Prevalence of non-Helicobacter pylori duodenal ulcer in Karachi, Pakistan

Background factors of idiopathic peptic ulcers and optimal treatment methods: a multicenter retrospective Japanese study

This study investigated the trends in idiopathic peptic ulcers, examined the characteristics of refractory idiopathic peptic ulcer, and identified the optimal treatment. The characteristics of 309 patients with idiopathic peptic ulcer were examined. We allocated idiopathic peptic ulcers that did not heal after 8 weeks' treatment (6 weeks for duodenal ulcers) to the refractory group and those that healed within this period to the healed group. The typical risk factors for idiopathic peptic ulcer (atherosclerosis-related underlying disease or liver cirrhosis complications) were absent in 46.6% of patients. Absence of gastric mucosal atrophy (refractory group: 51.4%, healed group: 28.4%; p = 0.016), and gastric fundic gland polyps (refractory group: 17.6%, healed group: 5.9%; p = 0.045) were significantly more common in the refractory group compared to the healed group. A history of H. pylori eradication (refractory group: 85.3%, healed group: 66.0%; p = 0.016), previous H. pylori infection (i.e., gastric mucosal atrophy or history of H. pylori eradication) (refractory group: 48.5%, healed group: 80.0%; p = 0.001), and potassium-competitive acid blocker treatment (refractory group: 28.6%, healed group, 64.1%; p = 0.001) were significantly more frequent in the healed group compared to the refractory group. Thus, acid hypersecretion may be a major factor underlying the refractoriness of idiopathic peptic ulcer.

Clinical, endoscopic, and demographic characteristics of idiopathic duodenal ulcers compared with helicobacter pylori positive ulcers

Background

Helicobacter pylori infection is the most common cause of peptic ulcer disease. However, the prevalence rates of non-helicobacter pylori idiopathic peptic ulcers have increased over the past few years. This study aims to compare the characteristics of Helicobacter pylori-positive with idiopathic duodenal ulcers.

Methods

A cross-sectional cohort study was conducted on 950 patients which were excluded from the analysis process duo to the concomitant presence of gastric ulcer, malignancy, Zollinger Ellison syndrome, Crohn's disease, esophageal varices, history of taking anti-Helicobacter pylori therapy, and history of taking NSAID or aspirin. Eventually, 647 subjects were enrolled for the analysis process. In this case, these subjects were divided into two groups: (I) Helicobacter pylori-positive ulcer group and (II) Helicobacter pylori-negative and non-NSAID (idiopathic) ulcer group.

Results

The findings showed that 417 patients (64.5%) had duodenal ulcers induced by Helicobacter pylori, and 111 patients (17.1%) had Helicobacter pylori-negative and non-NSAID ulcers. The mean ages of patients in Helicobacter pylori-positive and idiopathic ulcer groups were 39±15 and 42±17, respectively. In this case, 33 patients (29.7%) with idiopathic ulcers and 56 patients (25.1%) with Helicobacter pylori-positive ulcers had upper gastrointestinal bleeding. Also, 22 patients (21%) with idiopathic ulcers and 31 patients (16.5%) with Helicobacter pylori-positive ulcers had multiple duodenal ulcers.

Conclusion

The present study demonstrated that the idiopathic ulcers included 17.1% of duodenal ulcers. Also, it was concluded that patients with idiopathic ulcers were predominantly male with an age range older than the other group. In addition, patients in this group had more ulcers.

Upper gastrointestinal lesions in patients with lower extremity peripheral artery disease: data from a retrospective analysis

Aim. To assess the prevalence and structure of upper gastrointestinal (GI) lesions, as well as the factors associated with their development, in patients with lower extremity peripheral artery disease (PAD).

Material and methods. This retrospective analysis of medical records with lower extremity PAD includes data from 258 patients. All patients underwent multislice computed tomography angiography of abdominal aortic visceral branches and lower limb arteries, as well as esophagogastroduodenoscopy.

Results. Endoscopic evidence of upper GI lesions was detected in 164 (63,6%) patients. In particular, gastroduodenal erosions and ulcers were observed in 57,8% of patients. All patients were divided into two groups: group I — 149 (57,8%) patients with gastroduodenal erosions and ulcers, group II  — 109 (42,2%) patients without it. In group I patients, a higher incidence of mesenteric artery disease was recorded  — 61,7 vs 43,1% (p=0,003). An independent factor associated with the development of gastroduodenal erosions and ulcers in patients with PAD is mesenteric artery disease (relative risk: 4,43; 95% confidence interval: 1,15-17,12 (p=0,031)).

Conclusion. In patients with lower extremity PAD, upper GI diseases (63,6%) occur with a high frequency, while gastroduodenal erosions and ulcers was observed in 90,9% of them. The factors associated with the development of erosions and ulcers in patients with lower extremity PAD include mesenteric artery atherosclerosis.

Burden of Gastroduodenal Diseases from the Global Perspective

PURPOSE OF REVIEW

We reviewed the recent medical literature to show global burden of gastroduodenal disease, potential strategies, and further perspectives.

RECENT FINDINGS

Gastrointestinal and liver diseases are growing health problems, and cause more than 8 million deaths per year worldwide; encompass a range of long-term health conditions, such as digestive cancers, gastroesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, liver diseases, inflammatory bowel disease, coeliac disease, and functional gastrointestinal disorders. Scientific knowledge demonstrates that the noncommunicable disease burden can be greatly reduced if cost-effective preventive and curative actions, along with interventions for prevention and control of noncommunicable diseases already available, are implemented in an effective and balanced manner.

SUMMARY

Future research will have to elaborate on simple methods for preselection of patients at high risk to allow their implementation in strategies and respect all demand of cost-effectiveness. Understanding trends in GI illnesses could be helpful to meet the needs of patients and decrease the disease burden.

A systematic approach for the diagnosis and treatment of idiopathic peptic ulcers

An idiopathic peptic ulcer is defined as an ulcer with unknown cause or an ulcer that appears to arise spontaneously. The first step in treatment is to exclude common possible causes, including Helicobacter pylori infection, infection with other pathogens, ulcerogenic drugs, and uncommon diseases with upper gastrointestinal manifestations. When all known causes are excluded, a diagnosis of idiopathic peptic ulcer can be made. A patient whose peptic ulcer is idiopathic may have a higher risk for complicated ulcer disease, a poorer response to gastric acid suppressants, and a higher recurrence rate after treatment. Risk factors associated with this disease may include genetic predisposition, older age, chronic mesenteric ischemia, smoking, concomitant diseases, a higher American Society of Anesthesiologists score, and higher stress. Therefore, the diagnosis and management of emerging disease should systematically explore all known causes and treat underlying disease, while including regular endoscopic surveillance to confirm ulcer healing and the use of proton-pump inhibitors on a case-by-case basis.

Mechanisms of gastroprotection of methanol extract of Melastoma malabathricum leaves

BACKGROUND

Melastoma malabathricum L. (Melastomaceae) is a small shrub with various medicinal uses. The present study was carried out to determine the gastroprotective mechanisms of methanol extract of M. malabathricum leaves (MEMM) in rats.

METHODS

The extract's mechanisms of gastroprotection (50, 250, 500 mg/kg) were studied using the pylorus-ligation in rat model wherein volume, pH, free and total acidity of gastric juice, and gastric wall mucus content were determined. The involvement of endogenous nitric oxide (NO) and sulfhydryl (SH) compounds in the gastroprotective effect of MEMM were also measured. MEMM was subjected to the antioxidant, anti-inflammatory and phytochemical analysis and HPLC profiling.

RESULTS

MEMM contained various phyto-constituents with quercitrin being identified as part of them. MEMM and quercitrin: i) significantly (p < 0.05) reduced the volume and acidity of gastric juice while increasing the pH and gastric wall mucus content.; ii) significantly (p < 0.05) increased the level of SOD, GTP and GTR while significantly (p < 0.05) reduced the level of CAT, MPO and TBARS activities.; iii) exerted gastroprotective activity when assessed using the ethanol-induced gastric ulcer assay, which was reversed by N(G)-nitro-L-arginine methyl esters (L-NAME; an inhibitor of NO synthase) and N-ethylmaleimide (NEM; a sulfhydryl (SH) blocker). MEMM inhibited the lipoxygenase (LOX) and xanthine oxidase (XO) activities with the highest affinity for the former while quercitrin showed high affinity for XO activity.

CONCLUSIONS

MEMM exhibited a gastroprotective activity due partly to the presence of quercitrin, its antioxidant and anti-inflammatory activities, and via the modulation of NO and SH groups.

PEPTIC ULCER FREQUENCY DIFFERENCES RELATED TO H. PYLORI OR AINES

Background Peptic ulcer etiology has been changing because of H. pylori decline. Objectives To estimate peptic ulcer prevalence in 10 years-interval and compare the association with H. pylori and use of non-steroidal anti-inflammatory drugs. Methods Records assessment in two periods: A (1997-2000) and B (2007-2010), searching for peptic ulcer, H. pylori infection and non-steroidal anti-inflammatory drugs use. Results Peptic ulcer occurred in 30.35% in A and in 20.19% in B. H. pylori infection occurred in 73.3% cases in A and in 46.4% in B. Non-steroidal anti-inflammatory drugs use was 3.5% in A and 13.3% in B. Neither condition occurred in 10.4% and 20.5% in A and B respectively. Comparing both periods, we observed reduction of peptic ulcer associated to H. pylori (P=0.000), increase of peptic ulcer related to non-steroidal anti-inflammatory drugs (P=0.000) and idiopathic peptic ulcer (P=0.002). The concurrent association of H. pylori and non-steroidal anti-inflammatory drugs was also higher in B (P=0.002). Rates of gastric ulcer were higher and duodenal ulcer lower in the second period. Conclusions After 10 years, the prevalence of peptic ulcer decreased, as well as ulcers related to H. pylori whereas ulcers associated to non-steroidal anti-inflammatory drugs increased. There was an inversion in the pattern of gastric and duodenal ulcer and a rise of idiopathic peptic ulcer.

Oxidative DNA damage as a potential early biomarker of Helicobacter pylori associated carcinogenesis

Helicobacter pylori infection is an established risk factor for gastritis, gastric ulcer, peptic ulcer and gastric cancer. CagA +ve H. pylori has been associated with oxidative DNA damage of gastric mucosa but their combined role in the development of gastric cancer is still unknown. Here we compare the combined expression of cagA and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in normal, gastritis and gastric cancer tissues. Two hundred gastric biopsies from patients with dyspeptic symptoms, 70 gastric cancer tissue samples and 30 gastric biopsies from non-dyspeptic individuals (controls) were included in this study and 8-OHdG was detected by immunohistochemistry (IHC). Histological features and the presence of H. pylori infection were demonstrated by Hematoxylin and Eosin (HE), Giemsa and alcian blue-periodic acid-Schiff ± diastase (AB-PAS ± D) staining. DNA was extracted from tissues and polymerase chain reaction (PCR) performed to determine the presence of ureaseA and cagA genes of H. pylori. The results showed the presence of H. pylori in 106 (53 %) gastric biopsies out of 200 dyspeptic patients, including 70 (66 %) cases of cagA + ve H. pylori. The presence of cagA gene and high expression of 8-OHdG was highly correlated with severe gastric inflammation and gastric cancer particularly, in cases with infiltration of chronic inflammatory cells (36.8 % cagA + ve, 18 %), neutrophilic activity (47.2 %, 25.5 %), intestinal metaplasia (77.7 %, 35.7 %) and intestinal type gastric cancer (95 %, 95.4 %) (p ≤ 0.01). In conclusion, H. Pylori cagA gene expression and the detection of 8-OHdG adducts in gastric epithelium can serve as potential early biomarkers of H. Pylori-associated gastric carcinogenesis.

Anti-inflammatory, gastroprotective and anti-ulcerogenic effects of red algae Gracilaria changii (Gracilariales, Rhodophyta) extract

Background

Gracilaria changii (Xia et Abbott) Abbott, Zhang et Xia, a red algae commonly found in the coastal areas of Malaysia is traditionally used for foods and for the treatment of various ailments including inflammation and gastric ailments. The aim of the study was to investigate anti-inflammatory, gastroprotective and anti-ulcerogenic activities of a mass spectrometry standardized methanolic extract of Gracilaria changii.

Methods

Methanolic extract of Gracilaria changii (MeOHGCM6 extract) was prepared and standardized using mass spectrometry (MS). Anti-inflammatory activities of MeOHGCM6 extract were examined by treating U937 cells during its differentiation with 10 μg/ml MeOHGCM6 extract. Tumour necrosis factors-α (TNF-α) response level and TNF-α and interleukin-6 (IL-6) gene expression were monitored and compared to that treated by 10 nM betamethasone, an anti-inflammatory drug. Gastroprotective and anti-ulcerogenic activities of MeOHGCM6 extract were examined by feeding rats with MeOHGCM6 extract ranging from 2.5 to 500 mg/kg body weight (b.w.) following induction of gastric lesions. Production of mucus and gastric juice, pH of the gastric juice and non-protein sulfhydryls (NP-SH) levels were determined and compared to that fed by 20 mg/kg b.w. omeprazole (OMP), a known anti-ulcer drug.

Results

MS/MS analysis of the MeOHGCM6 extracts revealed the presence of methyl 10-hydroxyphaeophorbide a and 10-hydroxypheophytin a, known chlorophyll proteins and several unidentified molecules. Treatment with 10 μg/ml MeOHGCM6 extract during differentiation of U937 cells significantly inhibited TNF-α response level and TNF-α and IL-6 gene expression. The inhibitory effect was comparable to that of betamethasone. No cytotoxic effects were recorded for cells treated with the 10 μg/ml MeOHGCM6 extract. Rats fed with MeOHGCM6 extract at 500 mg/kg b.w. showed reduced absolute ethanol-induced gastric lesion sizes by > 99% (p < 0.05). This protective effect was comparable to that conferred by OMP. The pH of the gastric mucus decreased in dose-dependent manner from 5.51 to 3.82 and there was a significant increase in NP-SH concentrations.

Conclusions

Results from the study, suggest that the mass spectrometry standardized methanolic extract of Gracillaria changii possesses anti-inflammatory, gastroprotective and anti-ulcerogenic properties. Further examination of the active constituent of the extract and its mechanism of action is warranted in the future.

Non-Helicobacter pylori, non-NSAIDs peptic ulcers: a descriptive study on patients referred to Taleghani hospital with upper gastrointestinal bleeding

AIM

The purpose of the present study was to evaluate the number and proportion of various causes of upper gastrointestinal bleeding and actual numbers of non-NSAID, non-Helicobacter pylori (H.pylori) peptic ulcers seen in endoscopy of these patients.

BACKGROUND

The number and the proportion of patients with non- H.pylori, non-NSAIDs peptic ulcer disease leading to upper gastrointestinal bleeding is believed to be increasing after eradication therapy for H.pylori.

PATIENTS AND METHODS

Medical records of patients referred to the emergency room of Taleghani hospital from 2010 with a clinical diagnosis of upper gastrointestinal bleeding (hematemesis, coffee ground vomiting and melena) were included in this study. Patients with hematochezia with evidence of a source of bleeding from upper gastrointestinal tract in endoscopy were also included in this study.

RESULTS

In this study, peptic ulcer disease (all kinds of ulcers) was seen in 61 patients which were about 44.85% of abnormalities seen on endoscopy of patients. Among these 61 ulcers, 44 were duodenal ulcer, 22 gastric ulcer (5 patients had the both duodenal and gastric ulcers). Multiple biopsies were taken and be sent to laboratory for Rapid Urease Test and pathological examination. About 65.53% of patients had ulcers associated with H.pylori, 9.83% had peptic ulcer disease associated with NSAIDs and 11.47% of patients had ulcers associated with both H.pylori and consumption of NSAIDs. 13.11% of patients had non-NSAIDs non- H.pylori peptic ulcer disease.

CONCLUSION

The results of this study supports the results of other studies that suggest the incidence of H.pylori infection related with duodenal ulcer is common, and that non-H pylori and non-NSAIDs duodenal ulcer is also common.

Epidemiology of uninvestigated and functional dyspepsia in Asia: facts and fiction

Dyspepsia is a syndrome consisting of epigastric pain, burning, fullness, discomfort, early satiety, nausea, vomiting and belching. Functional dyspepsia (FD) is diagnosed if upper gastrointestinal endoscopy does not show structural abnormality explaining these symptoms. 8%-30% and 8%-23% of Asian people suffer from of uninvestigated dyspepsia and FD, respectively. Most patients with uninvestigated dyspepsia are found to have FD. Patients with FD are usually young and there is no predilection to any gender. Overlap of FD with other functional bowel diseases such as irritable bowel syndrome and gastroesophageal reflux disease is common in Asia. Cultural difference in reporting of symptoms of dyspepsia is well-known. Moreover, dietary factors, socio-cultural and psychological issues, gastrointestinal infection including that caused by Helicobacter pylori, frequency of organic diseases such as peptic ulcer and gastric cancer responsible for dyspeptic symptoms in the study population may also influence epidemiology of dyspepsia. There is considerable heterogeneity in the above issues among different Asian countries. More studies on epidemiology of FD are needed in Asia.

Helicobacter pylori negative, non-steroidal anti-inflammatory drug-negative peptic ulcers in India

INTRODUCTION

The past decade has witnessed a global rise in the prevalence of peptic ulcer disease which is unrelated to non-steroidal anti-inflammatory drugs (NSAIDs) or Helicobacter pylori infection. Although initially recognized in the West, this disease is being increasingly recognized in the Asian population. The higher risk of bleeding and ulcer recurrence in this subgroup of patients highlights the clinical importance of analyzing the changing trends of peptic ulcer disease in developing countries.

AIMS

To assess the proportion of non-NSAID, non-H. pylori peptic ulcer disease in an Indian cohort of patients with peptic ulcer disease managed at a tertiary care center; and to compare the gastric and duodenal ulcer subgroups in these patients.

METHODS

Patients diagnosed with peptic ulcer disease were screened for a history of NSAID use and those with a negative history were tested for H. pylori using a combination of rapid urease test (RUT) and (14)C-urea breath test (UBT). Only those cases which tested negative for both the tests were considered 'H. pylori-negative'. Serum gastrin was measured in all patients included in the study.

RESULTS

Seventy-four gastric ulcer (GU) and 54 duodenal ulcer (DU) patients with no history of NSAID use were enrolled. Of these, 36 GU (45.9%) and 16 DU (29.6%) patients were H. pylori-negative. The proportion of non-NSAID non-H. pylori gastric ulcers was significantly higher than duodenal ulcers (p < 0.05). However, patients who tested negative for H. pylori did not differ significantly from those who tested positive with regard to age, gender, serum gastrin level, and presence of risk factors, like smoking and alcoholism.

CONCLUSION

The current study indicates existence of high proportion of non-NSAID, non-H. pylori peptic ulcer disease in Indian patients.

H. pylori/NSAID--negative peptic ulcer--the mucin theory

The incidence of Helicobacter pylori (H. pylori) and non-steroidal anti inflammatory drug (NSAID)--negative peptic ulcer disease increases, especially in the Western world and in countries where H. pylori infection rate is low. For the diagnosis of "idiopathic ulcer" one should rule out, in addition to H. pylori infection and NSAID or aspirin therapy, also other drugs, other infectious agents, as well as malignant and benign rare diseases. The mucin unstirred layer keeps the pH above the mucosa stable, and prevents the enzymatic attack by pepsin. Inhibition of cyclo-oxygenase by NSAID and aspirin prevents mucin secretion and exposes the mucosa for toxic effect of acid and enzymes. There is also relationship between H. pylori and mucin that from one hand enables mucin invasion but on the other hand protects the gastric mucosa. Mucin genetic or epigenetic changes may be blamed for idiopathic peptic ulcer disease, but this hypothesis should be further investigated.

Review article: Helicobacter pylori-negative duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection rates in duodenal ulcer (DU) patients may be lower than previously estimated.

AIM

To review the real prevalence of H. pylori-negative DUs and its possible causes.

METHODS

Bibliographical searches in MEDLINE looking for the terms 'H. pylori' and 'duodenal ulcer'.

RESULTS

Mean prevalence of H. pylori infection in DU disease, calculated from studies published during the last 10 years including a total of 16 080 patients, was 81%, and this figure was lower (77%) when only the last 5 years were considered. Associations with H. pylori-negative DU were: (1) False negative results of diagnostic methods, (2) NSAID use (21% in studies with <90% infection rate), (3) Complicated DU (bleeding, obstruction, perforation), (4) Smoking, (5) Isolated H. pylori duodenal colonization, (6) Older age, (7) Gastric hypersecretion, (8) Diseases of the duodenal mucosa, (9) Helicobacter'heilmanii' infection and (10) Concomitant diseases.

CONCLUSION

In patients with H. pylori-negative DU disease, one should carefully confirm that the assessment of H. pylori status is reliable. In truly H. pylori-negative patients, the most common single cause of DU is, by far, the use of NSAIDs. Ulcers not associated with H. pylori, NSAIDs or other obvious causes should, for the present, be viewed as 'idiopathic'. True idiopathic DU disease only exceptionally exists.

Prevalence of Helicobacter pylori pathogenicity-associated cagA and vacA genotypes among Pakistani dyspeptic patients

The cytotoxin-associated gene A (cagA), and the vacuolating cytotoxin gene A (vacA) products are considered the most important pathogenic determinants of Helicobacter pylori, a gram-negative bacterium causing gastrointestinal disorders such as duodenal ulcers, gastritis and mucosa-associated lymphoid tissue disease. A higher prevalence of H. pylori has been reported in various regions in the Pakistani population; however, no data are available about the virulence-associated genetic determinants. The objective of this study was to determine the prevalence of virulence-associated genes, cagA, vacA and particularly vacA allelic variants among dyspeptic patients from Pakistan. Gastric biopsy samples were obtained from 78 adult patients presenting dyspepsia symptoms. DNA was isolated and analyzed for the presence of H. pylori and its genotypes by PCR. Genus-specific PCR involving 16S rRNA gene revealed that 66 of the 78 patients were positive for H. pylori, an overall prevalence of 84.6% for this particular study. The most common vacA genotype was s1b/m2 (54.5%) followed by s1a/m1 (19.7%). cagA was positive in 24.2% of the cases and strongly associated with s1a/m1, vacA. The prevalence of virulent cagA, and vacA allelic form s1a/m1 was lower than that reported from neighboring countries.