Management of duodenal ulcer disease in the era of H. pylori.

BACKGROUND: Today it is expected that the great majority of patients with duodenal ulcer (DU) respond to H. pylori eradication treatment without DU recurrence. The aim of the research is to identify patients who need a different therapeutic approach and the best management of their disease. METHODS: We examined retrospectively the medical history of 474 patients (326 males, mean age 61 years), followed up in 5 years in the outpatients department of a third level GI Center. From our research, 5 subgroups of patients emerged: 1) 63.5% carrying H. pylori infection, with successful eradication treatment and without DU recurrence; 2) 4% failing 3 courses of H.pylori eradication treatment; 3) 11% with DU lacking evidence of H. pylori infection or relapsing after verified eradication; 4) 8% being treated with NSAIDs; 5) 13% with DU complicated by hemorrhage or perforation. RESULTS: 23% of patients with DU need long-term therapy after H. pylori eradication treatment. Concerning this, the percentage of ulcerous recurrences in patients receiving anti-H2 therapy is 18.5%, but decreases considerably to 2% when PPI were used. CONCLUSIONS: Although representing the mainstay of DU therapy, H. pylori eradication treatment may not abolish all issue in DU management. Actually, of DU patients referred to a third level GI Center, 23% need a different therapeutic approach, which results from a thorough analysis of the medical history of the patient.

[Recurring duodenal ulcer. Evaluation of previous complications as a predictive factor of ulcer recurrence after eradication of Helicobacter pylori]. / Ulcera duodenale recidivante. Valutazione della pregressa complicanza come fattore predittivo di recidiva ulcerosa dopo eradicazione dell'Helicobacter pylori.

Duodenal ulcer is a chronic disease, punctuated by acute relapses. The pathogenic mechanism in 90-100% of cases is infection by Helicobacter pylori. Two major strains exist of this bacterium: I strain, which secretes a vacuolating cytotoxin (Vac-A), and another protein named cytotoxin-associated (Cag-A) and type II strain, unable to produce both proteins and unable to produce duodenal pathology. We sought to identify the natural history of relapsing duodenal ulcer after cure of the bacterial infection. In particular, we followed the outcome of patients who repeatedly had bled from their recurrent ulcer disease, after success in eliminating the microorganism from the stomach. None of 12 repeated bleeders had an ulcer recurrence after the cure of Helicobacter pylori infection. Only 3 (5%) of 60 frequent relapser had a new episode of duodenal ulcer during a follow-up reinfection by Helicobacter pylori. We demonstrated that the cure of bacterial infection is also the cure of duodenal ulcer recurrence, but for a few cases, in the latter, event one could hypothesize a defect in the production of growth factors (Epidermal Growth Factor, Fibroblast Growth Factor) or of cellular polyamines synthesis. It is important to improve the diagnosis of reinfection by implementing the urea breath test.

[Indications and limitations of 24-hour gastric pH-metry. Personal experience]. / Indicazioni e limiti della pH-metria gastrica delle 24 ore. Esperienze personali.

After a brief introduction regarding 24-hours gastric pH monitoring and a description of the instruments used, indications and the analysis of findings, the authors report their personal experience based on the study of 4 groups of subjects (healthy, hyersecretory, hyposecretory, dyspeptic). The analysis of pH-metries observed in these subjects show that 24-hour monitoring of gastric pH is a reliable method for assessing hypersecretion or hyposecretion of gastric acidity, whereas it is only of relative importance in essential dyspepsia. The authors therefore indicate the parameters to be taken into account in the evaluation of pH-metry findings in hypersecretory patients: 1) the percentage time of which pH is less than 1 (mean value 46.20 +/- 28.2);2) the pH pattern assessed according to the circadian rhythm which shows a prandial and post-prandial tamponade which is lower than normal with a rapid return of pH to extremely low values; 3) the visual graphic assessment for an overall judgement of pH patterns; and in hyposecretory patients: 1) the percentage time for which pH is higher than 7 (mean value 47.92 +/- 52.08); 2) enhanced pH levels ranging between 0 and 4 (mean percentage 9.67 divided by 27.08); 3) pH values at times 0, 1, 2, 3 which confirm hyposecretion in the meal causes a marked and long-lasting tamponade with pH levels above 6-7. Even in these cases the visual graphic assessment is important for an overall definition of 24-hour ph patterns.

Biliary reflux after cholecystectomy: a prospective study.

The authors carried out a prospective study to ascertain whether cholecystectomy itself might be the cause of duodenogastric reflux. Patients with cholelithiasis were examined and underwent the following tests: hemanalysis, gastroscopy with biopsy, 24 hour pH-metry and acetaminophen test. Twelve patients were selected. Six months after the operation the tests were repeated. All patients were asymptomatic. Hemanalysis was normal in all 12 patients and no difference was seen in the tests of 5 of the patients; however in the other 7 differences were observed in all the tests. The authors conclude that cholecystectomy helps to provoke duodenogastric reflux in predisposed patients, and that this reflux may be asymptomatic.

Different effects of atropine and cimetropium bromide on gastric emptying of liquids and antroduodenal motor activity in man.

Atropine (1 mg intravenously) and a new antimuscarinic compound, cimetropium bromide (5 mg intravenously), as well as placebo (physiological saline) were tested for their effects on gastric emptying and antroduodenal motility in healthy humans. In a first single-blind cross-over study, the emptying rate was assessed in 12 subjects by measuring paracetamol absorption. In a second single-blind parallel-group study, antroduodenal motor activity was measured in 20 subjects through four perfused open tip catheters with orifices positioned in the antroduodenal region. Atropine, unlike cimetropium bromide, significantly delayed gastric emptying. Antral and duodenal motility index was reduced significantly by atropine, but not by cimetropium bromide. Heart rate significantly increased only after atropine. Three subjects taking atropine complained of dry mouth and one of blurred vision. In conclusion, the results of these studies show that atropine, unlike cimetropium bromide, strongly inhibits gastric emptying of liquids and reduces antroduodenal motor activity in man.

[Treatment of recurrences of duodenal ulcer: seasonal or long-term therapy?]. / Trattamento delle recidive dell'ulcera duodenale: terapia stagionale o long-term?

Many recently published papers have focused on the problem of the treatment of recurring duodenal ulcers and time trends, given the rate of late recurrences observed with long-term protocol. The results of trials with seasonal protocols are therefore presented. Given the seasonal trends in duodenal ulcer recurrence, a stable oscillatory behaviour with fluctuations of 6-month periodicity was demonstrated with the use of conventional statistical methods. With the utilization of the more sophisticated spectral analysis of data from many centers in Italy, the time trends of this condition have been characterized in greater detail, and cycles of increased recurrences every 4, 6 and 12 months have been evidenced. On the basis of these data, a randomized controlled trial in 60 patients treated with cimetidine, 30 patients in long-term and 30 in seasonal treatment showed similar results: the recurrence rate was 30% in both groups over a 12-month period. Preliminary results of a new multicenter trial in 110 patients with the same protocol (cimetidine 400 mg nocte), confirm these results. In conclusion, the two trials tend to confirm the validity of preventive protocols that respect seasonal fluctuations.

Monthly fluctuations of active duodenal ulcers.

In an attempt to verify whether the periodicity of ulcer-related symptoms would be confirmed by a spring and fall exacerbation of peptic ulcers, we have analyzed the monthly variation of active duodenal ulcers found at endoscopy of the upper gastrointestinal tract in the years 1979-1981. Control diagnoses were active gastric ulcers, gastric and rectal adenocarcinomas, and rheumatoid arthritis. Data were also available on hospital admission for perforated ulcers. The calendar fluctuation of active duodenal ulcer is characterized by a significant fall in August which is associated with July and fall peaks. This pattern of variation for duodenal ulcer was evident in both sexes and across the different decades of age. Duodenal ulcer diagnosis and hospitalization for perforated ulcer fluctuated in a similar way. The shape of monthly variation for active duodenal ulcer was not paralleled by similar changes in gastric ulcers and in the control diagnoses, gastric and rectal carcinomas, and rheumatoid arthritis.