A prospective evaluation of 200 upper endoscopies performed in Alaska Native persons

OBJECTIVES

To characterize the nature and prevalence of disease in Alaska Native patients referred for evaluation of upper gastrointestinal signs and symptoms.

STUDY DESIGN

Cross-sectional.

METHODS

Two hundred consecutive Alaska Native patients referred to a statewide tertiary center were prospectively evaluated. A standardized data collection form documenting EGD findings was utilized. Routine biopsies of the antrum and fundus were taken on all patients. Additional tissue was obtained from any areas of clinical concern.

RESULTS

Among 200 patients who underwent EGD during the study period, 130 (65%) tested H. pylori-positive on histology. Among 173 patients with histologic evidence of gastritis, 114 (66%) tested H. pylori-positive on histology. Chronic gastritis (87%), gastric ulcer (GU 12%), duodenal ulcer (DU 3%) and gastric cancer (2%) were the predominant findings. The GU:DU ratio was 4:1, the inverse of that reported in the general U.S. population.

CONCLUSIONS

Alaska Native patients referred for upper endoscopy have a high rate of H. pylori infection with predominantly gastric manifestations of disease and a GU:DU ratio, which is the inverse of what is typically seen in the U.S. and other developed countries. The high prevalence of H. pylori in Alaska Native patients resembles prevalence patterns reported from developing countries and may be linked to a rate of gastric cancer that is over three times that found in the U.S. population at large.

Successful Conservative Treatment of a Cholecystoduodenal Fistula Caused by a Cytomegalovirus-associated Duodenal Ulcer

An 87-year-old woman on oral prednisolone was diagnosed with a cholecystoduodenal fistula (CDF) caused by a cytomegalovirus-associated duodenal ulcer (DU) and was managed conservatively. A CDF caused by a DU is extremely rare. Although surgical repair is recommended for the treatment of a CDF caused by cholecystolithiasis, appropriate treatment for CDF caused by a DU remains controversial. This case report of a CDF caused by a DU suggests that conservative treatment is feasible in the absence of DU-associated complications, such as an untreatable hemorrhage or obstruction; this finding is compatible with previously reported cases that were conservatively treated.

Efficacy of ilaprazole in the treatment of duodenal ulcers: A meta-analysis

AIM: To compare the efficacy and tolerance of ilaprazole compared with other proton pump inhibitors (PPIs) in the treatment of duodenal ulcer.

METHODS: An electronic database search of Medline, Embase, the Cochrane controlled trials register, Web of Science, PubMed, and the Chinese Biomedical Literature Database (updated to July 2013), and manual searches were conducted. A meta-analysis of randomized controlled trials comparing the efficacy and tolerance of ilaprazole and other PPIs in the treatment of duodenal ulcers was performed.

RESULTS: Five articles involving 1481 patients were included. The meta-analysis showed no difference in the 4-wk healing rate between ilaprazole and other PPIs [89.7% vs 87.0%; relative risk (RR) = 1.02; 95%CI: 0.98-1.06; Z = 1.00; P = 0.32]. The results did not change in the sensitivity analyses. The meta-analysis indicated that the adverse effect rate in the ilaprazole group was lower than that in the control group, but the difference was not significant (9.7% vs 13.0%; RR = 0.81; 95%CI: 0.60-1.07; Z = 1.47; P = 0.14).

CONCLUSION: Ilaprazole is a highly effective and safe PPI in the treatment of duodenal ulcers. Ilaprazole can be recommended as a therapy for acid-related disorders, especially in Asian populations.

Association of Helicobacter pylori babA2 with peptic ulcer disease and gastric cancer

AIM: To investigate the association between babA2 gene and peptic ulcer disease (PUD) and gastric cancer (GC) in Helicobacter pylori-infected populations.

METHODS: We evaluated the relationship between babA2 and clinical outcomes (PUD and GC) using a meta-analysis. A literature search was performed using the PubMed and Web of Science databases for relevant case-control studies that met the defined inclusion criteria. The ORs and 95%CIs were calculated to estimate the association between babA2 genotype and clinical outcomes. A fixed-effect or random-effect model was performed depending on the absence or presence of significant heterogeneity.

RESULTS: A total of 25 articles with 38 studies met the inclusion criteria and were finally included in this meta-analysis. The results showed that the babA2 genotype was significantly associated with an increased risk of PUD (OR = 2.069, 95%CI: 1.530-2.794, P < 0.001) and especially in the subgroup of duodenal ulcer (OR = 1.588, 95%CI: 1.141-2.209, P = 0.006). Moreover, a significant association between babA2 gene and PUD and duodenal ulcer (OR = 2.739, 95%CI: 1.860-4.032, P < 0.001; OR = 2.239, 95%CI: 1.468-3.415, P < 0.001, respectively) was observed in western countries but not in Asian countries.

CONCLUSION: We demonstrated that the presence of babA2 may be associated with increased risks for PUD, especially duodenal ulcer, in western countries.

Analysis of serum antibody profile against H pylori VacA and CagA antigens in Turkish patients with duodenal ulcer

AIM: To investigate the frequency of seropositivity against CagA, VacA proteins and to determine their independent effects on the development of duodenal ulcer (DU) in Turkish patients.

METHODS: The study was designed as a prospective one from a tertiary referral hospital. Dyspeptic patients who were referred to our endoscopy unit for upper gastrointestinal endoscopy between June 2003 and March 2004 and diagnosed to have DU or nonulcer dyspepsia (NUD) were included. Biopsies from the antrum and body of the stomach were taken in order to assess the current H pylori status by histology, rapid urease test and culture. Fasting sera were obtained from all patients and H pylori status of all sera was determined by IgG antibodies using an enzyme-linked immunosorbent assay (ELISA) kit. All seropositive patients were further analysed using Western blot assays detecting IgG antibodies against CagA and VacA proteins. The χ² test was used for statistical comparison of the values and age-sex adjusted multiple regression analysis was used to determine the independent effects of CagA and VacA seropositivities on the development of DU.

RESULTS: Sixty-three patients with DU and 62 patients with NUD were eligible for the final analysis. Seropositivity for anti-CagA was detected in 51 of 62 (82%), and in 55 of 63 (87%) patients with NUD and DU, respectively (P = no significance), and seropositivity for anti-VacA was found in 25 of 62 (40% ) and in 16 of 63 (25%) patients, with NUD and DU, respectively.

CONCLUSION: These findings suggest that none of these virulence factors is associated with the development of DU in the studied Turkish patients with dyspepsia.

Effects of 3-day IV pantoprazole versus omeprazole on 24-hour intragastric acidity at 3 days in Chinese patients with duodenal ulcer: A single-center, prospective, randomized, comparative, pilot trial

BACKGROUND

Pantoprazole and omeprazole are irreversible proton pump inhibitors that have been found to significantly reduce intragastric acidity in patients with peptic ulcer and/or esophagitis. It has been reported that gastric acid secretion is lower in the Chinese patients compared with the Western population. Based on a MEDLINE search, no studies of the treatment of intragastric acidity with IV pantoprazole have been conducted in the Chinese population to date.

OBJECTIVE

This trial was performed to compare the effects of IV pantoprazole versus omeprazole on 24-hour intragastric acidity in Chinese patients with endoscopically confirmed duodenal ulcer.

METHODS

This single-center, randomized, pilot study was conducted at the Division of Gastroenterology, Department of Medicine, Veterans General Hospital, Taipei, Taiwan. Chinese patients aged 18 to 80 years with endoscopically confirmed duodenal ulcer were randomly assigned to receive a continuous IV infusion of pantoprazole or omeprazole 160 mg/d for 3 days. On days 4 to 14, patients received pantoprazole 40 mg/d or omeprazole 20 mg/d orally. During endoscopic examination at enrollment, an antral biopsy specimen was obtained for rapid urease test, with each patient's agreement, by a blinded investigator. The primary end point was 24-hour intragastric pH on day 3. Secondary end points were percentage of the total time during the 24-hour period (%t) pH <3 and <4 and proportions of patients with healed ulcers on day-14 endoscopy. Endoscopic examination for monitoring of adverse effects of both drugs was repeated 8 weeks after study completion.

RESULTS

A total of 40 patients were enrolled (35 men, 5 women; mean age, 63.3 years; 20 per treatment group). Twenty-four-hour intragastric pH was not significantly different between the omeprazole and pantoprazole groups (mean [SD], 6.61 [1.27] vs 6.84 [0.78]). The %t pH <3 (mean [SD], 8.01% [19.60%] vs 2.70% [7.18%]) and pH <4 (mean [SD], 9.28% [21.41%] vs 3.87% [9.79%]) were not significantly different between the omeprazole and pantoprazole groups. On day-14 endoscopy, ulcers were found to be healed in 3 (15%) patients in each group. In the omeprazole group, 1 (5%) patient experienced mild diarrhea, and 1 (5%) experienced mild abdominal fullness. These adverse effects were considered treatment related. No adverse effects were reported in either treatment group at 8 weeks after the study.

CONCLUSIONS

The results of this pilot study of 3-day treatment with a continuous IV infusion of pantoprazole or omeprazole 160 mg/d found that these 2 treatments had similar effects on 24-hour intragastric pH in this small population of Chinese patients with duodenal ulcer. Both treatments were well tolerated.

[A study on HLA-DQB1 allele associated with genetic susceptibility to duodenal ulcer in Guangdong Hans]

OBJECTIVE

To study the genetic susceptibility of HLA-DQB1 alleles to duodenal ulcer in Chinese Hans from Guangdong area around.

METHODS

Hundred and five patients with duodenal ulcer and hundred and five healthy controls were examined for HLA-DQB1 genotypes. HLA-DQB1 allele typing was carried out by polymerase chain reaction with sequence specific primers (PCR-SSP).

RESULTS

The allele frequency of HLA-DQB1*0602 in patients with duodenal ulcer (64.8%) was significantly higher than that in healthy controls (14.3%).

CONCLUSION

These findings suggest that HLA-DQB1*0602 is a susceptible gene to duodenal ulcer in Guangdong Hans of China. And at HLA-DQB1 site, there are immunogenetic differences between duodenal ulcer patients and healthy controls.

Peptic ulcer disease in the Alaska Natives: a four-year (1967-1971) retrospective study

A four-year retrospective study of peptic ulcer disease in the Alaska Native confirmed our suspicion of a decreased ratio of duodenal to gastric ulcers. There were 92 patients with duo-denal ulcers, 75 with gastric ulcers, 6 with carcinoma of the stomach and 1 with gastric sarcoma. Ulcer disease in the Alaska Natives differs from ulcer disease among the Southwestern Indians as reported by Sievers.

Standard treatment for Helicobacter pylori infection is suboptimal in non-ulcer dyspepsia compared with duodenal ulcer in Chinese

BACKGROUND

Recent studies suggest that the Helicobacter pylori eradication rate in patients with non-ulcer dyspepsia is lower when compared to patients with peptic ulcer diseases.

AIM

The aim of this study was to study the efficacy of triple therapy for H. pylori infection in patients with duodenal ulcer vs. patients with non-ulcer dyspepsia.

METHODS

A total of 582 Chinese patients with proven H. pylori infection were recruited to receive: omeprazole 20 mg, amoxicillin 1000 mg and clarithromycin 500 mg all given twice daily for 7 days (OCA regime). Endoscopy with rapid urease test, histology and culture were performed before treatment. Post-treatment H. pylori status was determined by (13)C-urea breath test. Metronidazole, clarithromycin and amoxicillin resistance was defined as minimum inhibitory concentration (MIC) of >8 microg/mL, >1 microg/mL and >1 microg/mL, respectively.

RESULTS

A significantly higher (intention-to-treat/per-protocol) eradication rate was found in patients with duodenal ulcer than those with non-ulcer dyspepsia (91/94% vs. 84/88% respectively, P = 0.011 and P = 0.016). Clarithromycin resistance rate was higher in patients with non-ulcer dyspepsia than those with duodenal ulcer (14% vs. 6%, P = 0.015). Clarithromycin resistance (40% vs. 5%, P < 0.001, OR 12, 95% CI: 5.7-24.3) and the diagnosis of non-ulcer dyspepsia (91% vs. 84%, P = 0.011, OR 2.0, 95% CI: 1.2-3.3) significantly affected the success of H. pylori eradication.

CONCLUSION

Clarithromycin resistance accounts for the significantly lower and suboptimal H. pylori eradication rate of OCA regimen in Chinese patients with non-ulcer dyspepsia compared to those with duodenal ulcer.

The occurrence of a duodenal or gastric ulcer in two different populations living in the same region: a cross-sectional endoscopical study in consecutive patients

BACKGROUND

Marked differences in prevalence of Helicobacter pylori have been noted between population subgroups living in the same country. A cross-sectional endoscopical study in consecutive patients presenting with active ulcer disease was done, in order to study the H. pylori prevalence in relation to ethnicity in ulcer patients.

METHODS

Consecutive patients with an active duodenal or gastric ulcer were eligible for inclusion. Biopsy specimens from the gastric antrum were taken for detection of H. pylori. People originating from Turkey were studied separately.

RESULTS

In an 8-year period, 375 patients with active duodenal ulcer were seen. Three hundred one patients were ethnic Dutch. Seventy-four of the patients were of Turkish origin. These were statistically significant younger than ethnic Dutchmen, 35.9 vs. 61.2 years (P<0.0001). The number of men was significantly higher, 82.4% vs. 53.8% (P<0.001). H. pylori prevalence was significantly higher in Turkish patients with duodenal ulcer, 91 vs. 74% (P<0.0001). Gastric ulcer was seen in 218 patients. Only five patients were of Turkish descent. The number of Turkish patients was too small to permit statistical analysis, but the percentage of men is higher and the mean age is lower compared with ethnic Dutchmen.

CONCLUSIONS

It is concluded that if ulcer disease and H. pylori prevalence is studied in a given population, ethnicity of the population understudy has to be taken into account.

Helicobacter pylori infection in recurrent abdominal pain

BACKGROUND

Helicobacter pylori is associated with chronic gastritis and peptic ulcer in adults and in children. The purpose of the present study was to analyze the association of recurrent abdominal pain and H. pylori infection in children and to evaluate the efficacy of antimicrobial treatment in patients with evidence of infection.

METHODS

The clinical and histopathologic findings in children who underwent diagnostic upper endoscopy for recurrent abdominal pain were analyzed retrospectively. Patients with evidence of infection with H. pylori were treated with a combination of omeprazole, amoxicillin, and clarithromycin. Efficacy of treatment was assessed using the 13C-urea-breath test.

RESULTS

H. pylori was found in histopathologic sections of 29 (40%) of 73 patients undergoing diagnostic endoscopy for recurrent abdominal pain. Five children (17%) were of Swiss ethnic origin, and 24 (83%) were non-Swiss. All the infected patients had chronic gastritis and 4 (14%) had ulcerations in the duodenum. Treatment with omeprazole, amoxicillin, and clarithromycin resulted in eradication of the infection in all and in resolution of the clinical symptoms in 15 (80%) of 19 patients who had a follow-up examination.

CONCLUSIONS

The presented data suggest that gastritis induced by H. pylori may be associated with recurrent abdominal pain and that in Switzerland infections with H. pylori primarily involve persons who are non-Swiss. A combined therapy results in eradication of the bacterium and in improvement of the clinical symptoms in a significant majority of the patients.

Features associated with painless peptic ulcer bleeding

BACKGROUND

Painless peptic ulcer bleeding is well recognized, although clinical features associated with the absence of abdominal pain have received little attention.

METHODS

Patients admitted for upper GI bleeding at a large inner-city hospital were questioned prospectively at the time of initial evaluation regarding the presence of any dyspepsia and/or abdominal pain, including nocturnal symptoms, within 1 wk of admission. A number of other clinical and endoscopic features were also recorded. The cause of upper GI bleeding was determined in most patients by endoscopy. Patients were excluded if a reliable history could not be obtained or if the ulcer was malignant.

RESULTS

Over the 50-month study period, 449 patients with upper GI bleeding caused by peptic ulcer were evaluated, including 236 with gastric ulcer (53 prepyloric) and 213 with duodenal ulcer (28 with channel ulcer). Of these patients, abdominal pain was absent in 191 (43%; 95% confidence interval, 38-47%). There appeared to be no relationship of pain to race, gender, alcohol use, ulcer location, use and duration of nonsteroidal anti-inflammatory drugs, history of ulcer, or comorbidity. The only statistically significant correlates with abdominal pain were ulcer size (77% of patients with ulcers >2 cm reported pain as compared with 49% of patients with ulcers <1 cm; p < 0.001), tobacco use (p = 0.041), and age <80 yr (p = 0.02).

CONCLUSIONS

Approximately half the patients with a bleeding peptic ulcer have no abdominal pain. Large ulcer size, use of tobacco, and age <80 yr seem to be the main determinants of ulcer-related pain in this setting.

Genetic relationship among isolates of Helicobacter pylori: evidence for the existence of a Helicobacter pylori species-complex

We investigated the population genetics of 23 isolates of H. pylori by allozyme electrophoresis using 16 enzyme loci. Isolates were obtained from adult patients of whom 48% were of Greek extraction. Eight patients (35%) had an active duodenal ulcer. Allelic variation per loci ranged from 2 to 11 alleles. Four major genetic clusters were apparent, having > 75% fixed genetic differences. There was no distinct clustering (clonal structure) on the basis of the geographical origin of the persons from whom isolates were obtained, indicating that this bacterium has not recently jumped a species barrier into humans. Isolates associated with ulcer disease were not monophyletic, with isolates from ulcer patients being found in phylogenetically diverse branches of the dendogram derived from the data. Based on the genetic diversity of H. pylori isolates, we propose that isolates should be classified as belonging not to a single species but to a 'Helicobacter pylori species-complex'.

Ulcer recurrence among Filipino patients: clinical profile and risk factors

Patients with endoscopic diagnosis of gastric and/or duodenal ulcers who eventually had endoscopic confirmation of ulcer healing after any anti-ulcer medication were entered in a 3 year study to determine ulcer recurrence rate, onset of ulcer recurrence and factors associated with ulcer recurrence. Patients from two participating centres who are not on any maintenance treatment had endoscopic examinations at 3, 6 and 12 months after ulcer healing or at any time of symptom recurrence. There were 144 patients entered into the study. The 1 year recurrence rate observed among 125 Filipino patients who completed the study was 73% wherein 71% occurred within the first six months. This was comparable with those reported in the world literature. Thirty-three per cent of those with recurrent ulcers were asymptomatic. The difference in the recurrence rate between gastric and duodenal ulcers was not statistically significant. The only risk factors found to be associated with ulcer relapse were history of smoking and alcohol intake. CLO test for Helicobacter pylori done in 45 patients with recurrent ulcers were all positive, suggesting a strong association between H. pylori and ulcer recurrence.

High prevalence of duodenal ulcer in Indochinese immigrants attending an Australian university hospital

Indochinese migrants to Australia appear to have a high prevalence of duodenal ulcer (DU). To examine this hypothesis a 2 year audit of the prevalence of symptomatic DU among patients attending a general hospital was conducted. The last 6 months of this period included a prospective assessment of ulcer risk factors. In Australian-born patients DU prevalence was 8.4 per 1000 admissions. By comparison, prevalence in Indochinese was 24.6 per 1000 admissions (P < 0.001) with an age standardized prevalence of 30.3 per 1000 (P < 0.001). This represented a relative risk in Indochinese of 2.9 using crude data and 3.6 after age standardization. The increased risk was demonstrated only in males: very few DU were diagnosed in female Indochinese. Ulcer prevalence increased in Indochinese for each age decile between 10 and 80 years, with statistical significance (P < 0.01) reached in the age brackets 0-19, 20-39 and 60-79 years. Ulcer prevalence was also increased in some other ethnic groups. However, when referral bias was taken into account (by calculating the ratio of endoscopies to total admissions for each group), a significant increase in DU prevalence could only be confidently demonstrated in Indochinese. Analysis of risk factors showed that among DU patients, Indochinese were significantly less likely to smoke (P < 0.05) and also had a tendency to ingest less non-steroidal anti-inflammatory drugs (NSAID) and to consume less alcohol.

Gastric and duodenal mucosal prostaglandin concentrations in gastric or duodenal ulcer disease: relationships with demographics, environmental, and histological factors, including Helicobacter pylori

We measured gastric and duodenal mucosal prostaglandin concentrations in 69 patients with active or inactive duodenal or gastric ulcer disease and 26 non-ulcer controls. Each underwent endoscopy enabling us to obtain multiple biopsies from the gastric body and antrum and from the duodenal bulb and postbulbar duodenum for measurement of mucosal prostaglandin concentrations, as well as a single biopsy from each region for mucosal histology. Using a multivariate linear regression model, we found that neither gastric nor duodenal ulcer disease significantly affected gastric or duodenal mucosal prostaglandin concentrations. Mucosal prostaglandin concentrations were similar at the edge of the ulcer and in the adjacent non-ulcerated mucosa. Neither gender symptoms, smoking, use of H2-receptor antagonists, disease activity, nor Helicobacter pylori infection had an independent effect on mucosal prostaglandins in any region. Gastritis in the body of the stomach was associated with significantly higher prostaglandins, while older age was associated with significantly lower gastric and duodenal prostaglandins. Gastroduodenal mucosal prostaglandins are thus not altered in patients with active or inactive peptic ulcer disease, even when multiple demographic and histologic variables are taken into consideration.

A meta-analysis comparing the efficacy of omeprazole with H2-receptor antagonists for acute treatment of duodenal ulcer in Asian patients

A meta-analysis was performed on pooled data from five large double-blind studies (a total of 1057 patients), which were conducted in Asia to compare the effects of omeprazole with H2-receptor antagonists (H2-RA) in duodenal ulcer. As each study followed the same protocol and data evaluation procedures, a detailed analysis of ulcer healing, symptom relief and influence of prognostic factors across the data was possible. Patients received omeprazole 20 mg om or standard doses of H2-RA for a minimum of 2 and a maximum of 4 weeks, depending on healing (as verified by endoscopy). All efficacy analyses were based on per protocol data. The mean healing rates at 2 weeks were 72% for omeprazole and 42% for H2-RA (difference 30%; 95% CI: 24-36%; P < 0.0001) and at 4 weeks were 96% for omeprazole and 83% for H2-RA (difference 13%; 95% CI: 10-17%; P < 0.0001). In addition to treatment, ulcer size had a significant influence on healing, with large ulcers (diameter > 10 mm) taking longer to heal than small ulcers. There was no significant influence of smoking and alcohol drinking on ulcer healing. Patients on omeprazole experienced significantly less epigastric pain after 2 weeks than those on H2-RA, 79% of them being completely symptom-free on omeprazole compared with 65% on H2-RA. The incidence of adverse events was approximately 5% on each treatment and profiles were similar for each drug. It is concluded that omeprazole, even in the presence of adverse prognostic influences, results in significantly better healing of duodenal ulcer and relief from symptoms than H2-RA.

A prospective study of gastric and duodenal ulcer and its relation to smoking, alcohol, and diet

The effects of environmental exposures on the development of gastric and duodenal ulcers were investigated in a prospective study of 7,624 American men of Japanese ancestry in Hawaii. After 149,291 person-years of observation, there were 280 incident cases of gastric ulcer and 149 incident cases of duodenal ulcer. The risk of both gastric and duodenal ulcers progressively increased with increasing pack-years of cigarette smoking. In contrast, alcohol intake was not associated with either type of ulcer. The risk of gastric ulcer was positively associated with the use of table salt/soy sauce, but there was no association with the consumption of other oriental foods. The risk of duodenal ulcer was inversely associated with western style diet around 1940 and with bread intake of two or more servings per day. The authors did not find any protective or adverse effect of milk and fruit consumption on peptic ulcer risk.

A comparison of omeprazole and ranitidine for duodenal ulcer in South African patients. A multiracial study

The study was a multicenter double-blind parallel-group comparison of omeprazole, a proton-pump inhibitor, with the H2-receptor antagonist, ranitidine, in 206 patients with duodenal ulcer. There were 145 men and 62 women of mixed racial origin with an average age of 40 years (range 19-76); 63 of them were white, 7 black, 135 coloured and 1 Asian. Each drug was given for four weeks and ulcer healing rate, symptom relief, and adverse events were recorded and compared between treatment groups. Patients received either 20 mg omeprazole once daily in the morning (N = 104) or ranitidine 300 mg once daily at night (N = 106). Healing rates were significantly higher in the omeprazole group than in the ranitidine group at both two weeks (80% vs 52%, P less than 0.001) and four weeks (95% vs 85%, P less than 0.05), using the "per protocol" approach, and these results were confirmed using the "intention to treat" approach. Omeprazole-treated patients reported significantly less daytime epigastric pain (P = 0.02) and heartburn (P = 0.04) after two weeks than ranitidine-treated patients. By four weeks, there were no significant differences in symptom reporting between groups. Both treatments were well tolerated, and there were no serious adverse events.

Age of onset of symptoms in duodenal and gastric ulcer

The influence of the age of onset of symptoms on various clinical features of peptic ulcer was studied in a personal series of 492 patients (duodenal ulcer 363, gastric ulcer 98, combined gastric and duodenal ulcer 31). Duodenal ulcer patients whose age of onset of symptoms was within the first three decades (n = 166) were more likely to be men (77%) and to have a positive family history of dyspepsia (45%) and a history of haemorrhage (46%) when compared with late onset patients (n = 197, men 57%, positive family history 23%, history of haemorrhage 36%). Early onset duodenal ulcer patients also secreted more gastric acid than late onset patients. In contrast, while early onset gastric ulcer patients were more likely to be men, when compared to late onset patients, the two groups were similar in their family history of dyspepsia, their history of haemorrhage, and their gastric acid output. The age of onset of Malay duodenal ulcer patients (mean (SD) 43.6 (16.0] was higher than those for Chinese patients (33.7 (16.1].

Peptic ulcer in migrants. Seven case-reports from Italy

Migrant workers in Central Europe are reported to suffer from an increased prevalence of both duodenal and gastric ulcer as compared to native population. No information is available, however, as far as Italy is concerned. The Authors have thought of interest to report on 7 cases of peptic ulcer disease occurring in migrant workers in Italy. Patients were young adult males from African or Mediterranean developing Countries. In 5 cases the symptoms of their peptic ulcers began after their arrival in Italy. The etiopathogenesis of peptic ulcer was likely to include an interaction among emotional stress, low income, shift and manual work, cigarette smoking and nonsteroidal antiinflammatory drugs self-administration. This last factor has not been reported in literature. The hypothesis that migrant workers in Italy are a peptic ulcer-prone population needs further confirmation for its clinical and social implications.

Heterotopic and metaplastic gastric mucosa in the duodenum

The presence of gastric epithelium or mucosa at any level of the gastrointestinal tract is a well-known phenomenon. In duodenal mucosa, congenital heterotopic gastric mucosa or acquired metaplastic gastric surface epithelium (MGE) may be found. In the present study 325 duodenal biopsies (260 upper gastrointestinal endoscopy and 65 abdominal surgery biopsies) from 297 patients were retrospectively reviewed. Normal duodenal mucosa was present in 119 specimens, duodenitis in 155 and duodenal ulcer in 51. Heterotopic gastric mucosa was present in only one patient with duodenal ulcer, and MGE in 31% of the biopsies with a normal mucosa, in 21.7% with duodenitis and in 82% with duodenal ulcer (P less than 0.01). MGE was present in 120 biopsies of 109 patients--68 men and 41 women, 91% Jews, and 9% Arabs. The hospitalized population of our region comprised 82% Jews and 18% Arabs. Duodenal ulcer was more frequently found in Arab (69%) than in Jewish patients (41%). We conclude that MGE is a common finding, even in the presence of normal duodenal mucosa (30%) and occurs in most (80%) duodenal ulcer cases. The fact that MGE is more frequent in the Jewish population suggests that a genetic factor may be involved.

Comparison of gastric acid secretion rates and serum pepsinogen I and II concentrations in Occidental and Oriental duodenal ulcer patients

The purpose of these controlled studies was to determine the prevalence of acid-pepsinogen hypersecretion in 173 patients with duodenal ulcer disease [88 Americans (75 men, 13 women) and 85 Chinese (66 men, 19 women)]. One-half to two-thirds of duodenal ulcer patients of either sex had acid hypersecretion or hyperpepsinogenemia, or both. When Chinese and American duodenal ulcer patients were compared, the two ethnic groups had similar serum pepsinogen I and II concentrations and similar maximal acid outputs per kilogram body weight. In contrast, Chinese duodenal ulcer patients had significantly lower basal acid outputs per kilogram body weight than American duodenal ulcer patients. We conclude that acid-pepsinogen hypersecretion is present in the majority of American and oriental duodenal ulcer patients.

Antibody response to Campylobacter pylori in an ethnic group lacking peptic ulceration

The association between duodenal ulcer, gastritis and gastroduodenal colonization with Campylobacter pylori suggests a causal role for this newly described bacterium. In an attempt to challenge the verity of this association we studied a group of people in whom duodenal ulcer is apparently absent. Serological evidence of infection was sought with a sensitive, specific ELISA assay for C. pylori specific IgG and was compared with results from control sera from teenagers referred for respiratory viral serology, volunteer blood bank donors, patients with duodenal ulcers and patients in whom the presence or absence of C. pylori had been determined by histological and microbiological examination of gastric tissue. A relatively isolated group of Australian Aborigines in whom peptic ulceration is virtually unknown, was observed to possess age-specific mean C. pylori antibody levels comparable those found in a group of white Australian dyspeptic patients without microbiological evidence of infection with this organism. The antibody levels of Aborigines were lower than those found in an aged-matched group of 'healthy' white Australians, both of these groups having levels which were significantly lower than the levels found in culture positive white Australian dyspeptic patients. It was found that 21/144 'healthy' white Australians (14.6%) had antibody levels greater than or equal to the lower 99% confidence interval of the mean level found in culture positive patients, while only 2/274 Aborigines (0.7%) had such elevated levels. By contrast, 89/142 (62.7%) patients with endoscopically proven duodenal ulcer had similarly elevated specific antibody levels. These differences were highly significant. We consider these findings to be consistent with the hypothesis that C. pylori is important in the pathogenesis of duodenal ulcer.

Antibody response to Campylobacter pylori in diverse ethnic groups

Antibody response to Campylobacter pylori was measured in ethnic groups of Vietnamese, El Salvadorean and Ethiopian origin. The results were compared with the previously reported antibody titres found in sera of culture positive and culture negative patients, patients suffering from duodenal ulcer, white Australian blood donors and Australian Aboriginals. While in Vietnamese the prevalence of serologically positive sera was found to be similar to the white Australian population, numbers of serologically positive sera in El Salvadorean and Ethiopian ethnic groups was found to be very high. The high incidence of serologically positive sera in the Ethiopians correlated with the reported high incidence of duodenal ulcer in this population.

Peptic diseases compared endoscopically in indigenous Fijians and Indians

Analysis was undertaken of 693 endoscopies performed in Suva, from July 1984 to June 1986. Although Indians presented more often in the ratio of 5:2, Fijians had a higher percentage of abnormalities. Gastric ulcer and carcinoma were more common in Fijians, whereas duodenal ulcer dominated in Indians. Gastric ulcer size and location showed no racial differences. Erosive disease of the oesophagus, stomach or duodenal bulb was uncommon in both races. Fijians were much more likely to present with bleeding, most commonly from gastric or duodenal ulcer (equal numbers).

Nizatidine as maintenance therapy of duodenal ulcer disease in remission

A new H2-receptor antagonist, nizatidine (150 mg h.s.), was compared with placebo as maintenance therapy in a randomized, parallel, double-blind, one-year study of 513 patients with recently healed duodenal ulcer. Endoscopies were performed at 0, 3, 6, and 12 months and at unscheduled times if symptoms of active peptic ulcer disease were present. Cumulative ulcer recurrence rates for nizatidine and placebo were 13 versus 40% at 3 months, 24 versus 57% at 6 months, and 34 versus 64% at 12 months. The differences were significant (p less than 0.001) at each treatment period. Smokers in both treatment groups had significantly greater recurrence rates than non-smokers. Symptoms of peptic ulcer disease were significantly less in nizatidine-treated patients in the first 3 months of treatment. Adverse events, including those related to peptic ulcer disease, occurred more frequently in placebo-treated patients. Nizatidine proved to be safe and effective in preventing recurrences of duodenal ulcer.