Acute perforated duodenal ulcer is not associated with Helicobacter pylori infection

Most patients with chronic duodenal ulcer disease have Helicobacter pylori infection and eradicating it considerably reduces the relapse rate. The prevalence of H pylori in 80 patients (mean age = 52 years, range 17-85) presenting with acute perforated duodenal ulcer was examined and compared with age and sex matched hospital control patients. H pylori state was assessed by serum anti-H pylori IgG (Helico-G kit, Porton) using a titre of 18 or less as negative with a specificity of 89% and sensitivity of 88%. Only 47% of the perforated duodenal ulcer patients were positive for H pylori and this was similar to the value of 50% in the controls. In 51 of the perforated duodenal ulcer patients 14C-urea breath tests were also performed 4-10 weeks after surgery and this confirmed that only 49% were positive for H pylori. None of these patients had received perioperative drugs that might have eradicated the infection. The H pylori positive and H pylori negative perforated duodenal ulcer patients were similar with respect to age (53, 51), smoking (84%, 83%), and consumption of more than 15 units of alcohol per week (42%, 38%). Duodenal ulcer disease had been diagnosed before acute perforation in only 24% of those with H pylori and also 24% of those without the infection. Regular non-steroidal anti-inflammatory drug (NSAID) use was common in both those with (44%) and without (45%) H pylori. In conclusion, the lack of association of acute perforated duodenal ulcer and H pylori infection suggests that perforated duodenal ulcer has a different pathogenesis from chronic duodenal ulcer disease, and that the first should not be regarded simply as a complication of the second.

Helicobacter pylori infection in perforated peptic ulcer disease

This study examined a possible aetiological agent, namely, Helicobacter pylori, in perforated peptic ulcer disease and its relationship to persisting ulcer. Twenty-nine patients with perforated peptic ulcer underwent simple closure of the perforation at laparotomy. A 13C urea breath test carried out on the eighth day after operation was positive in 24 patients. Fourteen of 17 patients who underwent upper gastrointestinal endoscopy 6 weeks after discharge from hospital had a positive 13C urea breath test. The biopsy urease test performed on mucosal samples taken at endoscopy was positive in 12 of these 14 patients, indicating continuing active infection with H. pylori. Seven patients with positive 13C urea breath and biopsy urease tests had persisting duodenal ulceration. None of the three patients with a negative 13C urea breath test had evidence of duodenal ulceration at endoscopy. The association between a high rate of duodenal ulcer persistence and a high incidence of H. pylori infection suggests that antibiotic therapy to eradicate this microorganism should be given to all patients with perforated peptic ulcer disease.

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies

BACKGROUND

The possible advantage of eradication of Helicobacter pylori in patients with perforated duodenal ulcer is unknown. This study was planned to assess the prevalence of H. pylori after simple closure of a perforated duodenal ulcer and to study the effect of H. pylori eradication on ulcer persistence and recurrence.

METHODS

Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group). A second group of 60 patients was reviewed 5 years or more after perforation closure (retrospective group). The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls. Patients in the prospective group were randomized to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth subcitrate, metronidazole and tetracycline) after operation. The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulcer were studied. In the retrospective group long-term ulcer recurrence was correlated with H. pylori status.

RESULTS

The prevalence of H. pylori in patients with perforated duodenal ulcer was not significantly different from that in controls. At every interval of follow-up in the prospective group and in the retrospective group the H. pylori infection rate was significantly higher in patients who had recurrent or residual ulcers.

CONCLUSION

Eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent ulcers.

Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, prognosis and susceptibility to fluconazole and amphotericin B

Sixty-two cases of peritonitis due to peptic ulcer perforation were diagnosed between January 2000 and December 2000. Of these 62 cases, 23 isolates of Candida in 23 cases (CP) were cultured from peritoneal fluid. Cultures of peritoneal fluid of 10 (BP) of the remaining 39 cases was positive for bacteria only. Cultures of peritoneal fluid of the remaining 29 cases was negative. Comparison of CP, BP and culture-negative cases did not reveal any significant risk factor. Of the 23 Candida isolates, the Candida species and 48-h MICs of fluconazole and amphotericin B (mean, range ug/ml) were C. albicans 18 (0.688, 0.125-1.0; 0.297, 0.031-0.5), C. glabrata 3 (0.542, 0.125-1.0; 0.25, 0.125-0.5), C. tropicalis 1 (0.25; 0.5), C. intermedia 1 (1.0; 0.125) respectively. Mortality rates of CP, BP and culture-negative peritonitis due to infection were 5/23(21.7%), 0/10 and 1/29(3.4%) respectively. Without effective antifungal therapy, the mortality rate of CP was not low.

Helicobacter pylori and perforated peptic ulcer prevalence of the infection and role of non-steroidal anti-inflammatory drugs

AIMS

To study the prevalence of Helicobacter pylori infection in patients with perforated peptic ulcer, to compare it with the prevalence in patients with uncomplicated ulcer, and to assess the role of non-steroidal anti-inflammatory drugs in this prevalence.

METHODS

Consecutive patients with perforated peptic ulcer were included in this retrospective study. As a control group, patients undergoing elective outpatient evaluation for the investigation of dyspepsia during the same time period and found to have a peptic ulcer at endoscopy were included. A 13C-urea breath test was carried out in all patients to diagnose H. pylori infection.

RESULTS

Sixteen patients with perforated peptic ulcer and 160 with non-complicated peptic ulcer were included. Sixty-two percent of the patients with perforated peptic ulcer were infected by H. pylori, while the microorganism was detected in 87% of the patients without this complication (P = 0.01). Non-steroidal anti-inflammatory drugs intake was more frequent (P = 0.012) in patients with perforated peptic ulcers (56%) than in those without perforation (26%). H. pylori prevalence in perforated peptic ulcers was of 44% in patients with non-steroidal anti-inflammatory drugs intake, but this figure increased up to 86% when only patients not taking non-steroidal anti-inflammatory drugs were considered (P = 0.09). In the multivariate analysis, non-steroidal anti-inflammatory drugs intake was the only variable that correlated with peptic ulcer perforation [odds ratio, 3.6 (95% confidence interval, 1.3-10); P = 0.016].

CONCLUSION

The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is, overall, of only about 60%, which contrasts with the 90-100% figure usually reported in non-complicated ulcer disease. However, the most important factor associated with H. pylori-negative perforated peptic ulcer is non-steroidal anti-inflammatory drugs use, and if this factor is excluded, prevalence of infection is almost 90%, similar to that found in patients with non-perforating ulcer disease.

High prevalence of Helicobacter pylori infection in duodenal ulcer perforations not caused by non-steroidal anti-inflammatory drugs

There has been controversy regarding the relationship between Helicobacter pylori and perforated peptic ulcer, which is known to have a high recurrence rate if only simple patch repair is performed. The aim of this study was to evaluate the association between H. pylori infection and intake of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with perforated duodenal ulcers. Of the 73 patients recruited over a 16-month period, 51 (70 per cent) had evidence of H. pylori infection by intraoperative gastroscopy and antral biopsies. The infection rate rose to 80 per cent if NSAID users were excluded. The H. pylori-infected group was significantly younger (mean 47.6 versus 62.5 years), with a male preponderance (49 of 51 versus 14 of 22 patients), and had significantly less NSAID consumption (three of 51 versus ten of 22) and more prolonged dyspepsia (40 of 51 versus ten of 22), compared with H. pylori-negative patients. H. pylori infection probably plays an important role in the causation of non-NSAID-induced duodenal ulcer perforation. Whether eradication of the bacteria can alleviate the strong ulcer diathesis in this subgroup of patients is unknown.

Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment

Although the role of Helicobacter pylori infection on noncomplicated peptic ulcer disease has been definitively established, the precise relationship between the organism and complicated ulcer has hardly been studied. The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is of only about 65-70%, which contrasts with the almost 90-100% figure reported in noncomplicated ulcer disease. However, H. pylori infection rates in various studies range markedly from 0% to 100%, suggesting that differences in variables as number and type of diagnostic methods used to diagnose H. pylori infection, or frequency of nonsteroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. Recurrent ulcer disease after peptic ulcer perforation mainly occurs in patients with H. pylori infection, which suggests that the microorganism plays an important role in this complication. All patients with perforated peptic ulcer should be treated by simple closure of the perforation and with therapy aimed at healing of the ulcer and eradicating the H. pylori infection, as disappearance of the organism prevents, or at least decreases, ulcer recurrence and ulcer perforation in patients with H. pylori-associated perforated ulcers after simple closure. Therefore, H. pylori eradicating treatment should be started during the immediate postoperative period. The patients with intractable recurrent symptoms of peptic ulcer despite adequate medical treatment, but without H. pylori infection (e.g. a patient using nonsteroidal anti-inflammatory drugs), is probably the only remaining indication for elective definitive surgical treatment of peptic ulcer disease.

Density of Helicobacter pylori infection in patients with peptic ulcer perforation

BACKGROUND

A lack of change in prevalence of severe ulcer complications requiring emergency operation has been reported, despite the common use of histamine-2 (H2)-receptor antagonists and proton pump inhibitors. This may be attributable to use of ulcerogenic drugs or Helicobacter pylori (HP) infection, or both. In this study, HP infection was evaluated semiquantitatively in patients with peptic ulcer who required surgery, and the severity of histologic change was investigated.

METHODS

We reviewed a total of 113 consecutive patients (98 men and 15 women) operated on for perforation, hemorrhage, or stenosis of gastroduodenal ulcer between January 1986 and December 1995. Detection of HP was carried out by immunohistochemical staining. We graded the density of HP infection according to the number of individual HP bacteria counted in a highly magnified visual field (x 1,000 of light microscopy). The grade of HP infection was defined as follows: (0) = 0; (1+) = 1-9; (2+) = 10-29; (3+) = 30-99; (4+) > or = 100. The severity of gastritis was evaluated by histologic examination using the criteria of Rauws.

RESULTS

Although the number of operations for gastroduodenal ulcer declined significantly, the rate of emergency operation for gastroduodenal ulcer increased from 60% to 90%, with the result that the frequency of operations for perforation or bleeding remained virtually constant and that for stenosis significantly decreased. HP infection was more prevalent in perforated ulcer (92%) than hemorrhagic ulcer (55%) or stenotic ulcer (45%). The grades of HP infection were 3.0 +/- 0.14 (mean +/- SEM) in perforated ulcer, 2.3 +/- 0.34 in hemorrhagic ulcer, and 2.5 +/- 0.22 in stenotic ulcer. Perforated ulcer was associated with significantly more severe HP infection and gastritis changes than hemorrhagic ulcer or stenotic ulcer.

CONCLUSIONS

This study indicates that patients with perforated ulcer were infected with HP more severely than those with hemorrhagic ulcer or stenotic ulcer at the time of surgery. A close relationship was observed between the perforated ulcer and the density of HP infection determined semiquantitatively using immunohistochemical stain.

Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer

Background

The incidence of postoperative fungal infection is increasing and the gastrointestinal tract is the major source, but antifungal therapy in perforated peptic ulcer (PPU) is still controversial. The aim of this study was to determine the significance of intraoperative peritoneal fluid culture of fungus and establish the indications for treatment.

Methods

Between July 1997 and September 2001, all patients admitted with a PPU were studied. Clinical data and peritoneal fluid for culture were collected. Risk factors for a positive peritoneal fluid culture of fungus and outcome were evaluated, and related to the development of surgical site infection, duration of hospital stay and mortality rate.

Results

One hundred and forty-five patients with a PPU were included; 63 (43·4 per cent) had positive peritoneal fluid fungal culture. Age, preoperative organ failure, delay in operation, high Mannheim Peritonitis Index (MPI) and Acute Physiology And Chronic Health Evaluation (APACHE) II scores, and preoperative antibiotic therapy were risk factors for a positive fungal culture. Sex and an MPI score of 20 or more remained significant in multivariate analysis (P < 0·001). Patients with a positive fungal culture had a higher incidence of surgical site infection, a longer hospital stay and a significantly higher mortality rate, especially when this was combined with a high MPI score.

Conclusion

Positive peritoneal fungal culture was common and was a significant risk factor for adverse outcome in patients with a PPU. A high MPI score could be used as an indicator for prophylactic antifungal therapy.

Role of Helicobacter pylori infection in perforation of peptic ulcer: an age- and gender-matched case-control study

Evidence showed a marked decrease in recurrence rate of peptic ulcer after eradication of Helicobacter pylori infection. However, whether H. pylori infection is etiologically related to perforation of peptic ulcer remains to be clarified. We therefore conducted an age- and gender-matched case-control study between perforated and nonsurgical peptic ulcers in H. pylori infection and examined differences in the cytotoxin genes cagA and vacA. Serum H. pylori IgG antibody (ELISA) was positive in 20/21 (95%) of perforated vs. 37/40 (93%) of nonsurgical duodenal ulcers and in 5/5 (100%) of perforated vs. 24/28 (86%) of nonsurgical gastric ulcer patients. Positivity of H. pylori DNA in gastric juice, which was amplified by PCR and identified by Southern blot hybridization, was 17/23 (74%) of perforated vs. 32/45 (71%) in the nonsurgical duodenal ulcer group. Positivity of the cytotoxin genes cagA and vacA in H. pylori DNA-positive gastric juice was as follows: perforated vs. nonsurgical duodenal ulcer, cagA 11/ 13 (85%) vs. 24/27 (89%); vacA1: 9/13 (69%) vs. 22/27 (82%); vacA2 8/13 (62%) vs. 21/27 (78%). There were no significant differences between the perforated and nonsurgical peptic ulcer groups for these H. pylori serum and gene markers. It is assumed that H. pylori infection is not etiologically related to perforation of peptic ulcer.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom

BACKGROUND

The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer.

METHODS

A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001.

RESULTS

Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01).

CONCLUSION

Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.

Helicobacter pylori eradication prevents recurrence after simple closure of perforated duodenal ulcer

BACKGROUND AND AIM

Evidence remains inconclusive as to whether eradication of Helicobacter pylori prevents ulcer relapse after simple closure of a perforated duodenal ulcer. This study was conducted to determine the effect of H. pylori eradication using a quadruple drug regimen along with a probiotic on ulcer recurrence after perforation closure.

METHODS

A total of 93 patients who had presented with perforated duodenal ulcer and had a simple closure of a duodenal perforation comprised the study group. Three months postoperatively, patients who were found to be positive for H. pylori infection (n = 60) were administered quadruple therapy consisting of omeprazole, clarithromycin, amoxicillin and colloidal bismuth subcitrate for 10 days along with the probiotic Lactobacillus sporogenes for 14 days. Diagnosis of H. pylori was carried out by urease test and histology. Patients were followed for 18 months. Recurrence of ulcer was analyzed for correlation with H. pylori status.

RESULTS

Of 60 patients who received H. pylori eradication therapy, 53 were available for subsequent follow up. H. pylori eradication was achieved in 43/53 (81.1%) patients. The ulcer recurrence in the eradicated group was 18.6% (8/43) compared to 70% (7/10) in the noneradicated group (P = 0.003).

CONCLUSION

Eradication of H. pylori significantly reduces the relapse of duodenal ulcer after simple closure of perforation. Anti H. pylori therapy must be recommended for all H. pylori positive patients after simple closure of a perforated duodenal ulcer.

Tuberculous gastric perforation: report of a case

A 21-year-old woman presented with a 2-day history of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed a perforation in the lesser curve of the stomach. The patient suffered a bout of hematemesis, following which an endoscopy showed a bleeding blood vessel at the edge of the perforation. We performed an emergency distal gastrectomy, including the ulcer site. Histopathological examination revealed tuberculous granulation tissue and acid-fast bacilli in the ulcer. The patient was given antituberculosis therapy (ATT) postoperatively, and was well when last seen 1 year 5 months after surgery. We analyzed the clinical data of five cases of tuberculous gastric perforation (TGP), reported between 1948 and 2003, including our patient. The patients ranged in age from 21 to 45 years, with a mean age of 36.8 years (SD +/- 10.21), and a male to female ratio of 3 : 2. The diagnosis was confirmed by surgery or autopsy. Abdominal lymphadenopathy was present in all patients. Gastrectomy was performed in four patients, and two were given ATT. All four patients in the previous reports died of their disease.

Diversity of Helicobacter pylori genotypes among Estonian and Russian patients with perforated peptic ulcer, living in Southern Estonia

To compare the genomic variation of Helicobacter pylori in samples obtained from patients with perforated peptic ulcer, living in the same area of Estonia but belonging to different nationalities, 50 non-consecutive patients (32 Estonians and 18 Russians) admitted in the Tartu University Hospital in 1997-1999 were studied. Gastric samples of antral mucosa were obtained during operation and analysed histologically and with PCR for detection of different genotypes of H. pylori (cagA and vacA s and m subtypes). Among the 50 perforated peptic ulcer patients with histologically proven H. pylori colonisation no sample of gastric mucosa showed the s1b subtype of the vacA gene. The perforated peptic ulcer patients were mainly infected with cagA (82%) and s1 (98%) genotypes of H. pylori. The distribution of s1a/m1, s1a/m2 and s2/m2 subtypes of vacA genes was statistically different in Estonian and Russian patients (P<0.05). In conclusion differences in the distribution of vacA s and m subtypes of H. pylori were revealed between Estonian and Russian patients with perforated peptic ulcer from Southern Estonia.

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.

Helicobacter genotyping and detection in peroperative lavage fluid in patients with perforated peptic ulcer

INTRODUCTION AND OBJECTIVES

Certain Helicobacter pylori genotypes are associated with peptic ulcer disease; however, little is known about associations between the H. pylori genotype and perforated peptic ulcer (PPU). The primary aim of this study was to evaluate which genotypes are present in patients with PPU and which genotype is dominant in this population. The secondary aim was to study the possibility of determining the H. pylori status in a way other than by biopsy.

MATERIALS AND METHODS

Serum samples, gastric tissue biopsies, lavage fluid, and fluid from the nasogastric tube were collected from patients operated upon for PPU. By means of PCR, DEIA, and LIPA the presence of the "cytotoxin associated gene" (cagA) and the genotype of the "vacuolating cytotoxin gene" were determined.

RESULTS

Fluid from the nasogastric tube was obtained from 25 patients, lavage fluid from 26 patients, serum samples from 20 patients and biopsies from 18 patients. Several genotypes were found, of which the vacA s1 cagA positive strains were predominant. Additionally, a correlation was found between the H. pylori presence in biopsy and its presence in lavage fluid (p=0.015), rendering the latter as an alternative for biopsy. Sensitivity and specificity of lavage fluid analysis were 100% and 67%, respectively.

CONCLUSION

This study shows the vacA s1 cagA positive strain is predominant in a PPU population. The correlation found between the H. pylori presence in biopsy and its presence in lavage fluid suggests that analysis of the lavage fluid is sufficient to determine the H. pylori presence. Risks associated with biopsy taking may be avoided.

[Treatment of perforated gastroduodenal ulcer by simple suture followed by Helicobacter pylori eradication]

AIMS OF THE STUDY

To determine the prevalence of Helicobacter pylori (HP) infection in Vietnam in case of perforated gastro-duodenal ulcer and to evaluate efficiency of medical treatment to obtain eradication of HP and ulcer healing.

PATIENTS AND METHODS

One hundred and eleven patients with perforated gastro-duodenal ulcer underwent surgical suture. HP infection was diagnosed by urease test and pathologic examination of peroperative antral biopsies, and by postoperative detection of HP-specific immunoglobulins G. HP infection was defined by positivity of at least one test. Medical treatment included omeprazole, clarithromycin, and amoxicillin for 7 days followed by omeprazole for 3 weeks for duodenal ulcer and 5 weeks for gastric ulcer. Follow-up endoscopy with biopsies was performed 4 to 6 weeks after treatment cessation.

RESULTS

Among 111 patients, 107 (96%) were infected by HP. The 4 patients non-infected by HP were treated by omeprazole alone and excluded from the study. Ulcer healed in 99 patients (93%). HP eradication was obtained in 102 patients (95%). The 8 patients with a non-healed ulcer and the 5 patients in whom HP eradication was not obtained at the first endoscopic control received additional medical treatment. Ultimately HP eradication and ulcer healing were obtained in all cases.

CONCLUSION

In a country in which prevalence of HP infection is high, acid-reduction surgery is unnecessary in case of perforated gastro-duodenal ulcer treated by simple surgical closure.

Gastric ulcer associated with a Helicobacter-like organism in a cougar (Felis concolor)

A 12-year-old captive female cougar (Felis concolor) died following perforation of a gastric ulcer. Histologically, erosions and ulcers were present in the antral area of the stomach. Fibroplasia and infiltrates of neutrophils bordered the ulcers. Modified Steiner silver stain revealed numerous tightly coiled helical bacteria. The bacteria stained positively with a rabbit polyclonal anti-Helicobacter pylori antibody. Morphology, location, and positive immunohistochemical staining suggests that the organism is a Helicobacter.

Persistence of Helicobacter pylori infection in patients with peptic ulcer perforation

OBJECTIVE

In patients with perforated peptic ulcer (PPU) the convergence between the high eradication rate of Helicobacter pylori infection and low rates of ulcer relapse after treatment has been associated with reinfection by non-virulent strains. The objective of this study was to evaluate the persistence of infection by virulent H. pylori strains and ulcer recurrence in 33 patients with PPU one year after surgery and antimicrobial treatment.

MATERIAL AND METHODS

The histological evaluation and molecular detection of H. pylori cagA and ureA genes, vacA allelic types and the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analyses of the glmM gene products from antral mucosa specimens were performed initially, 2-5 months and 1 year after therapy.

RESULTS

The density of H. pylori colonization was temporarily decreased (p<0.05) 2-5 months after therapy. After one year, complete eradication was achieved in only 7 patients (23%) at histological examination and recurrent ulcers were found in 3/33 (9%) patients. The vacA s1a allelic type of cagA-positive strains persisted in 19/33 (58%) PPU patients with identical PCR-RFLP fingerprints in 8/9 (89%) of the patients.

CONCLUSIONS

In PPU patients with a low eradication rate of H. pylori infection after surgical and antimicrobial treatment, the frequent recrudescence of the infection is mostly caused by the persisting virulent strains of the cagA and vacA s1a subtypes. In the 1-year follow-up period the recurrent ulceration can be postponed just by the lowered colonization density of H. pylori after eradicative therapy.

Candida albicans aggravates duodenal ulcer perforation induced by administration of cysteamine in rats

BACKGROUND

Candida sp are frequently isolated from the ascitic fluid of patients with perforated ulcers. The present study was performed to examine whether Candida infection may be involved in the process of ulcer perforation.

METHODS

Male Wistar rats were divided into a saline group (n = 15) and a Candida group (n = 17). Cysteamine-HCl (Sigma; 31 mg/100 g) was administered thrice on day 1 to both groups of animals. Candida albicans at a density of 10(8) in 0.5 mL of saline was administered 1 h before, and 12 h and 24 h after the first administration of cysteamine in the Candida group.

RESULTS

Perforated duodenal ulcers were observed in 94.1% of the rats in the Candida group, but only 26.7% of the rats in the saline group (P < 0.01). The area of the duodenal ulcers in the Candida group was 40.89 +/- 33.07 mm2, whereas that in the saline group was 16.53 +/- 20.4 mm2 (P < 0.05). The mortality rate was significantly higher in the Candida group than in the saline group. In the Candida group, colonization by C. albicans was recognized at the ulcer base, surrounded by marked granulocytic infiltration. The number of eosinophils infiltrating the ulcer base was also significantly greater in the Candida group than in the saline group. Immunohistochemical analysis revealed the expression of secretory aspartyl protease (SAP) in the region of the ulcer showing colonization by C. albicans in the Candida group.

CONCLUSION

Candida albicans aggravates duodenal ulcer perforation in the experimental model of cysteamine-induced duodenal ulcer perforation. The present findings suggest that SAP and host-parasite relationships, including granulocyte-dependent mechanisms, may be involved in the aggravation of ulcer perforation by C. albicans.

Surgical management of perforated peptic ulcer disease

BACKGROUND

Surgery for perforated peptic ulcer disease is one of the most common emergency procedures carried out in the western world. The role of postoperative empiric Helicobacter Pylori eradication therapy is controversial.

METHODS

The clinical, operative and postoperative surveillance details of 84 consecutive patients who underwent surgery for perforated peptic ulcer were reviewed.

RESULTS

All patients underwent omentopexy +/- simple closure followed by proton pump therapy. Patients were followed-up for an average of 44 +/- 19 months. Females were older than male patients (59 +/- 20 vs. 46 + 17 years; p<0.05), presented with symptoms of a longer duration (17.9 +/- 16 vs. 8.9 +/- 9 hours; p=0.045) and had a higher mortality rate (18% vs 3%; p<0.05). Seventy-nine per cent of patients received postoperative empiric Helicobacter Pylori eradication therapy.

CONCLUSIONS

Surgery for perforated peptic ulcer is associated with a significant perioperative mortality rate. Elderly female patients are particularly at risk.