Epidemiological study of peptic ulcer in the south of India. Observations from Madras on the changing incidence of peptic ulcer, with special reference to causation

Epidemiology of Helicobacter pylori and peptic ulcer in India

BACKGROUND

There is a wide variation in the prevalence of peptic ulcer in India both before and since the use of endoscopy. We studied the prevalence of peptic ulcer disease in a community in northern India and its relationship with Helicobacter pylori infection.

METHODS

A house-to-house survey of residents aged 15 years or above in a sub-sector of Chandigarh was performed as part of a pilot survey. Subsequently, the study randomly covered all sectors of Chandigarh and we screened 2649 persons. A questionnaire was administered to each subject by trained staff. All individuals with history of peptic ulcer/dyspepsia and an equal number of asymptomatic individuals were asked to attend the outpatient department of the Institute. Diagnosis of peptic ulcer was based on endoscopy or history of previous ulcer surgery.

RESULTS

Two hundred and fifty-four individuals attended the outpatient department at the Institute and 147 underwent endoscopy, biopsy for histology and rapid urease test, and blood was collected for H. pylori serology. There were 80 symptomatic and 67 asymptomatic individuals. Helicobacter pylori was positive in 38 (56.7%) asymptomatic and 49 (61.3%) symptomatic individuals (P > 0.05). The point prevalence of active peptic ulcer was 3.4% and the lifetime prevalence was 8.8%. The duodenal-to-gastric ulcer ratio was 12:1. Helicobacter pylori was present in 11/13 (84.6%) subjects with peptic ulcer. Peptic ulcer was more common in elderly and dyspeptic individuals and there was no effect of sex or socioeconomic status. Helicobacter pylori was associated with age only and did not depend on sex, socioeconomic status or dyspepsia. Of the 38 asymptomatic persons having H. pylori infection, none had active peptic ulcer.

CONCLUSIONS

This study demonstrates frequent occurrence of peptic ulcer and H. pylori in this part of the country. Peptic ulcer was more prevalent in the elderly and dyspeptic subjects. Helicobacter pylori was not associated with dyspepsia, and was more prevalent in elderly subjects. There was a low prevalence of peptic ulcer in asymptomatic H. pylori-infected persons in this community.

Post-bulbar and coexisting ulceration: unique features of peptic ulcer in Hyderabad

Post-bulbar ulceration is uncommon, but a pilot study in Hyderabad showed a high incidence. We therefore carried out a prospective endoscopic study of the distribution of peptic ulceration and its relation to symptoms and demography. Of the 360 consecutive patients referred for endoscopy, 113 (92 men, 21 women) had peptic ulceration. Median age 35 years, median duration one year. Five patients (4%) had gastric ulcer, 77 (68%) had duodenal ulcer, and 31 (28%) had coexisting gastric and duodenal ulcer. The duodenal ulcer was found in the pyloric canal in 14% of patients, in the bulb in 80%, and the post-bulbar region in 56% of patients. Sixty seven per cent of duodenal ulcers were located at more than one site. The incidence of post-bulbar v bulbar ulcer was 1:1.5. Deformed bulb was seen in 50% of duodenal ulcer patients, but haemorrhage and stenosis were uncommon. Except for nocturnal pain, there were no differences in symptoms between the groups. Forty two per cent of patients smoked, 15% chewed tobacco, and 18% drank alcohol; almost all were men. Sixty four per cent drank tea. The staple diet (85%) was rice, and 70% used tamarind and spices daily. Duodenal ulcer was three times more common than gastric ulcer with a high incidence of post-bulbar and coexisting ulcer. It affected a younger and predominantly male population, and was not associated with a higher rate of complication.

Dyspepsia, Helicobacter pylori, and peptic ulcer in a randomly selected population in India

There seems to be a worldwide geographic variation in the prevalence of peptic ulcer disease, although there are few reliable population based studies. This study aimed to determine the prevalence of peptic ulcer disease in a community in southern India and to evaluate the relationship between dyspeptic symptoms, Helicobacter pylori infection, gastritis, and peptic ulcer disease. A sample population was selected randomly from a rural monastic settlement in southern India. Subjects were interviewed using a standardised symptom and demography questionnaire then underwent upper endoscopy and antral biopsy for histology and CLO rapid urease test. Altogether 197 subjects from a population of 1499 (13.1%) were studied. All were male monks and ethnically Tibetan. The median age was 28 years (range: 21-81). None smoked or took NSAIDs. The six month period prevalence of dyspeptic symptoms was 68.5%. Current symptoms were present in 58.9% of subjects. Dyspepsia was more common in subjects aged 40 years or younger (p < 0.0001). H pylori was detected in 77.2% subjects. There was no association between dyspepsia and the presence of H pylori or histological gastritis, although there was a strong correlation between symptoms and ulcer (p < 0.003). The point prevalence of active peptic ulcer was 6.6% (13/197). All ulcers detected were either prepyloric or pyloroduodenal in location. A further 6.6% of subjects had definite evidence of scarring or deformity indicative of ulceration in the past. Subjects with past or present ulcers comprised 17.8% of dyspeptic subjects. H pylori was present in all subjects with active ulcers and in 12/13 of those with scarring. Dyspepsia, H pylori infection, gastritis, and peptic ulcer are all more common in this population than in those from developed countries. Ulcer disease, however, accounts for only a small proportion of subjects with symptoms and neither H pylori infection nor gastritis are significantly associated with the presence of dyspepsia.

Prevalence of peptic ulcer in India: an endoscopic and epidemiological study in urban Kashmir

The prevalence of peptic ulcer disease in the general population of Kashmir, India, was determined by endoscopy in a randomly selected sample population of 2763 adults aged 15 years and above who were interviewed using a questionnaire. Of 239 persons with ulcer symptoms, 193 (80.7%) had an oesophagogastroduodenoscopy. A randomly selected 177 individuals from among the remaining population without ulcer symptoms, were also endoscoped. The point prevalence of peptic ulcer was 4.72% and the lifetime prevalence was 11.22%. The duodenal to gastric ulcer ratio was 17.1:1. Duodenal and gastric ulcer were common in men. The prevalence of peptic ulcer increased with age, with a peak prevalence of 28.8% in the 5th decade of life. Peptic ulcer was not related to socio-economic status. The prevalence of complications, such as bleeding, stenosis, or perforation were similar to those reported in the West.

Benign gastric ulceration in a health district: incidence and presentation

In a survey of benign gastric ulceration conducted in the Hounslow Health District from 1981 to 1982, there was an annual incidence for this condition of 43.6 per 100,000 of the population older than 14 y, with a male:female ratio of 0.9:1. This incidence is comparable to that found in other surveys over the last 30 y, but the male:female ratio is lower than in the past. This reduction is accounted for by a rise in the peak age incidence for gastric ulcer, particularly in women, and a greater proportion of the total population in this higher age group being women. In spite of a large local Asian population, no gastric ulcers occurred in this ethnic group. Thirty-eight per cent of the patients presented with acute bleeding, and 44% of these bleeders gave a history of previous ingestion of non-steroidal anti-inflammatory drugs compared with only 14% of the non-bleeding group (P less than 0.015).

Secretin, glucagon, insulin-antibodies, islet-cell exhaustion and diabetes mellitus : a hypothesis

There are many studies that show that important and interesting differences exist in the patterns of diabetes mellitus, not only between countries but from group to group in the same country. Such big differences suggest the causes may be environmental, most of which are dietary and, therefore, preventable. In these dietary factors it is perhaps the pattern of eating, the presence or absence of cellulose, roughage and vegetable fibre, milk and fermented milk products such as yoghurt, which are of crucial importance. There is a quicker rise of blood glucose in the case of "non-masticatory-roughage-poor" dietary regimens as compared with "masticatory" milk, milk-products and roughage-rich regimens on account of faster gastric emptying in the former and slower gastric emptying in the latter. The hyperchlorhydria caused by fibre-poor non-masticatory meals produces an instantaneous secretin-release which results in hyperinsulinism. Such "sucrose-induced hyperinsulinism" leads to formation of insulin antibodies. Diabetes is caused by this excessive inactivation of insulin by antibodies, brought about by dietary factors, setting up the vicious cycle of hurried meals - hyperchlorhydria and secretin resulting in instantaneous insulin-release - neoglucogenesis more insulin-release - insulin antibodies and a further secretion of insulin - insulin antagonism - islet cell exhaustion - diabetes mellitus. There is evidence of an alternative mechanism in which diabetes appears to be caused by interference with insulin-release even though islets manufacture insulin normally.

New approaches to the pathogenesis of peptic ulcer based on the protective action of saliva with special reference to roughage, vegetable fibre and fermented milk products

Epidemiologic studies have shown differences in the prevalence of peptic ulcer disease among various communities to be related to variation in diet and eating patterns. Results of studies of the effect of diet and pattern of eating on saliva, on gastric juice, and on the amount of bile are reviewed. It is suggested that bile, and not hydrochloric acid, plays the causative role in pathogenesis of peptic ulceration. The role of saliva in the prevention of peptic ulcer is emphasized. The salivary mucus swallowed with food is protective because it decreases the flow rate of bile which, when held in the gall bladder longer, loses its alkalinity and therefore its ability to damage the mucous cells. Roughage, cellulose and vegetable fibres and fermented milk products act in a similar manner. When food is well masticated, containing plenty of vegetable fibres and fermented milk products such as ghee and yoghurt, resulting in an increase in the amount of salivary mucus, peptic ulceration may be prevented and cured and relapses may be prevented. This does not require a big change in the pattern of diet but only a change in the manner of eating so that hasty eating is avoided and good is chewed well. The pattern of diet, especially the relative dietary preponderance of short-chain fatty acids, such as those present in milk, yoghurt and other fermented milk products, have a protective action; the short-chain fatty acids retard gall bladder contraction and thus diminish the amount of bile entering the duodenal lumen.

A comparison of unrefined wheat and rice diets in the management of duodenal ulcer

Twenty-one chronic duodenal ulcer patients in a rice-eating area were put on to an unrefined wheat diet and twenty-one continued on their previous rice diet. After 5 years only 14% of the first group had had relapses compared with 81% of the second group. A similar 5-year relapse rate (80%) was obtained in a group of thirty patients from another area with a more varied rice diet. The author attributes this difference to the increased mastication required by the unrefined wheat diet, which is associated with an increase in saliva, lower stomach acidity and reduced bile output.