptor antagonists (defined as not healed after 3 months' treatment) and comments on onset, outcome and spontaneous decline.

METHODS

Patients were treated mainly with cimetidine, the dose being titrated (up to 3.2 g daily) according to response, and followed by serial check endoscopy and clinical assessment.

RESULTS

A total of 782 of the 4032 duodenal ulcer patients seen (19%) were refractory; the incidence declined over time: 1976-1978: 124/379 (33%); 1979-1983: 390/1240 (31%); 1984-1988: 190/1295 (15%); 1989-1993: 78/1118 (7%). A total of 344 were refractory for the first time on their first healing course and 174 on their second. Healing was achieved in two-thirds after a mean of 7 months' treatment with cimetidine 1 g; treatment for 12-18 months with higher doses was needed in the remainder. Relapse occurred in up to three-quarters of patients despite maintenance cimetidine up to 3 g daily. Eventually 47 patients were operated upon but good results (i.e., no ulcer, no symptoms) were achieved in only 11.

CONCLUSION

Refractoriness was common until recently. Its incidence has declined dramatically, the fall preceding the newer more powerful treatment with proton pump inhibitors and with Helicobacter pylori eradication. We suggest this phenomenon is a modern example of a spontaneous change in the natural history of the disease.

A prospective study of fungal infection of gastric ulcers: clinical significance and correlation with medical treatment

A prospective study was performed to evaluate the prevalence of fungal infection in gastric ulceration and its effect on ulcer healing in 178 benign and 97 malignant gastric ulcers. Fungal infection was defined as presence of fungal hyphae or spores in the biopsy forceps specimen. For patients with benign gastric ulcers, sucralfate 1 g q.i.d. was prescribed and a second panendoscopy examination was carried out after 6 weeks to evaluate ulcer healing. Fungal colonization was found in 36 (20.2%) patients with benign gastric ulcers and 26 (26.8%) patients with gastric cancers (p > 0.2). The mean age of patients with benign gastric ulcer with fungal infection (group I) was 64.2 +/- 11.4 years, whereas the mean age of those without fungal infection (group II) was 56.2 +/- 13.1 years (p < 0.01). Follow-up panendoscopy after 6 weeks of sucralfate therapy revealed 6 of 24 patients (25%) in group I and 19 of 81 patients (23%) in group II with unsatisfactory healing (difference not significant). Comparison of confounding factors such as smoking, daily tea or coffee intake, underlying disease, ulcer location, and endoscopic appearance between these two groups revealed no significant differences. In conclusion, the presence of fungus in gastric ulcers is a secondary phenomenon and it does not affect ulcer healing.

Association between gastrointestinal tract carriage of Candida, blood group O, and nonsecretion of blood group antigens in patients with peptic ulcer

Of 112 patients with peptic ulcer disease examined for oral carriage of Candida, 66 (59%) were carriers. Candida carriage was associated with blood group O (P < 0.05) and, independently, with nonsecretion of blood group antigens (P < 0.01). For each subject, the presence or absence of yeasts was found to be a constant characteristic, and only among patients positive for Candida was blood group O or nonsecretion more frequent than expected in the general population. The quantity of yeasts isolated was significantly greater in patients than in normal subjects (P < 0.002), as was the frequency of carriage in the patient population (59% vs 32%). This increase was not associated with treatment with H2-receptor antagonists. The results of paired oral and gastroduodenal aspirate cultures suggested that identifying Candida in the oral cavity was a good indicator of the presence of yeasts elsewhere in the gastrointestinal tract. Mechanisms whereby overgrowth of Candida in the upper gastrointestinal tract might contribute to the inflammatory background of peptic ulcer disease are discussed.

Peptic ulcer disease. How to treat it now

Options for treatment of peptic ulcer disease are becoming more diverse. Most new agents are effective yet offer no real advantage over more traditional therapy. However, omeprazole (Prilosec) may be of benefit owing to its potent inhibition of acid secretion, but it is not yet approved for this purpose. Whether treatment of Helicobacter pylori infection will prove beneficial is not yet known, but the answer should be forthcoming. Finally, as with any disease process, alleviation of risk factors is always important. Appropriate counseling regarding use of nonsteroidal anti-inflammatory drugs and cigarette smoking is a necessity.

A model of sustained gastrointestinal colonization by Candida albicans in healthy adult mice

Three-month-old male Crl:CD1(ICR)BR and C3H/HeJ mice were fed chow containing Candida albicans for 14 days, while similar control mice were fed regular food. Stool cultures were done for all mice before and after administration of the special diet. Stool cultures were repeated 48 h, 1 week, and 1 and 3 months after stopping the diet for Crl:CD1(ICR)BR mice and again 5 months afterward for C3H/HeJ mice. Some animals were sacrificed at the end of the special diet, and cultures and histopathologic examination of various organs were performed. Colonization with C. albicans occurred in the Candida-fed mice, and the fungus was maintained in the gastrointestinal tract at a concentration of 10(3) to 10(4) CFU/g of stool for up to 5 months. There was no histologic evidence of organ infection with Candida spp. The fungus was not found in stool cultures or organs of mice in the control group. The results suggest that persistent gastrointestinal colonization of adult mice by C. albicans can be achieved without immunosuppression. Thus, with additional manipulations, this model could be useful for studying the role of gastrointestinal colonization by C. albicans in the development of systemic infection.

Invasive candidiasis does not complicate short-term cimetidine treatment of duodenal ulcer

The purpose of this study was to record the frequency of invasive candidiasis of duodenal ulcer and to determine whether or not it is enhanced by cimetidine treatment. Our multicenter prospective trial involved 99 patients with endoscopically proven duodenal ulcer who were undergoing a 4- or 8-week cimetidine (800 mg/day) treatment program. At the endoscopic examination, performed before and after the 4- or 8-week treatment, three biopsy samples were taken from the ulcer edge or from the healed tissue. Ulcer infiltration by Candida was presumed by the presence of mycetes in stained tissue samples. Healing rate was 76% at 4 weeks and 89.9% at 8 weeks. Candida infiltration was not seen in any biopsy specimen. Short-term treatment with cimetidine does not promote invasion of mycetes into the duodenal ulcer lesion.