Relationship of postprandial serum gastrin response to sex, body weight, blood group status, familial dyspepsia, duration, and age of onset of ulcer symptoms in duodenal ulcer

Helicobacter pylori eradication for peptic ulceration: an observational study in a Scottish primary care setting

Despite being established for the treatment of peptic ulcer (PU) disease, few studies have assessed the long-term effectiveness and economic benefits of Helicobacter pylori (Hp) eradication in primary care. Our aim was to investigate the effect of community based Hp eradication for patients with chronic peptic ulcer disease requiring maintenance acid suppression. The endpoints used were the patients dyspeptic symptoms and the requirement for the prescription of maintenance acid suppression therapy. The study area covered seven general practices in the Glasgow area. Patients with previously diagnosed peptic ulcer disease receiving prescribed acid suppression therapy were invited to a dyspepsia clinic. Hp status was assessed by Helisal rapid blood test (HRBT). Positive patients received Hp eradication therapy and were reviewed six weeks later. At six months a review of practice records was carried out, and two years after eradication a postal questionnaire was sent to participating patients. A total of 243 patients attended the initial clinic of which 81.9% were HRBT positive. 156 of 196 patients offered Hp eradication re-attended at six weeks. The per protocol eradication rate was 91.7%. After six months patients who had received eradication therapy were less likely to require maintenance acid suppression therapy compared with those to whom eradication was not given. Two years after treatment 76.5% of patients felt their symptoms were improved, but 42.2% were still receiving maintenance therapy. The estimated cost of treatment per month per patient had fallen from 20.23 Pounds to 9.39 Pounds after eradication. In conclusion we felt that community based Hp eradication for patients with chronic PU disease is effective, however it does not completely alleviate dyspepsia. Predictors of symptomatic response or of no longer requiring acid suppression therapy after two years were younger age of onset of PU disease and absence of pre-documented gastro-oesophageal reflux disease or hiatus hernia. Hp eradication improves patients symptoms, reduces the requirement for maintenance acid suppression and is cost-effective after two years follow-up in this targeted group.

Epidemiology and genetics of peptic ulcer

At the turn of the century, duodenal ulcer rose from rarity to affect 10% of males in their life time, subsequently declining in some countries such as UK, levelling off in others such as Germany, and continuing to increase in still others such as Hong Kong. The annual incidence per 1000 population varies from about 1 in Japan to 1.5 in Norway, 1.8 in USA and 2.7 in Scotland, and the frequency also varies within many individual countries, such as Australia, China and India, and among races such as a higher prevalence among whites than blacks in USA and among Chinese than Javanese in Indonesia. Ulcer frequency is higher in winter months, and this appears universal, being true in cold as well as in warm countries. Most places report a rise of ulcer rates among the elderly in recent decades. The male to female ratio also varies geographically, for example from 1:1 in USA to 18:1 in India, and with time such as moving from 2:1 to 1:1 in the last two decades in USA, and the duodenal ulcer to gastric ulcer ratio varies widely from place to place, for example from 0.8 in Japan to 19:1 in Africa and 32:1 in India. Placebo healing rates also differ geographically, ranging from 5% in Philippines to 78% in Mexico. These epidemiological data can only be explained by the presence of multiple aetiological factors, including analgesics, society stress, cigarette smoking, Helicobacter pylori, dietary factors, and genetic factors. Three lines of evidence support a genetic role: family studies, twin studies and blood group studies. Family aggregation occurs more commonly in patients with early-onset (< 30 yr) of symptoms. Blood group O prevalence is more associated with late-onset of symptoms. Other genetic markers include nonsecretor status, HLA antigens, phenylthiocarbamide taste sensitivity, and alpha-1-antitrypsin. Genetic syndromes such as MEN I also support a genetic role and give insight into pathogenetic mechanisms. The best physiological marker is still hyperpepsinogenemia I, which is transmitted by autosomal dominance, despite recent report of lower serum pepsinogen 1 after healing of Helicobacter pylori associated gastritis.

Gastric histology and plasma gastrin response to a meal in patients with duodenal ulcer disease after five years treatment with ranitidine

Fifty asymptomatic patients with duodenal ulcer disease, aged 31-82 years, who had received ranitidine maintenance therapy continuously for five or more years without a symptomatic recurrence, were studied. Fasting plasma gastrin concentrations were normal (mean 24 pmol/L, S.D. +/- 22) while the post-prandial gastrin response was variable with maximum plasma concentrations ranging from 16 to 309 pmol/L. Endoscopy revealed six asymptomatic peptic ulcers. Histological examination of gastric biopsies showed mild, superficial inflammatory cell infiltration of the fundic mucosa, but more extensive inflammatory cell infiltration with some atrophy of the mucosal glands in the antral mucosa. Patchy intestinal metaplasia was evident in the antral mucosa of 18 patients. No fundic ECL cell hyperplasia was seen. Helicobacter pylori were detected in the corpus and antrum of most patients. These results suggest that maintenance treatment with ranitidine for 5 years is not associated with either significant hypergastrinaemia or with changes in the fundic mucosa which could be interpreted as pre-malignant.

The fasting and food-stimulated serum gastrin concentration in 151 duodenal ulcer patients compared to 41 healthy subjects

The basal and postprandial serum gastrin concentrations (SGC) were compared between 151 duodenal ulcer (DU) patients and 41 non-dyspeptic volunteers. All DU patients had an eventful history and were submitted to us for surgery. The basal SGC was significantly higher in DU patients (40 +/- 30 vs 17 +/- 8 pg/ml). The peak post-prandial SGC was also significantly higher (123 +/- 83 vs 52 +/- 28 pg/ml) and the integrated gastrin output twice as high as in healthy subjects (5311 +/- 3879 vs 2554 +/- 1995 pg/ml x min; P less than 0.01). A statistically significant linear correlation for fasting and maximal postprandial SGC was found. No statistically significant interrelation between gastrin and acid parameters existed. In the DU patients no differences in SGC were found according to age. Fifteen patients complained of nonalimentary vomiting as part of their ulcer symptoms. They had significantly higher SGC although no differences in acid secretion were found. No significant differences in gastrin or acids were related to ulcer complications.

Multiple duodenal ulcer: natural history and pathophysiology

It has not been established whether multiple duodenal ulcer is associated with a different natural history, pathophysiology, and therapeutic response than a single duodenal ulcer. A consecutive series of 96 patients with two or more duodenal ulcers at endoscopy, representing 9.6% of the total number of new patients with duodenal ulcer seen during the period 1980-1985, were compared with a random series of 200 patients with single duodenal ulcer seen in the middle years of this period. Multiple duodenal ulcer was associated with higher (p less than 0.02) male to female ratio, more (p less than 0.05) late onset patients (those with ulcer symptoms starting after age 30 years, more (p less than 0.05) chronic cigarette smokers, and more frequent (p less than 0.05) moderate to severe deformity of the duodenal bulb. More (p less than 0.05) patients with multiple duodenal ulcer had abnormally low D50 derived from pentagastrin dose response tests, indicating that they were more sensitive to gastrin stimulation. Furthermore, their mean fasting and meal stimulated serum gastrin concentrations were significantly higher than those of patients with single ulcer (p less than 0.005), or of controls (p less than 0.05). Compared with single duodenal ulcer, multiple ulcer had significantly lower placebo healing rate, and required a higher dose of misoprostol (1200 v 800 micrograms/day) to achieve a similar healing efficacy at four weeks. We conclude that multiple duodenal ulcer is associated with different clinical features, pathophysiology, and possibly therapeutic response from single duodenal ulcer, and appears to represent the more aggressive side of the ulcer spectrum.

Fasting and food-stimulated serum gastrin concentration in 151 duodenal ulcer patients and 41 non-dyspeptic volunteers. Significant sex differences

In 41 non-dyspeptic volunteers (18 females and 23 males) the fasting and food-stimulated serum gastrin concentration was investigated. No significant sex differences were found in the basal serum gastrin concentration. The integrated postprandial gastrin output, however, was significantly higher in females than in males. In 151 duodenal ulcer patients (31 women and 120 men) significant sex differences were found in both the fasting and the food-stimulated serum gastrin concentration. Women had values approximately 60% higher than men. In 116 of the patients (27 women and 89 men) the basal and pentagastrin-stimulated gastric acid concentrations were investigated. In the basal state no significant sex differences in acid output were found. After stimulation women had significantly lower gastric acidity and gastric acid output than men.

Efficacy of sucralfate in corpus, prepyloric, and duodenal ulcer-associated gastric ulcers. A double-blind, placebo-controlled study

A 12-week study with two weekly endoscopic assessments was performed in 138 patients to compare the efficacy of sucralfate fine granules (900 mg one-half hour before breakfast, lunch, and dinner, and at bedtime) versus placebo in the healing of gastric ulcers prestratified into corpus, prepyloric, and duodenal ulcer-associated. For corpus and prepyloric ulcers, the respective healing rates achieved by sucralfate at six weeks (69 and 80 percent) and at eight weeks (80 and 93 percent) were significantly (p less than 0.005) better than those obtained with placebo (33 and 25 percent at six weeks, and 41 and 33 percent at eight weeks). The design of the study permitted life-table analysis that further demonstrated the efficacy of sucralfate in these two ulcer types (p less than 0.0001). Symptomatic response was likewise significantly better with sucralfate than with placebo. Similar healing rates and symptomatic responses were observed for patients with duodenal ulcer-associated gastric ulcer but were not significantly better with sucralfate than with placebo. From 38 prospectively obtained clinical, personal, physiologic, and endoscopic characteristics, it was found that ulcer size and a history of pain had significant influence on healing with sucralfate. It is concluded that sucralfate is safe and effective for the treatment of corpus and prepyloric ulcers.

Acid and gastrin responses during intragastric titration in normal subjects and duodenal ulcer patients with G-cell hyperfunction

Amino acid induced acid and gastrin responses during intragastric titration at pH 2.5 and 5.5 were compared in normal subjects and duodenal ulcer patients with G-cell hyperfunction. The latter were identified on the basis of raised basal or maximal acid outputs and increased gastrin responses to feeding. In normal subjects the mixed amino acid meal stimulated only modest increases in serum gastrin, and the highest observed increase was about 30% that after a standard meal. In contrast, in the G-cell hyperfunction group the highest gastrin concentrations were similar to those after a standard meal. In the G-cell hyperfunction group the increment in serum gastrin at pH 2.5 expressed as a proportion of that at pH 5.5 was 0.29 indicating that the capacity of acid to inhibit gastrin release was well established in these patients. Acid secretory rates were close to maximal at both pH 2.5 and 5.5 during intragastric titration in the ulcer patients, but in normal subjects acid output was about 50% maximal at 2.5 and close to maximal at 5.5. The results suggest that the enhanced gastrin response to feeding in G-cell hyperfunction patients is because of increased sensitivity to amino acid stimulation rather than to diminished acid-inhibitory mechanisms.

Factors influencing healing of duodenal ulcer. Control of nocturnal secretion by H2 blockade and characteristics of patients who failed to heal

To study the efficacy of a single bedtime dose of H2-receptor antagonist in the healing of duodenal ulcer, a 12-week randomized double-blind controlled trial of oxmetidine, which is equipotent to cimetidine and has a similar duration of action, was performed in 80 patients. Oxmetidine, 600 mg bedtime, resulted in significantly more complete healing than placebo at weeks 2, 4, 6, 8, 10, and 12 as assessed endoscopically. At weeks 4 and 6, 72.5% and 85%, respectively, of ulcers were completely healed by oxmetidine, and 36.8% and 41.7%, respectively, by placebo. Of 45 prospectively obtained patient characteristics, high pentagastrin-stimulated maximal acid output and large ulcer diameter significantly affected healing adversely. These results indicate that duodenal ulcer healing may be achieved by reducing the nocturnal acid secretion alone.

Randomised crossover trial of tripotassium dicitrato bismuthate versus high dose cimetidine for duodenal ulcers resistant to standard dose of cimetidine

Of 212 patients with duodenal ulcer treated with four weeks of one gram daily cimetidine, 25 had ulcers which underwent no reduction in size despite treatment. The effects of tripotassium dicitrato bismuthate (TDB) tablet four times a day or cimetidine 1.6 g daily on the healing of these cimetidine resistant ulcers were compared in a randomised crossover trial. Ten of 12 patients on tripotassium dicitrato bismuthate and five of 13 patients on high dose cimetidine had complete healing (p less than 0.02). On crossing over, seven of the eight ulcers not healed by high dose cimetidine completely healed with TDB in another four weeks, and one of the two ulcers not healed by TDB healed with high dose cimetidine. Overall, TDB healed 85% of cimetidine resistant ulcers, whereas high dose cimetidine healed 40% (p less than 0.006). Tripotassium dicitrato bismuthate is recommended for cimetidine resistant duodenal ulcers.

Early- and late-onset duodenal ulcers in Chinese and Scots

Two unselected series of 528 Chinese and 539 Scottish patients with duodenal ulcer were compared. In both races, early-onset patients (symptoms began before age 30 years) in contrast to late-onset patients (symptoms began after age 30 years) constituted significantly more males, more patients with positive familial dyspepsia, more acid hypersecretors, and more gastrointestinal bleeding, but, unlike late-onset patients, there was no significant blood group O predominance, and their females did not have an older onset age than males. Among early-onset patients, Scottish patients developed symptoms at a significantly later age and had significantly more acid hypersecretors than Chinese, whereas among late-onset patients the Scots had significantly more patients with positive familial dyspepsia, in whom the frequency of acid hypersecretion was increased. These findings indicate that (i) early and late-onset duodenal ulcers are distinct subgroups, with many features common to both Chinese and Scots despite different ethnic backgrounds, suggesting the occurrence of similar pathophysiological mechanisms in the two races, (ii) for early-onset disease, these mechanisms appear to operate sooner in the Chinese, (iii) in the Scottish patients, familial late-onset duodenal ulcers with acid hypersecretion form a substantial and distinct subgroup.