Smoking and ulcer perforation

The Prevalence, Etiology and Treatment of Gastroduodenal Ulcers and Perforation: A Systematic Review

(1) Background: Gastroduodenal perforation (GDP) is a life-threatening condition caused by a spontaneous or traumatic event. Treatment should be based on the mechanism of damage, timing, location, extent of the injury, and the patient's clinical condition. We aimed to examine several etiologic factors associated with gastroduodenal perforation and to search for the best method(s) for its prevention and treatment. (2) Methods: We conducted extensive literature reviews by searching numerous studies obtained from PubMed, Science Direct, and Cochrane for the following keywords: gastroduodenal perforation, Helicobacter pylori, NSAIDs' use, side effects of GDP, laparoscopy, and surgery. The primary outcome was the reported occurrence of GDP. (3) Results: Using keywords, 883 articles were identified. After applying the inclusion and exclusion criteria, 53 studies were eligible for the current analyses, with a total number of 34,692 gastroduodenal perforation cases. Even though the risk factors of gastroduodenal perforation are various, the prevalence of H. pylori among patients with perforation is considerably high. As technology develops, the treatment for gastric perforation will also improve, with laparoscopic surgery having a lower mortality and complication rate compared to open surgery for GDP treatment. (4) Conclusions: H. pylori infection plays the most significant role in GDP, more than NSAIDs, surgery, chemotherapy, or transplantation. Treatment of H. pylori infection is essential to decrease the prevalence of GDP and speed up its recovery. However, urgent cases require immediate intervention, such as laparoscopic or open surgery.

Emergency Laparoscopic Management of Perforative Peritonitis: A Retrospective Study

Background

Peritonitis was previously considered a contraindication for minimally invasive surgery due to the risk of malignant hypercapnia partial pressure of carbon-dioxide (PCO2) and toxic shock syndrome. The objective of this retrospective study was to evaluate the role of laparoscopic surgery (LS) in selected patients with perforative peritonitis and to study its feasibility, safety, and outcomes.

Patients and methods

This was a retrospective study of 25 patients spanning over five years from 2015 to 2020. This study comprised all patients who were diagnosed with perforative peritonitis on preoperative physical/clinical examination, radiological evaluations, and who were stable enough to withstand pneumoperitoneum. Patients were evaluated for causes, operative time, duration of hospital stay, intra-, and postoperative complications, time taken to resume normal activity, and conversion to open surgery. Data was extracted from the hospital electronic medical records, for the above-mentioned parameters.

Results

Twenty-five patients with perforative peritonitis underwent diagnostic and therapeutic LS in our institute. The mean age was 46 years (35-79 years). Ten patients (40%) were diagnosed with gastro-duodenal perforation. Out of these ten patients, ninepatients (90%) were managed totally laparoscopically, while one patient (10%) required conversion to open surgery. There were 15 patients (60%) with small bowel perforation. Thirteen of the 15 patients were managed laparoscopically, with the remaining two requiring conversion to open surgery. The average time taken for the procedure was 90 minutes. The mean time to initiate the postoperative peroral liquid diet was 3.4 days. The mean postoperative stay was 6.9 days. The time taken to resume normal activity was 10-12 days.

Conclusions

Laparoscopic management is feasible and safe for patients with perforative peritonitis. Careful patient selection and the surgeon’s experience with the procedure are critical determinants of success.

Laparoscopy: A Better Approach for Perforated Duodenal Ulcer

Background

Laparoscopic surgery is becoming the gold standard for most abdominal surgeries in recent times. Laparoscopic repair of perforated duodenal ulcer (PDU), however, is still an area of debate. The purpose of this study was to evaluate the safety and efficacy of laparoscopic repair of PDU versus open repair.

Methods

In this cross-sectional study, patients were consecutively sampled. Out of 101 patients with clinically diagnosed PDU, 36 patients underwent laparoscopic Graham patch repair and 65 underwent open Graham patch repair in a tertiary care academic hospital. Open repair was via upper midline incision, and laparoscopic repair by the three-port technique. The following stages were calculated: operative time, duration of postoperative analgesia, time taken to mobilize, and patient length of stay after the operation.

Results

The mean operative time was somewhat longer in the laparoscopy group compared to the open repair group (74.01 vs 56.17 minutes, respectively). Mean postoperative analgesia requirement, time taken to mobilize, and hospital stay were significantly shorter after laparoscopy than after open repair (1.21 days, 9.32 hours, and 3.12 days vs 3.83 days, 16.20 hours, and 4.85 days, respectively). Three patients (8%) in the laparoscopy group and 35 (54%) in the open repair group had postoperative complications.

Conclusions

Laparoscopic repair of PDU is a safe approach and better than open repair in terms of operative time with the right level of expertise only, postoperative analgesia requirement, mobilization, duration of hospital stay, and incidence of postoperative respiratory and wound complications.

High altitude area - A risk factor for gastric perforation? : A case series

INTRODUCTION

This is an original case series on soldiers evacuated from HAA(High Altitude Area) over last one year(Sept 2017-Aug 2018), of which 100% cases were found to have gastric antrum perforation. This is a deviation from the usual trend that is being noted in Indian subcontinent where duodenal perforations are commonest.

DISCUSSION

High altitude associated dyspepsia is a common phenomenon and some studies done in high altitude population have recorded high incidence of antral gastritis and mucosal atrophy on histo-pathological evaluation. This is also supported by high incidence of H. pylori infection. The presence of atrophic gastric mucosa associated with antral gastritis, when exposed to hypobaric hypoxemic conditions faced by soldiers posted to heights above 15,000 ft, may leads to increased intra-luminal pressure and ischemia which probably predisposes individuals for gastric antrum perforations.

CONCLUSION

This is a relatively untouched topic as we have not found studies onhigh altitude related gastric perforations and probably this is the first case series of its kind. The acknowledgement of this phenomenon may pave way for further studies for defining the role of high altitude in gastric perforations.

Pyloroplasty for Benign Gastric Outlet Obstruction — Indications and Techniques

The understanding of peptic ulcer disease (PUD) etiology, and improvements in treatment during the last two decades, has dramatically decreased the once so frequently performed procedures for PUD and its complications. Benign gastric outlet obstruction may, however, still require operative intervention when non-operative treatment fails. Today, surgeons in training, and even practicing surgeons, may have limited operative experience with procedures required to alleviate an obstructed pylorus. Our aim of this paper is to review the techniques (the Heineke-Mikulicz and Finney pyloroplasties, and modifications) and indications for pyloroplasty in the modern surgical era.

Perforated peptic ulcer

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Epidemiology of perforated peptic ulcer: Age- and gender-adjusted analysis of incidence and mortality

AIM: To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population.

METHODS: A retrospective, population-based, single-center, consecutive cohort study of all patients diagnosed with benign perforated peptic ulcer. Included were both gastric and duodenal ulcer patients admitted to Stavanger University Hospital between January 2001 and December 2010. Ulcers with a malignant neoplasia diagnosis, verified by histology after biopsy or resection, were excluded. Patients were identified from the hospitals administrative electronic database using pertinent ICD-9 and ICD-10 codes (K25.1, K25.2, K25.5, K25.6, K26.1, K26.2, K26.5, K26.6). Additional searches using appropriate codes for relevant laparoscopic and open surgical procedures (e.g., JDA 60, JDA 61, JDH 70 and JDH 71) were performed to enable a complete identification of all patients. Patient demographics, presentation patterns and clinical data were retrieved from hospital records and surgical notes. Crude and adjusted incidence and mortality rates were estimated by using national population demographics data.

RESULTS: In the study period, a total of 172 patients with PPU were identified. The adjusted incidence rate for the overall 10-year period was 6.5 per 100 000 per year (95%CI: 5.6-7.6) and the adjusted mortality rate for the overall 10-year period was 1.1 per 100 000 per year (95%CI: 0.7-1.6). A non-significant decline in adjusted incidence rate from 9.7 to 5.6 occurred during the decade. The standardized mortality ratio for the whole study period was 5.7 (95%CI: 3.9-8.2), while the total 30-d mortality was 16.3%. No difference in incidence or mortality was found between genders. However, for patients ≥ 60 years, the incidence increased over 10-fold, and mortality more than 50-fold, compared to younger ages. The admission rates outside office hours were high with almost two out of three (63%) admissions seen at evening/night time shifts and/or during weekends. The observed seasonal variations in admissions were not statistically significant.

CONCLUSION: The adjusted incidence rate, seasonal distribution and mortality rate was stable. PPU frequently presents outside regular work-hours. Increase in incidence and mortality occurs with older age.

A 41-Year-Old Man with Two Types of Metachronous Peptic Ulcer Complication due to Zollinger-Ellison Syndrome-Regression of Pancreatic Primary after Chemoembolization of Hepatic Metastases: A Case Report

Introduction. Gastrinoma should be suspected when the peptic ulcer(s) is postbulbar, multiple, refractory, or recurrent, or ulcer is associated with nephrolithiasis, hypocalcaemia, or erosive esophagitis. The majority of gastrinomas are malignant. Case Presentation. The patient is a 41-year-old Iranian man who has been in good health until 36 months ago when duodenal perforation and two bouts of upper GI bleeding (GIB), each two months apart occurred. He also mentioned mild watery diarrhoea and decreased appetite. Serum gastrin level was elevated. Abdominal CT scan revealed pancreatic mass and three enhancing hepatic masses. CT-guided pancreatic biopsy revealed monotonous cells. Chemoembolization of hepatic metastases was done. New ct images 6 months later showed nearly total regressed hepatic and pancreatic lesions. Conclusion. Beside previously defined situations that take gastrinoma into account as the etiology of PUD, accumulation of PUD complications is highly suggestive of Zollinger-Ellisone syndrome (ZES). Regression of pancreatic primary after chemoembolization of hepatic metastases is unexplainable at the present time.

Changes in the localization of perforated peptic ulcer and its relation to gender and age of the patients throughout the last 45 years

Background

Throughout recent decades there has been noticeable change in the incidence of peptic ulcer disease and its complications. The aim of the present study was to determine the character of changes over the last 45 years in the localization of perforation, in patient age, and in patient gender.

Methods

A group of 881 patients admitted to the Second Department of General Surgery in Krakow, Poland, from 1962 to 2006 were included in the study and constituted the material for the analysis. The study was divided into three time periods (1962–1976, 1977–1991, and 1992–2006) to allow statistical analysis of trends.

Results

The general incidence of perforations of peptic ulcer did not show changes; however, the percentage of women with perforated duodenal ulcer markedly increased. Patients with perforated stomach ulcer—regardless of gender—and females suffering from perforated duodenal ulcer were, on the average, about 10 years older than males with perforated duodenal ulcers. The mean age of male and female patients with perforated duodenal ulcer over the last 45 years showed an insignificant upward trend.

Conclusions

(1) The percentage of women with perforated duodenal ulcer continuously and statistically significantly rose. (2) Men with perforated duodenal ulcer were significantly younger than other patients. (3) The mean ages of male and female patients with perforated duodenal ulcer over the last 45 years showed an insignificant upward trend.

Generalized peritonitis requiring re-operation after leakage of omental patch repair of perforated peptic ulcer

BACKGROUND/AIM

Peptic ulcer perforations are a common emergency, but available literature is silent on the exact definition, incidence, management, and complications of peritonitis due to omental patch leakage.

PATIENTS AND METHODS

Retrospective data were collected on 422 patients who underwent omental patch repair of perforated peptic ulcer between March 20, 1999 and March 20, 2006. The definitive diagnosis of perforated peptic ulcer and omental patch leakage was obtained at surgery.

RESULTS

Seventeen (4%) patients experienced generalized peritonitis due to omental patch leakage. Mean age was 60.6 years. Mortality rate was 29.4%, and the mean hospital stay was 23.6 days. Delay in surgical approach, shock on admission, and age were all significantly associated with increased mortality.

CONCLUSIONS

Peritonitis due to omental patch leakage can result in significant morbidity and mortality. The most common causes of omental patch leakage and operative procedures were unknown and reinsertion of omentum, respectively. Factors such as shock on admission or delayed surgery, have significantly contributed to fatal outcomes and need careful attention.

Perforated peptic ulcer in southeastern Taiwan

BACKGROUND

No studies focus on the population with perforated peptic ulcer in southeastern Taiwan. The present study aimed to assess the differences between the different races and the risk factors related to mortality and morbidity in postoperative patients in southeastern Taiwan.

METHODS

The medical records of 237 patients were reviewed retrospectively. The following factors were analyzed: patient profiles, coexisting illnesses, diagnostic method, fever, preoperative shock, clinical data at emergency room, delay operation, site of perforation, operative method, positive ascites culture, species of microbes in ascites culture, postoperative complications, death and the length of hospital stay.

RESULTS

Aborigines were significantly different from non-aborigines in the ratio of female cases and in the habits of alcohol drinking and betel nut chewing. There were also four significantly different variables between them: fever, hemoglobin value, site of perforation and operative method. Total postoperative complication rate was 41.3% and 39 patients (16.6%) died. In multivariate analysis, age > or = 65 years, lipase > upper normal limit and preoperative shock were independent predictors of mortality. Significant risk factors associated with morbidity were NSAIDs use, creatinine > 1.5 mg/dL and preoperative shock.

CONCLUSION

Aborigines were different from non-aborigines in several categories. In southeastern Taiwan, NSAIDs use, creatinine > 1.5 mg/dL and preoperative shock were independent risk factors of morbidity, and age > or = 65 years, lipase > upper normal limit and preoperative shock were independent risk factors of mortality in postoperative perforated peptic ulcer. Lipase > upper normal limit is needed for further research on the influence on mortality.

Perforated peptic ulcer: how to improve outcome?

Despite the introduction of histamine H2-receptor antagonists, proton-pump inhibitors and the discovery of Helicobacter pylori, both the incidence of emergency surgery for perforated peptic ulcer and the mortality rate for patients undergoing surgery for peptic ulcer perforation have increased. This increase has occurred despite improvements in perioperative treatment and monitoring. To improve the outcome of these patients, it is necessary to investigate the reasons behind this high mortality rate. In this review we evaluate the existing evidence in order to identify significant risk factors with an emphasis on risks that are preventable. A systematic review including randomized studies was carried out. There are a limited number of studies of patients with peptic ulcer perforation. Most of these studies are of low evident status. Only a few randomized, controlled trials have been published. The mortality rate and the extent of postoperative complications are fairly high but the reasons for this have not been thoroughly explained, even though a number of risk factors have been identified. Some of these risk factors can be explained by the septic state of the patient on admission. In order to improve the outcome of patients with peptic ulcer perforation, sepsis needs to be factored into the existing knowledge and treatment.

Factors affecting mortality and morbidity in patients with peptic ulcer perforation

BACKGROUND AND AIM

With the introduction of H2 receptor antagonists and proton pump inhibitors, the incidence of elective surgery for peptic ulcer (PU) diseases has decreased, although complications of PU such as perforation and bleeding have remained fairly constant. The purpose of this study was to identify the risk factors that predict morbidity and mortality in patients with perforated PU.

METHODS

The records of 269 patients who were operated on for perforated PU were reviewed retrospectively. The following factors were analyzed in terms of morbidity and mortality: age >65 years; gender; associated medical illness; chronic ingestion of non-steroidal anti-inflammatory drugs, aspirin, corticosteroids or immunosuppressants; alcohol ingestion and smoking habits; American Society of Anesthesiologist (ASA) status; season; delayed operation; site of ulcer perforation; and shock on admission and type of operation.

RESULTS

There were 30 female (11.16%) and 239 male (88.84%) patients. Seventy-one (26.4%) patients had associated diseases. Simple closure was performed in 257 (95.5%) patients; 12 patients (4.5%) underwent definitive operations. A total of 108 postoperative complications were present in 65 (24.2%) patients. Twenty-three patients died (8.55%). Multivariate analysis showed that only age, ASA score, treatment delay, presence of shock and definitive operation were independent predictors of mortality. Significant risk factors that led to morbidity were ASA status, time of surgery, season, presence of shock and type of surgery. There was a significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery.

CONCLUSIONS

Age, delayed surgery, presence of shock, ASA risk and definitive surgery are factors significantly associated with fatal outcomes in patients undergoing emergency surgery for perforated PU. Therefore, proper resuscitation from shock, improving ASA grade, decreasing delay and reserving definitive surgery for selected patients is needed to improve overall results.

30-day mortality after peptic ulcer perforation among users of newer selective COX-2 inhibitors and traditional NSAIDs: a population-based study

OBJECTIVES

Nonsteroidal anti-inflammatory drug (NSAID) use is a strong risk factor for peptic ulcer perforation, yet little is known about the outcome of this condition among NSAID users. We examined 30-day mortality after peptic ulcer perforation associated with the use of traditional NSAIDs and newer selective cyclo-oxygenase-2 (COX-2) inhibitors.

METHODS

We conducted a cohort study of patients with the first hospitalization for peptic ulcer perforation, identified in discharge registries of three Danish counties between 1991 and 2003. Data on preadmission NSAID use, other ulcer-related drugs, and comorbidity were likewise from population-based registries. Mortality was ascertained from the Civil Registration System. We compared 30-day mortality in NSAID users and nonusers while adjusting for age, gender, comorbidity, previous uncomplicated peptic ulcer, and ulcer medication use.

RESULTS

Of the 2,061 patients hospitalized with peptic ulcer perforation, 38% were current NSAID users. The 30-day mortality was 25% overall, and 35% among current NSAID users. Compared with never-use, the adjusted 30-day mortality rate ratios (MRRs) were 1.8 (95% CI 1.4-2.3) for current use of NSAIDs alone and 1.6 (95% CI 1.2-2.2) for current use combined with other ulcer-associated drugs. The mortality increase associated with the use of COX-2 inhibitors was similar to that of traditional NSAIDs: adjusted MRR for users of COX-2 inhibitors alone and in combination, 2.0 (1.3-3.1) and 1.4 (0.8-2.5), and for users of traditional NSAIDs alone or in combination, 1.7 (1.3-2.3) and 1.6 (1.2-2.3).

CONCLUSION

Current use of NSAIDs, including COX-2 inhibitors, is associated with a poor prognosis for patients hospitalized with peptic ulcer perforation.

Prevention and treatment of gastrointestinal symptoms and complications due to NSAIDs

The mechanisms by which aspirin(ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal symptoms are poorly understood. They probably arise from several causes, including direct and indirect mucosal injury, exacerbation of underlying peptic ulcer disease or non-ulcer dyspepsia, exacerbation of Helicobacter pylori gastritis, and possibly motility disorders. No single form of therapy has been generally successful. Because, in most cases, symptoms abate fairly rapidly with continued treatment, there is little evidence that benefit associated with any symptom-directed drug therapy is superior to placebo beyond 4 weeks. Exceptions may be the subsets of patients with pre-existing ulcer disease or heartburn, exacerbated by the NSAID therapy, who usually benefit from acid-suppressive drug treatment. Different NSAIDs vary in the frequency with which their use leads to gastrointestinal(GI) complications such as haemorrhage, perforation, obstruction, or the symptomatic ulcers from which about 40% of the complications arise. Most gastroduodenal ulcers heal over time, albeit more slowly, with conventional doses of any of the available anti-ulcer drugs. Maintenance therapy may be needed in many patients who continue NSAID therapy. Anti-ulcer drugs have not, thus far, been shown to be more effective than placebo in preventing ulcer complications or their recurrence. The use of COX-2-selective inhibitors appears, in outcome studies, to reduce gastrointestinal bleeding, including bleeding from ulcers, but it is not established that the ulcers protected were caused by NSAIDs, as distinct from ulcers exacerbating or recurring from antecedent peptic ulcer disease. To-date, perforation or obstruction have not been shown to be affected by selective COX-2 inhibitor drugs. If the major problem giving rise to severe NSAID complications is pre-existing peptic ulcer disease, it may yet emerge that the most effective approach will be the use of proton pump inhibitor drugs, for the duration of NSAID therapy, in a small subset of high-risk patients. Most other low-risk patients may not need any special care. Co-morbid conditions have a major impact on outcome of NSAID therapy. Morbidity or even death attributable solely to NSAIDs is probably small in normal patients, and requires little in the way of prophylaxis.

Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors

BACKGROUND AND PURPOSE

Anticoagulants and antiplatelet agents are underutilized in the nursing home setting, perhaps because trials demonstrating treatment efficacy excluded people resembling those with long-term care needs. We sought to quantify the effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among an elderly nursing home population.

METHODS

We used a case-control design and identified first hospitalizations for bleeds using Medicare claims data from 1992 to 1997 as potential cases. Cases had at least one minimum data set (MDS) assessment within the 6 months before that hospitalization and a diagnosis of stroke. We identified up to 5 controls residing in the same facility during the same year and quarter as the case with a diagnosis of stroke. Our sample consisted of 3433 cases and 13 506 controls. Using the MDS, we identified standing orders for aspirin, dipyridamole, ticlopidine, or warfarin and used conditional logistic regression modeling to estimate the effect of these agents on risk of hospitalization for a bleed.

RESULTS

After adjustment, use of warfarin (odds ratio [OR], 1.26; 95% CI, 1.11 to 1.43) and combination therapy (OR, 1.34; 95% CI, 0.99 to 1.82) were associated with an increased risk of hospitalization for a bleed compared with nonusers. The odds of aspirin use was greater among cases than controls (OR, 1.07; 95% CI, 0.96 to 1.18) after adjustment.

CONCLUSIONS

Although present, the risk associated with use of these agents is small. The numbers needed to treat to harm 1 resident with aspirin and warfarin were 467 and 126, respectively.

Smoking and alcohol intake as risk factors for bleeding and perforated peptic ulcers: a population-based cohort study

Both the incidence of and mortality from bleeding and perforated peptic ulcers are increasing. We assessed the association between smoking, intake of alcohol (including type of alcoholic beverage), and risk of a complicated peptic ulcer in a population-based study of 26,518 Danish subjects followed up for an average of 13.4 years. There were 214 cases of incident bleeding and 107 cases with perforated ulcers. We estimated relative risks (RRs) for incident bleeding and perforated peptic ulcers using Poisson regression analysis. Smoking more than 15 cigarettes per day compared with never smoking increased the risk of a perforated ulcer more than threefold [RR = 3.5; 95% confidence interval (CI) = 1.7-7.1)]. Drinking more than 42 drinks per week increased the risk of a bleeding ulcer fourfold (RR = 4.4; 95% CI = 2.3-8.3) compared with drinking less than one drink per week. Using the same comparison group, subjects who drank more than 21 drinks per week but no wine were at a higher risk of a bleeding ulcer (RR = 8.8; 95% CI = 2.2-35) than drinkers of the same amount of alcohol, but with more than 25% of their intake as wine (RR = 2.4; 95% CI = 1.0-6.0).

Comparative toxicity of nonsteroidal anti-inflammatory drugs

To compare the gastrointestinal (GI) toxicities of various nonsteroidal anti-inflammatory drugs (NSAIDs), it is first necessary to dismantle the imprecise entity "NSAID gastropathy" into its component conditions, and understand their pathogenesis. In this article, toxicities are reviewed only in so far as they affect the upper GI tract, the site of approximately 80% of GI injuries caused by NSAIDs. The phenomena discussed are platelet dysfunction, causing hemorrhage from various lesions, including but not confined to ulcers; various mucosal injuries, ranging from small erosions to large ulcers; and "complications," such as bleeding or perforations, causing admission to hospital, that may arise from ulcers but may also arise from other lesions. Ulcers, when complicated, may either be those caused by an NSAID or "peptic" ulcers that preceded NSAID therapy (having a high prevalence in the population) and gave rise to complications resulting from NSAID effects on platelets, tissues, or biologic processes, for example, healing, necrosis/apoptosis, leukocyte adherence, vasoconstriction, or generation of free radicals. NSAIDs have been compared in various ways, including fecal blood loss, endoscopic lesion development, prospective preclinical cohort studies measuring perforations, ulcers, and bleeds, post-marketing surveillance studies, and studies of the incidence of serious adverse events in populations followed in large databases linked to each individual patient record with regard to drug consumption and outcome. All methods show considerable differences between NSAIDs. Modern studies on the relative toxicities of NSAIDs are summarized and reviewed, and a number of marketed and emerging drugs that appear less toxic than classic NSAIDs are identified.

A genome-wide search identifies potential new susceptibility loci for Crohn's disease

Chronic inflammatory bowel disease (IBD) presents as two major clinical forms, Crohn's disease (CD) and ulcerative colitis (UC). Genetic epidemiological studies and animal models suggest that inherited factors play significant roles in the susceptibility to both forms of IBD. From four genome-wide scans, putative susceptibility loci on chromosome 16 (IBD1 for CD), and on chromosomes 1, 3, 4, 6, 7, 10, and 12 for IBD, have been identified. Several other groups, including ours, have confirmed linkage to the loci on chromosomes 12 and 16. The aim of this study is to identify other potential susceptibility loci for CD with a genome-wide search approach. In our sample of 222 individuals from 46 families (20 Jewish and 26 non-Jewish), with a total of 65 sibpairs diagnosed with CD, we observed a novel locus with suggestive linkage [multipoint logarithm of the odds score (Mlod) > 2] at chromosome 14q11.2 (Mlod = 2.8, p = 0.0002). In addition, suggestive linkage was observed in our Jewish families at chromosome 17q21-q23 (Mlod = 2.1, p = 0.01) and chromosome 5q33-q35 (Mlod = 2.2, p = 0.0003). The syntenic regions of the latter locus are mapped within two putative loci on mouse chromosomes 11 and 18, which were identified in a mouse IBD model induced by dextran sulfate sodium (29). Our preliminary results provide potential evidence for several susceptibility loci contributing to the risk of CD. The observation of man-mouse synteny may accelerate the identification of CD susceptibility gene(s) on human chromosome 5.

Potentiating effect of passive cigarette smoking on gastrointestinal damage induced by indomethacin in rats

Cigarette smoking and nonsteroidal antiinflammatory drugs (NSAIDs) have been associated with gastroduodenal ulcers. The present study aimed to clarify the ulcerogenic mechanisms of passive cigarette smoking on gastrointestinal damage induced by indomethacin in fasted or in fasted and refed rats. Rats were exposed to cigarette smoke (0%, 1%, 2%, or 4%, v/v) before and/or after indomethacin administration. Cigarette smoke dose-dependently potentiated indomethacin-induced gastric mucosal lesions in the fasted animals and further lowered gastric blood flow. The gastric myeloperoxidase activity (a marker enzyme for neutrophils) was also potentiated. In addition, passive cigarette smoking increased the mortality and aggravated duodenal ulceration and also the reduction of duodenal blood flow in the fasted and refed rats after indomethacin treatment. The results indicated that the potentiating effect of passive cigarette smoking on indomethacin-induced gastroduodenal lesions is probably due to the depression of blood flow in the gastroduodenal mucosa and to the aggravation of neutrophil infiltration in the gastric mucosa.

Causes of death in patients with peptic ulcer perforation: a long-term follow-up study

BACKGROUND

Survival is lower in ulcer perforation patients than in the general population. This study assesses the causes of death in patients treated for peptic ulcer perforation.

METHODS

Cause-specific mortality in a population-based cohort of 817 patients treated for ulcer perforation in western Norway during the period 1962-1990 was compared with cause-specific population death rates. Analyses were based on observed and expected mortality curves for major causes of death and on standardized mortality rates (SMRs). Cox regression models were used to analyse possible differences on the basis of sex, birth cohort, surgical procedure, and ulcer location.

RESULTS

Ulcer perforation patients experienced increased mortality from neoplasms (SMR = 1.8; 95% confidence interval (CI) = 1.4-2.1), lung cancer (SMR = 3.6; 95% CI = 2.3-4.9), circulatory diseases (SMR = 1.3; 95% CI = 1.1-1.6), ischaemic heart disease (SMR = 1.3; 95% CI = 1.03-1.6), and respiratory diseases (SMR = 1.9; 95% CI = 1.3-2.6). Postoperative deaths accounted for 38% of all excess deaths. Death from recurrent peptic ulcer was increased also in subjects who survived the 1st year after the perforation (SMR = 5.8; 95% CI = 1.2-10.4) but accounted for only a few deaths. The increase in mortality from lung cancer was higher in subjects born after 1910 than in patients of older generations. Excess mortality from lung cancer and from circulatory diseases was higher in male than in female patients.

CONCLUSIONS

Increased mortality in ulcer perforation patients could mainly be attributed to smoking-related diseases. This is indirect evidence that smoking may be an important aetiologic factor for ulcer perforation.