Causes and Treatment of Gastric Ulcers

Beat Ulcers

The system is all natural and easy to use. You are just minutes away from taking your first steps to having painless days and nights. In less than 2 weeks, you can be totally free from ulcers, living without the pain and feeling free to eat without the thought of pain. All you need do is follow the plan. Beat Ulcers is a step by step guide that shows you how you can eliminate ulcers in as little as 10 days. All you need do is use the readily available natural products in the correct proportions at the correct times. Here is what you will learn in the Beat Ulcers guide: How to Eliminate an Ulcer without the use of medication. How to rid your body of the ulcer causing bacteria and keep it away. How to stop the aching. How to eliminate the burping and bloating. Focus on the root cause of ulcers rather than the symptoms. How to be totally free from pain and sleep soundly at night. How to stop using dangerous medications that are prescribed over and over. Learn the causes of ulcers and how to eliminate them forever.

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Peptic Ulcer

A peptic ulcer is a sore or hole in the lining of the stomach or duodenum and is a term used to describe a lesion in the esophagus, stomach, or duodenum. More specific names are used to describe an ulcer located at a specific site. Duodenal ulcers (the first part of the small intestine) are more common than other types of peptic ulcers. Peptic ulcers are caused by hypersecretion of hydrochloric acid and pepsin that erode the GI mucosal lining. Anyone can get an ulcer. Most ulcers are caused by an infection with the bacterium Helicobacter pylori not spicy food, acid, or stress and can be cured with antibiotics in about two weeks. The most common ulcer symptom is burning pain in the stomach V2-IV2 hours after eating with gastric ulcers 2-3 hours for a duodenal ulcer. Gastric ulcers frequently occur because of a breakdown of the GMB. Treatment of peptic ulcers is given in two-drug, three-drug, and four-drug regimens, or a combination medication consisting of multiple drugs combined into...

Peptic ulcer disease

Peptic ulcer disease is strongly associated with acid and pepsin secretion. However, ulcers are not the simple result of acid hypersecretion, but rather are due to an tend to secrete more acid than normal subjects, while patients with gastric ulcers tend to have a low acid secretion. Thus the mucosal defense mechanisms of gastric ulcer patients are likely to be impaired. Intramucosal infection by Helicobacter pylorii causes chronic gastritis this seems to be an important causative factor, particularly in duodenal ulcer disease.

Pyrimidine Antagonists

Meta-analysis of several randomized trials comparing various 5-FU schedules of administration has shown the superiority of continuous infusion of 5-FU over bolus administration when given as a single agent.87 Moreover, bolus drug administration cannot achieve effective radiosensitization, as this requires constant drug exposure given the short half-life of 5-FU. Clinical toxicities also have some correlation with schedule of administration. Myelosuppression, especially leukopenia, is more pronounced with IV bolus schedules than with continuous infusion. Mucositis along the GI tract can be debilitating and dose limiting, especially with continuous infusion. Other GI symptoms, such as nausea, vomiting, and anorexia, can also be more severe with continuous infusion. With HAI regimens, systemic toxicities of 5-FU are dose limiting whereas hepatitis is usually mild. On the other hand, local-regional toxicities such as gastritis, gastric ulcers, enteritis, hepatitis, cholestasis, or...

Preface to the First Edition

Part II, Mucosal Diseases, addresses the secretory immune system with special reference to mucosal diseases. Section E consists of chapters on the stomach, intestine, and liver, and includes diseases of GALT and intestinal tract, a chain and related lymphoproliferative disorders, gastritis and peptic ulcer, malabsorption syndrome, food allergy, intestinal infections, and diseases of the liver and biliary tract (Chapters 35-42). Section F covers selected areas of lung and lower airway and

Gastrointestinal Tract

Drugs also inhibit gastric acid secretion and gastrointestinal motility, because both processes are partly under the control of the vagus nerve. Relatively large doses of atropine are required to inhibit acid secretion, and side effects such as dry mouth, tachycardia, ocular disturbances, and urinary retention are drawbacks to the use of muscarinic antagonists in the treatment of peptic ulcers.

Uses in Disorders of the Digestive System

Nonselective antimuscarinic drugs have been employed in the therapy of peptic ulcers (see Chapter 40) because they can reduce gastric acid secretion they also have been used as adjunctive therapy in the treatment of irritable bowel syndrome. Antimuscarinic drugs can decrease the pain associated with postprandial spasm of intestinal smooth muscle by blocking contractile responses to ACh. Some of the agents used for this disorder have only antimuscarinic activity (e.g., propanthe-line), while other drugs have additional properties that contribute to their antispasmodic action. Dicyclomine (Bentyl) and oxybutynin (Ditropan) at therapeutic concentrations primarily have a direct smooth muscle relaxant effect with little antimuscarinic action.

Gastroduodenal sources

Peptic ulcers may occur in the esophagus as a complication of reflux esophagitis, the stomach, or the duodenum. They may also be found in the jejunum in patients who have previously undergone a partial gastrectomy with gastrojejunostomy (Billroth 2 anastomosis), and are occasionally multiple (mainly duodenal and jejunal) in patients with the Zollinger-Ellison (hypergastrinemia) syndrome. Hemorrhage is a common complication of peptic ulcer at any site, and occurs in about 20 per cent of patients with untreated lesions. Most patients with peptic ulcer have been symptomatic prior to bleeding. Many report a previous diagnosis of ulcer and may have been treated in the past with sucralfate, H2-blocking agents, or gastric acid pump inhibitors. Untreated patients often relate a history of epigastric pain relieved for several hours by meals or antacids, and occurring between meals and while asleep. Loss of weight and vomiting are uncommon symptoms, suggestive rather of obstruction of the...

Chapter References

Caputi Iambrenghi, O., Lospalluti, M., Piccinni, G., and Lippolis, A. (1995) Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995 Surgical Endoscopy, 9, 1090-9. Lin, H.J., Wang, K., Perng, C.L., Lee, C.H., and Lee, S.D. (1995). Emergency endoscopy is needed in patients with a bleeding peptic ulcer and bloody nasogastric aspirate a prospective randomized study (Abstract). Gastroenterology, 108, A150.

Clinical features

Endocrine tumours of the duodenum produce symptoms either by virtue of local infiltration causing obstructive jaundice, pancreatitis, haemorrhage, and intestinal obstruction (nonfunctioning tumours) or, less frequently, by secreted peptide hormones (functioning tumours). The prevalent position of somatostatin-cell tumours, gangliocytic paraganglio-mas, and small cell carcinomas in the ampullary region explains their frequent association with obstructive biliary disease. About 20 of the tumours, especially those located in the duodenal bulb, are asymptomatic and often incidentally discovered, e.g. by imaging analysis, endoscopy or pathological examination of gastrectomy and duodenopancreate-ctomy specimens removed for gastric and pancreatic cancers. Zollinger-Ellison Syndrome (ZES) with hypergastrinaemia, gastrin hypersecretion, and refractory peptic ulcer disease, is the only syndrome of endocrine hyper-function consistently observed in association with endocrine tumours of the...

Metabolism in the healing wound

The gut has received the most attention when evaluating the effects of glutamine supplementation. The importance of circulating glutamine in maintaining gut function and integrity was illustrated in a number of animal studies. In one study, the enzyme glutaminase was infused into several animal species to lower blood glutamine levels to nearly undetectable levels 46 . These animals rapidly developed diarrhea, mild villous atrophy, mucosal ulcerations, and intestinal necrosis. Likewise, Hwang et al. demonstrated that glutamine-enriched parenteral solutions increased jejunal mucosal weight and DNA content and significantly decreased the villous atrophy associated with the use of standard TPN 47 . Others have demonstrated the ability of glutamine-supplemented intravenous or enteral diets to increase villous height and mucosal nitrogen content and stimulate intestinal mucosal growth following starvation 48 . Furthermore, enteral or parenteral glutamine may offer some protection against...

Antibiotic regimens for H pylori infection

Follow-up after treatment of H pylori. Patients with uncomplicated peptic ulcer disease treated for H pylori infection do not require a test of cure to confirm eradication of H. pylori. However, if their symptoms return, further evaluation for recurrent or persistent H. pylori infection is required.

Mechanism of Action

Liver dysfunction (especially at high doses), decreased glucose tolerance, hyperglycemia, and hyperuricemia. Thus, it is contraindicated in patients with hepatic dysfunction, peptic ulcer, hyperuricemia, or diabetes melli-tus. A paradox associated with nicotinic acid is that it is the most widely available hypolipidemic drug (it is sold over the counter), yet its use requires the closest management by the physician.

Natural history of PV

Untreated PV carries a significant risk of thrombotic complications and a further long term risk of transformation into myelofibrosis or less commonly AML. There is also an 4 risk of bleeding notably from peptic ulcers. The aim of treatment is to reduce the risk of thrombotic complications and to prevent progression to myelofibrosis or leukaemia. Current treatments improve the untreated median survival of 18 months to 15 years though some myelosuppressive treatments (notably chlorambucil and 32P) have been associated with an increased risk of AML. Thrombotic complications notably MI, stroke and venous thromboembolism are the most

Important Bacterial Groups

Some proteobacteria cause diseases in plants and animals. For example, species of the genus Agrobacterium cause tumors in plants. Rickettsiae cause diseases such as Rocky Mountain spotted fever in humans. Helicobacter pylori, shown in the chapter opener photo, is a bacterium that commonly causes stomach ulcers.

Differential Diagnosis

Most reported patients underwent a Whipple procedure because preoperative differentiation between groove pancreatitis and pancreatic cancer was difficult 7 . A mass lesion should be verified by intraoperative pathological examination to rule out a malignant lesion and to avoid unnecessary radical surgery. In addition, a duodenal mucosal biopsy of a markedly thickened duodenum is required, when endoscopy reveals luminal narrowing of the duodenum. When Brunner's gland hyperplasia is confirmed histopathologically, GP is favored, in patients with no history of gastrectomy, peptic ulcer or disease of the biliary tree.

Proton Pump Inhibitors

The proton pump inhibitors available in the United States are omeprazole (Prilosec), lansoprazole (Prevacid), pan-toprazole (Protonix), rabeprazole (Aciphex), and es-omeprazole (Nexium). These are substituted benzimida-zole prodrugs, which accumulate on the luminal side of parietal cells' secretory canaliculi. They become activated by acid transport and then bind covalently to the actual H+-K+ ATPase enzymes (proton pumps) irreversibly blocking them. These drugs markedly inhibit gastric acid secretion. New proton pumps are continuously formed, and thus no tolerance develops. Peptic ulcers and erosive esophagitis that are resistant to other therapies will frequently heal when these agents are used. The proton pump inhibitors are also used to treat patients with Zollinger-Ellison syndrome, which is the result of a gastrin-hypersecreting neuroendocrine tumor.

Biological Effects

Intracerebroventricular or intracisternal administration of neurotensin produces physiological and behavioral alterations, including potentiation of barbiturate-mediated effects and effects mediated by ethanol. In addition, it induces hypothermia, reduces food intake and prevents the development of stress-induced gastric ulcers in rats.

Cellular Targets of Cigarette Smoke Induced Microvascular Dysfunction

Beside the stimulation of leukocyte adhesion to endothelial cells, several authors have demonstrated a breakdown of endothelial barrier function in response to cigarette smoke and or nicotine. Ultrastructural studies have demonstrated modifications in intercellular cleft morphology, the opening of interendothelial junctions, and the formation of subendothelial edema in response to cigarette smoke. Likewise, a compromised endothelial barrier function of microvessels in the oral mucosa has been found in response to smokeless tobacco exposure. Similar observations have been made by intravital microscopy in the hamster cheek pouch and in the gastric microcirculation in rats. The latter findings are of particular importance because they provide an adequate pathophysiological explanation for the clinical observation of delayed gastric ulcer healing and increased frequency of ulcer recurrence in smokers. Indeed, laser Doppler flowmet-ric studies in heavy smokers have demonstrated...

Potassium Perchlorate

The perchlorate ion of potassium perchlorate, KClO4, is a competitive inhibitor of thyroidal I transport via the Sodium Iodide Symporter (NIS).This drug can cause fatal aplastic anemia and gastric ulcers and is now rarely used. If administered with careful supervision, in limited low doses and for only brief periods, serious toxic effects can be avoided. The compound is especially effective in treating iodine-induced hyperthyroidism, which may occur, for example, in patients treated with the antiar-rhythmic compound amiodarone. Perchlorate ion can also be used in a diagnostic test of I incorporation into Tg, the so-called perchlorate discharge test.

Dinoprostone Carboprost Tromethamine and Misoprostol

Misoprostol (Cytotec) is a prostaglandin Ej analogue that is being evaluated as a cervical ripening agent. It also is used in the treatment and prevention of peptic ulcer disease (see Chapter 40). Clinical trials show that misoprostol is an effective agent for both cervical ripening and labor induction. It appears to be as effective as dinoprostone and is much less expensive.

Nanowires as Electrochemical DNA Sensors

The utility of nanowire electrodes for nucleic acid analysis was tested using oligonucleotide sequences that correspond to a portion of the 23S rRNA gene from Helicobacter pylori (a pathogen implicated in gastric ulcers and cancer) 11 . When hybridization of sequences from this pathogen was monitored electrocataytically, very low detection limits were established 5 attomoles of DNA could be sensed at a three dimensional nanowire electrode (Figure 6.4). The analysis was performed on an electrode with an exposed geometric area of 0.07 cm2, indicating that zeptomole detection limits could easily be achieved with a modest decrease in the size of the aperture used in the electrochemical analysis. Previous studies that used the Ru(III) Fe(III) electrocatalysis assay to detect the same DNA sequences using macroscopic gold electrodes achieved femtomole sensitivity. An attomole-level detection limit compares favorably with recently reported electrochemical methods for the direct detection of...

Adverse Reactions Contraindications Interactions

Garlic should be avoided in gastroesophageal reflux disease and peptic ulcer disease. High doses should be avoided in pregnancy. Garlic does pass into breast milk but so far has not been shown to be harmful. Cases of botulism have been reported from chopped garlic or garlic oil left out for long periods at room temperature. Administration of garlic with anticoagulant and an-tiplatelet drugs should be avoided because of the risk of bleeding.

Clinical presentation

Clinical Presentation Kawasaki

The lifetime risk of peptic ulcer disease is approximately 3-25 , depending on the population 19, 24 . In children, the risk for peptic ulcer is low in one Japanese study, the prevalence of H. pylori in duodenal ulcer, and gastric ulcer was 83.0 , and 44.2 , respectively 18, 25 . In those with H. pylori infection and peptic ulcer disease, there is now little doubt that eradication of H. pylori is superior to ulcer-healing drugs for duodenal ulcers for gastric ulcers, eradication achieves similar result to ulcer-healing drugs. In terms of preventing recurrence of peptic ulcer disease, eradication is superior to placebo 26 .

Helicobacter pylori Infection and PPI

H. pylori is a major cause of gastritis, peptic ulcer disease, and gastric carcinoma. Eradication of H. pylori with a triple therapy involving a combination of antibiotics (amoxicillin, clarithromycin, metronidazole) and a proton pump inhibitor (PPI) (omeprazole, lansoprazole, rabeprazole) is effective in the treatment of these diseases. Suppression of acid secretion by PPIs increases the concentration of antibiotics and allows H. pylori to Some studies have shown that the therapeutic effects of PPIs and therefore the cure rates for H. pylori infection are significantly dependent on the CYP2C19 genotype status PM, heterozygous extensive metabolizers (hetEM), and homozygous extensive metabo-lizers (homEM) . A better cure rate was achieved with dual therapy rabeprazole and amoxicillin in patients with the PM genotype (93.8 ) than the hetEM (91.7 ) or the homEM (60.6 ) genotype (145). In a second study using triple therapy including a PPI and amoxicillin and clarithromycin, the majority...

Filamentous Protein Appendages

In some cases, flagella are important in the ability of an organism to cause disease. For example, Helicobacter pylori, the bacterium that causes gastric ulcers, has powerful multiple flagella at one end of its spiral-shaped cell. These flagella allow H. pylori to penetrate the viscous mucous gel that coats the stomach epithelium. Helicobacter pylori, p. 605

Gastric Acid Related Disorders

Gastric acid-related disorders include heartburn, gastric and duodenal ulcers, symptomatic gastroesophageal reflux disease (GERD), erosive esophagitis, and pathological hypersecretory conditions such as ZollingerEllison syndrome. The conventional treatment for these acid-related disorders is the suppression of gastric acid secretion by H2 blockers and proton pump inhibitors (PPIs). PPIs are currently the drugs of choice in the management of acid-related disorders. The use of antisecretory agents in combination with antibiotics is beneficial in the healing of H-pylori related peptic ulcers. The approved H2 blockers in the United States include cimetidine, ranitidine, famotidine, and nizatidine. Approved PPIs include omeprazole, esomeprazole (enantiomer of omeprazole), pantoprazole, lansoprazole, and rabeprazole.

EFruits and Vegetables

Fruits and vegetables are readily available in developed countries and are a natural source of nutrients, fiber, and potent antioxidants. During an intervention assay the amount of DNA damage in the peripheral lymphocytes of test subjects was substantially reduced. Thus, the number of mutations can be reduced, as well as the possibility of developing tumors.29 Fruits and vegetables may be up to 20 d.w. of the diet of vegetarians, which includes high levels of phenolics. Some phenolics have been considered as trapping agents of nitrates, preventing the formation of the mutagenic N-nitroso compounds, which in turn have been linked to cancers of the nasopharynx, esophagus, and stomach. Additionally, phenolics are part of the detoxification systems.30 Currently, blueberries are emerging as one of the brightest prospects among fruits. Products from blueberries and other Vaccinium sp. can be marketed as dietary supplements in the United States with a structure-function claim such as promote...

Case Presentation

CagA into host cells causing the cells to elongate and spread out. CagA also provokes a strong immune response. Once established, H. pylori infections persist for years and often for a lifetime. It is not known why some people develop gastric or duodenal ulcers and others do not. Both host and bacterial factors are almost certainly involved. For example, strains of H. pylori isolated from peptic ulcer patients tend to be more virulent than those from patients who just have gastritis patients with blood group O have more receptors for the bacterium and a higher incidence of peptic ulcers than do other people. Stomach acid and peptic enzymes probably play a role in ulcer formation by acting on damaged epithelium unprotected by normal mucus. Claude Bernard, a scientist of Pasteur's time, put it this way It is that which we do know which is the greatest hindrance to our learning that which we do not know. In 1983, when Dr. Barry J. Marshall proclaimed before an international gathering of...

Adverse Effects Contraindications

The major advantage of the COX-2 inhibitors is their decreased GI effects and formation of gastric ulcerations compared with the COX nonselective agents. However, once an ulcer is present, COX-2 is induced in response, and the COX-2 enzyme is essential for wound healing. Therefore, celecoxib and rofecoxib can delay in wound healing and increase the time for ulcer repair and tissue regeneration. Patients with gastric ulcers

Acute mucosal ulceration

Peptic ulcers may recur during critical illness. However, other forms of acute ulceration of the gastroduodenal mucosa are more commonly encountered in critically ill patients without actual association with peptic ulcer disease. This mucosal injury is often referred to as a stress ulcer. However, the pathological anatomical definition of this lesion is an erosion (a superficial lesion not penetrating the mucosa). In contrast, an ulcer by definition penetrates at least down to the muscular layer. A special form of acute ulceration is the Curling ulcer seen in major burn injury. Burn patients often have single ulcers which may penetrate quite deep into the gastric or upper duodenal wall and, in contrast with stress ulcers, may even cause perforation. Cushing ulcers, which are seen in patients with neurological injury, fall between the two other acute ulcer forms. For completeness, a fourth type of acute mucosal ulceration caused by drugs, mainly non-steroidal anti-inflammatory drugs...

Effects of the autonomic nervous system on hormone secretion

They mediate the 'cephalic phase' of insulin secretion in response to the sight or smell of food, mentioned in Chapter 3 (Section 3.2.1). Also, in patients whose vagus nerve is cut at surgery to reduce gastric acid secretion (a former treatment for gastric ulcers), insulin secretion in response to a glucose drink is impaired, as is glucagon secretion in response to hypoglycaemia.

Supplemental Reading

Prim Care 2001 28 487-503. Case Study Peptic Ulcer Disease Answer Peptic ulcer disease is most frequently secondary to either Helicobacter pylori infection or use of NSAIDs. The patient does admit to NSAID use (naproxen), but should also be checked for concomitant H. pylori infection at time of endoscopy or by a serology test. If the patient was found to have H. pylori, an appropriate eradication regimen should be prescribed. The patient should also be counseled to avoid NSAIDs. The patient should be prescribed a proton pump inhibitor for 8 weeks to heal the ulcer. A repeat endoscopy should be done at that time to document ulcer healing and rule out gastric cancer. In addition, the patient should be counseled to stop smoking, which is a risk factor for more severe peptic ulcer disease.

Principles of management

An International Normalised Ratio (INR) between 1.5-2.5 and or platelet count of (20-40) x 109 l do not usually require correction if the patient is not bleeding or at high risk e.g. active peptic ulcer, recent cerebral haemorrhage, undergoing an invasive procedure. 5-10 units of platelets will raise the count by only 10-20 x 109 l. The effect is often transient (50 x 109 l. A target INR

Refractory irondeficiency and H pylori infection

There are a number of potential biological explanations for iron deficiency observed in H. pylori infection apart from bleeding secondary to peptic ulcer disease. Currently, there is no evidence to support that chronic gastritis secondary to H. pylori results in occult blood loss. However, H. pylori infection in some settings might give rise to hypochlorhydria, low ascorbic acid levels, and increased lactoferrin (a host iron-binding protein) sequestration by the organisms. Also, H. pylori possesses multiple iron acquisition systems in its genome, which makes it an avid competitor for iron uptake with the host in the gastric microenvironment 46 .

Aerobic Microaerophilic Motile Helical Vibroid Gram Negative Bacteria

Campylobacter fetus causes spontaneous abortion in domestic animals. Campylobacter jejuni causes inflammation of the digestive tract (enteritis) resulting in food-borne intestinal diseases. Another common aerobic microaerophilic, motile, helical vibroid, gram-negative bacterium that is pathogenic is Helicobacter pylori. Helicobacter pylori cause gastric ulcers in humans.

Sociocultural Influences

Instead of thinking in terms of a multiplicity of so-called social problems, each demanding special attention and a different remedy, we can view all of them as different symptoms of the same disease. That would be a real gain even if we cannot entirely agree upon the exact nature of the disease. If, for example, we could regard crime, mental disorders, family disorganization, juvenile delinquency, prostitution and sex offenses, and much that now passes as the result of pathological processes (e.g., gastric ulcer) as evidence, not of individual wickedness, incompetence, perversity or pathology, but as human reactions to cultural disintegration, a forward step would be taken.

Systemic Side Effects and Complications

Systemically, the use of these drugs may result in fat redistribution, muscle and bone weakness, fluid and electrolyte imbalances, growth retardation, stomach ulcers, and various psychoses. In addition, patients undergoing corticosteroid therapy become much more susceptible to a new or relapsing infection. This is especially true of herpetic infections. The reason is simply that the body's immune response is decreased during therapy. As a result, the body cannot mount a substantial defense against its attackers, and infections become more likely. Wound healing may also be delayed. Therefore, corticosteroids must be used cautiously in patients with active infection, a history of recurrent infection, or a decreased immune system.

Measlesmumpsrubella Vaccine

Disease prevalence data were collected by means of a postal questionnaire. The vaccinated group and their partners were asked whether they had, or had ever been told, by a doctor, that they had Crohn's disease, ulcerative colitis, coeliac disease or peptic ulcer disease. The unvaccinated group were asked about any condition that required regular medical supervision, the presence of any long-standing illness, disability, or infirmity, and details of all out-patient appointments and hospital admissions. Reports of Crohn's disease and ulcerative colitis were confirmed with the subject's physicians in the vaccinated and unvaccinated groups only.

Incorporating cultural issues

In Chinese culture, exposure to wind is thought to be harmful.(47) Disorders of a specific organ system may carry complex meanings and fear for members of a particular culture patients fear 'heart distress' in Iranian culture, (48 and Puerto Ricans are fearful of loss of even small amounts of blood. Chinese patients will often report somatic symptoms rather than psychological ones due to the stigma that psychological distress places on the patient as well as the family. (49 Peptic ulcer disease may carry positive connotations in Japan, where it is seen as a sign of diligence and hard work. In Mediterranean cultures, it is considered healthy to express emotions, and some illnesses are attributed to 'not having cried enough' after a loss. Antidepressant or anxiolytic treatment in such cases can be counterproductive.

Granular cell tumour

Lesions similar to those in peripheral soft tissues are occasionally encountered in the stomach, where they principally occur as small submucous nodules and less commonly as intramural or sub-serous masses. These lesions occur predominantly in middle age, and show a strong predilection for Blacks. Associated gastric ulcer symptoms are common. See chapter on mesenchymal tumours of the oesophagus for pathological features 862 .

Operative management

In general, the source of intra-abdominal sepsis is eliminated by resection, closing the perforated viscus or resection of any necrosis. For pathology located in the large intestine, resection is usually performed followed by creation of a proximal enterostomy (Hartmann's procedure). In this location, primary anastomosis is avoided because of the high risk of anastomotic dehiscence. The risk associated with primary anastomosis of the small intestine following resection of a diseased segment is considered to be much lower. However, if peritoneal soiling is particularly extensive, resection plus proximal and distal enterostomy is advocated. Suturing a perforation is now mainly performed for perforated peptic ulcer. Additionally, it may be considered for a single small foreign body or traumatic perforation of the small intestine, if diagnosed early.


Helicobacter pylori (HP), a spiral-shaped, flagellated organism, is the most frequent cause of peptic ulcer disease (PUD). Nonsteroidal anti-inflammatory drugs (NSAIDs) and pathologically high acid-secreting states (ZollingerEllison syndrome) are less common causes. More than 90 of ulcers are associated with H. pylori. Eradication of the organism cures and prevents relapses of gastroduodenal ulcers. B. Complications of peptic ulcer disease include bleeding, duodenal or gastric perforation, and gastric outlet obstruction (due to inflammation or strictures).

Activated Protein C

Activated Protein C has anti-inflammatory, anticoagulant and pro-fibrinolytic properties. Its beneficial effects in sepsis are most likely to be related to its anti-inflammatory properties. A large prospective randomised controlled trial demonstrated outcome benefit for patients with severe sepsis treated within 48h of presentation with a 96h infusion of 24pg kg h aPC. Most benefit was seen in those with 2 organ dysfunctions. The major side effect was bleeding so caution should be exercised in those at high risk of potentially catastrophic bleeding, e.g. concurrent coagulopathy, or a recent history of surgery, major trauma, head injury and or peptic ulcer disease.


With regard to the etiopathogenetic possibilities, Stolte et al. summarized four clinical characteristics of GP (1) previous diseases of the biliary system, peptic ulcer and gastric resection (2) mild dilation of the pancreatic duct (3) higher frequency of narrowing of the duodenal lumen, and (4) cyst formation in the duodenal wall. The etiology of GP, however, so far remains controversial. Currently, two types of research approach have reported on etiopathogenetic possibilities.

Acute gout

Contraindicated in patients with peptic ulcer disease or systemic anticoagulation side effects include gastropathy, nephropathy, liver dysfunction, central nervous system dysfunction and reversible platelet dysfunction may cause fluid overload in patients with congestive heart failure

Figure 401

The mucosal surface, both the local blood supply and the ability of the local cells to buffer this ion will ultimately determine whether peptic ulceration will occur. With duodenal and gastric peptic ulcer disease, a major causative cofactor is the presence of gastric Helicobacter pylori infection. Medications that raise intragastric pH are used to treat peptic ulcer disease and gastroesophageal reflux disease. In addition, agents that enhance mucosal cyto-protection are used to decrease ulcer risk.


Prostaglandins of the A, E, and I type inhibit gastric acid secretion. The prostaglandins also stimulate increased mucus and bicarbonate secretion by gastric mucosa. Misoprostol (Cytotec), which is an analogue of prostaglandin E1, has been approved for use in the prevention of nonsteroidal antiinflammatory drug-induced ulceration. It also is approved in other countries for the treatment of peptic ulcer disease. Misoprostol is absorbed rapidly after oral administration and is hy-drolyzed to the active compound. It is metabolized by the liver and excreted mainly in the urine. Adverse effects include crampy abdominal pain, dose-related diarrhea, and uterine contractions. The last-named effect has led to its use in the control of postpartum bleeding (see Chapter 62).


The pharmacokinetics of ampicillin and amoxicillin are similar (Table 45.1). Both have good oral bioavailability ampicillin is also bioavailable after intramuscular injection. Concomitant ingestion of food decreases the bioavailability of ampicillin but not amoxicillin. Consequently, oral doses of ampicillin should be given on an empty stomach. Ampicillin achieves therapeutic concentrations in the cerebrospinal fluid only during inflammation. Therefore, ampicillin is effective treatment for meningitis caused by Listeria monocytogenes. Amoxicillin does not reach adequate concentrations in the central nervous system and is not appropriate for meningitis therapy. Other indications for ampicillin include serious infections like enterococcal endocarditis and pneumonia caused by p-lactamase-negative H. influenzae. Amoxicillin oral therapy is appropriate for clinically acute nonserious bacterial infections like otitis media and sinusitis. Amoxicillin also has use in mul-tidrug regimens for...


H. pylori is generally acquired in childhood and the prevalence in developed countries is now decreasing. The clinical manifestations of disease are a result of the host, bacteria and environment interaction, and are only seen in a subset of infected individuals. Its association with peptic ulcer disease, gastric cancer and MALT lymphoma is beyond dispute. A test-and-treat strategy is not indicated for children with recurrent abdominal pain. New indications in children are now emerging advocating its eradication, such as refractory iron deficiency, ITP and a strong family history of gastric cancer, although further studies are needed. Stool antigen tests and urea breath tests have emerged as some of the best non-invasive tests for H. pylori. Antibiotic resistance is on the rise, and novel treatment strategies are needed. Improving the social situation of children such as better housing, sanitation and hygiene remain one of the key pillars in reducing the prevalence of this infection...


H2 receptor antagonists are weak bases with water-soluble hydrochloride salts and tend to be less lipophilic than H antagonists (3). The early agents, which were developed for their gastric acid inhibitory properties, were either not strong enough for clinical use or hazardous because of serious associated side effects (e.g., neutropenia, bone marrow suppression) (111,112). Cimetidine (Tagamet) was introduced to the United States in 1982 and has been proved safe and effective in the treatment of peptic ulcer disease (15). Cimetidine and oxmetidine resemble the earliest agents structurally because they have an imidazole ring similar to histamine's structure. The newer agents vary structurally by having different internal ring components. For example, ranitidine (Zantac) has a furan ring, whereas famotidine (Pepcid) and nizatidine (Axid) are composed of thiozole rings (15). H2 antagonists act primarily by competitive inhibition of the H 2 receptors, with the exception of famotidine,...


The discovery of H-, receptor antagonists has proved to be a significant breakthrough in the treatment of allergic diseases. Chemical modifications of these early agents have yielded the second-generation antihistamines, which are of equal antagonistic efficacy but have fewer side effects because of their lipophobic structures. Newer nonsedating antihistamines, which are metabolites or isomers of existing agents, are now under development. H 2 receptor antagonists have been found extremely useful in the treatment of peptic ulcer disease. However, they have been disappointing in the treatment of allergic and immunologic disorders in humans. Newer selective nonsedating H-, antagonists and dual-action antihistamines, because of their lower side-effect profiles, have provided therapeutic advantages over first-generation agents for long-term management of allergic rhinitis.


Sodium bicarbonate is a systemic antacid that has many side effects including sodium excess that causes hypernatremia and water retention. Sodium bicarbonate also causes metabolic alkalosis related to the excess bicarbonate. Therefore, sodium bicarbonate is seldom used to treat peptic ulcers.


In addition to causing oesophageal injury, it has been shown in endoscopic studies in volunteers that alendronate, and likely risedronate, can cause acute gastric mucosal damage and gastric ulceration (Graham, 2000). The incidence of adverse gastrointestinal events in users of alendronate was assessed from computerised pharmacy claims of the United Health Group-affiliated health plans in the United States (Park et al, 2000). Over 1400 persons who received alendronate prescriptions were identified. Amongst those who had no prior oesophageal or gastric diagnoses, the cumulative incidence of upper gastrointestinal events was 3.3 in females, 2 in males and 3 overall. This included 22 patients with oesophagitis, 2 with oesophageal ulcer, 1 with gastric ulcer and 15 with gastritis duodenitis.

The stomach

On the oxyntic cells drugs which block binding at these receptors, the -antagonists (e.g. cimetidine, ranitidine), have found widespread use as anti-ulcer agents, since they reduce acid secretion. The parasympathetic nervous system is activated during digestion, as noted earlier, by the taste, smell and sight of food when food enters the stomach, distension of its walls activates stretch receptors which send signals to the brain, which in turn causes further activation of the parasympathetic nervous system (the vagus nerve), and enhances acid secretion. A traditional surgical treatment for gastric ulcers (now out of fashion) was to sever the vagus nerve, thus removing one stimulus for acid secretion. When we consider later other effects of the vagus nerve (e.g. the modulation of insulin secretion) we shall see that this could have widespread, unwanted effects. In more recent years, highly selective vagotomy was introduced, in which only those branches innervating the stomach were cut,...

Chris Good

As Sir William Osler, the father of modern medicine, said The desire to take medicine is perhaps the greatest feature which distinguishes man from animals . Alone in the wilderness beyond the rigid confines of modern states, people may indulge their predilection to take medicines without any restriction save their ability to obtain the requisite ingredients. The conjoined paternalism of the modern state and the medical profession ensures that people are not allowed to indulge this desire without strict controls. These controls have themselves created problems with pricing and rationing. There is a tacit assumption in making certain medicines only available on prescription that the state and doctor know better than the patient what is best for that patient. This assumes that the state committees and doctors are adequately educated, a big presumption. It also assumes that all diseases have been discovered and named and their aetiology is known. Such pompous paternalism is obviously...


Abdominal pain, nausea, and possible reactivation of peptic ulcer have been reported. The drug should be used with caution in patients with compromised renal function, and adequate fluid intake should always accompany sulfinpyrazone administration to minimize the possibility of renal calculus formation.

Regulatory Theories

The US Food and Drug Administration (FDA) approved Rituxan, a monoclonal antibody to CD20 (developed by IDEC Pharmaceuticals) to treat non-Hodgkin lymphoma McLaughlin et al. 1998 . The process also led to the development of Herceptin, spearheaded by Dennis Slamon, an antibody that targets the receptor ERBB2 (HER-2 NEU) that is overexpressed on the surface of about 30 of breast cancers. Because antitumor immunity is predominantly cellular immunity, other research has been directed toward turning T-lymphocytes against tumors. Steven A. Rosenberg focused his efforts to generate antitumor vaccines on tumor associated antigens. In a similar approach, Martin Kast studied the development of peptide-based vaccines. Glenn Dranoff demonstrated the high effectiveness of irradiated tumor cells transfected with the cytokine GM-CSF in inducing antitumor immunity Dranoff et al. 1993 . Over time it became clear, on the other hand, that the immune system could also impact negatively on cancer risk in...


Ulcers usually form in the duodenum, the upper part of the small intestine a peptic ulcer is in the stomach as well as the duodenum and is so called because of the involvement of pepsin, a digestive enzyme. Ulcers are sores that can bleed. They form when there is too much acid for the mucosal lining to tolerate. They are often caused by an infection of the bacteria, Helicobacter pylori food allergies are also a possibility. It is believed that this bacteria releases acids into the area and may also be the cause of gastritis. Antibiotics are necessary for its eradication.


Egd Children Antrum Pictures

Tage of being able to detect upper gastrointestinal pathology including the complications of H. pylori infection such as nodular gastritis, peptic ulcer disease, gastric cancer, and MALT lymphoma. In pediatrics, the primary indication for upper GI endoscopy is the presence of persistent, severe upper abdominal symptoms and not simply the presence of H. pylori 33 . It is difficult to differentiate symptoms secondary to the complication of H. pylori infection such as peptic ulcer disease and functional dyspepsia. The most common endoscopic finding in children with H. pylori infection is nodular gastritis, which is seen most commonly in the antrum with an irregular (cobblestone) appearance, which is highlighted with blood from a bleeding biopsy site. When nodular gastritis is found, it has high specificity (98 ) for H. pylori infection, and therefore a high predictive indicator for H. pylori infection, but it has low sensitivities (44 ) 17, 74 . In naive patients, antral biopsy had the...

Hans Anton Lehr

Cigarette smoke contains large amounts of carcinogenic and cocarcinogenic substances that explain the increased burden of malignant tumors in smokers, particularly in the lungs, the upper gastrointestinal system, and the urinary bladder. Nonneoplastic diseases associated with cigarette smoking include chronic bronchitis and pulmonary emphysema, gastrointestinal ulcers, and a significantly increased risk of cardiovascular diseases, ranging from peripheral artery disease to myocardial infarction and cerebrovascular incidences. Although the exact pathophysiological link between cigarette smoking and cardiopulmonary disease progression remains incompletely understood, it has been recognized that a key role is played by effects on diverse aspects of the microcirculation both in terms of morphological (i.e., vessel wall injury, capillary loss) and functional aspects. The latter concerns predominantly changes in tissue perfusion and its regulatory mechanisms (i.e., reactive hyperemia,...

Ionizing Radiation

In addition to benzene, exposure to ionizing radiation is also considered an established risk factor for adult acute leukemia. Much of what we have learned about the effects of radiation on hematopoietic neoplasms comes from studies of atomic bomb survivors. In an evaluation of leukemia mortality among survivors of Nagasaki and Hiroshima, the highest risk for AML appears to be among individuals exposed to radiation aged 45 years or greater, while ALL risk appears higher in those exposed under the age of 30.134,135 Occupational exposure to ionizing radiation has also been explored with radium workers and early cohorts of radiologists demonstrating elevated risks of leukemia.108 Moreover, patients irradiated for benign conditions including menorrhagia, peptic ulcer, or ankylosing spondylitis have been reported to be at an increased risk of leukemia.136-139 Leukemia risk following radiation fallout from nuclear plants is less conclusive. Earlier studies reported excess risk among nuclear...


Diverticulitis is characterized by the abrupt onset of unremitting left-lower quadrant abdominal pain, fever, and an alteration in bowel pattern. Diverticulitis of the transverse colon may simulate ulcer pain diverticulitis of the cecum and redundant sigmoid may resemble appendicitis. Frank rectal bleeding is usually not seen with diverticulitis.