Peptic Ulcer Disease Treatment and Management
Perforation of a peptic ulcer can cause acute abdominal pain both with and without a prior history of peptic ulcer. It is an acute surgical emergency requiring immediate diagnosis. Consider a history of drugs, especially NSAIDs and H2 antagonists. Perforated ulcers may follow a heavy meal. There is The maximal incidence is 45-55 years, most common in males, and a perforated duodenal ulcer is more common than a gastric ulcer. Consider the clinical syndrome in 3 stages
Aloe gel is traditionally used for burns, wounds and inflammatory skin disorders. There is good scientific evidence that aloe may be of benefit in these conditions however, the chemical composition of Aloe vera products will vary depending on geographical and processing factors. Traditionally, aloe is also used internally for dyspepsia, gastrointestinal ulcers and IBS. 2007 Elsevier Australia
It is important to remember that, despite abnormal laboratory studies, the most common cause of bleeding in liver disease is a mechanical defect (hole in vessel). Thus, evaluation in patients with severe bleeding should be aimed at identifying sites of bleeding. Many patients will have dramatic gastrointestinal bleeding due to bleeding varices or gastric ulcers. In these situations replacement of coagulation factors provides an adjunctive therapy role to definitive therapy. Except for certain coagulation defects (thrombocytopenia, fibrinolysis), corrections of mild-to moderate coagulation defects in the severely bleeding patient are probably not important and correction of severe coagulation defects is impossible.
Gastrointestinal medicines (section 17 of the Model list) are included primarily because of the need for peptic ulcer prophylaxis in severely injured patients. Insulin (section 18) is included in the light of increasing evidence of improved outcome for severely injured patients with tighter blood glucose control.
The most common causes of acute abdomen are acute appendicitis, acute gastroenteritis, an irritable bowel syndrome, the various 'colics' and ovulation pain (mittelschmerz). Mesenteric adenitis is common in children. The various causes of chronic or recurrent abdominal pain are presented in Table 30.3 . A study on chronic abdominal pain 4 showed that the commonest reasons (approximate percentages) were no discoverable causes (50 ), minor causes including muscle strains (16 ), irritable bowel syndrome (12 ), gynaecological causes (8 ), peptic ulcers and hiatus hernia (8 ).
Local symptoms may result from compression or invasion of mediastinal structures and include cough, dysphagia, recurrent pulmonary infection, dyspnoea, pain and rarely haemoptysis. Most bronchial, gastric and gastroenteric cysts are asymptomatic although the latter can be life threatening because of gastric secretion leading to haemorrhage, peptic ulcer and perforation. Superior vena cava (SVC) syndrome, due to compression or invasion of the superior vena cava usually indicates the presence of malignancy but can be caused by benign fibrosing mediastinitis.
Chronic gastritis predisposes to peptic ulceration, gastric carcinoma and malignant lymphoma. Unusual variants such as lymphocytic, granulomatous or eosinophilic gastritis are occasionally seen - infective gastritis occurs in immunosuppressed patients (e.g., CMV) or opportunistically overlying ulceration (e.g., candida fungus). Peptic ulceration there are two patient groups 2. HP pangastritis hypoacidity weakening of the mucosal mucous barrier further gastritis erosion and gastric ulceration (GU). Further risk factors include smoking, alcohol and drugs (NSAIDs, aspirin, steroids). DU outnumbers GU (4 1). Benign gastric ulcers are usually on the lesser curve in the vicinity of the incisura. Complications include acute or chronic bleeding from the ulcer base, perforation with peritonitis, penetration and fistula to an adjacent organ (e.g., colon or pancreas), fibrotic repair resulting in mechanical obstruction such as pyloric stenosis, and rarely, cancer. Surgery for peptic ulceration...
Glucocorticoids have important effects on the nervous system, including behavior and intracranial pressure. Large doses of glucocorticoids have been associated with the development of peptic ulcer, possibly by suppressing the local immune response against Helicobactor pylori. Glucocorticoids given chronically suppress the pituitary release of adrenocorticotropic hormone, growth hormone, thyroid-stimulating hormone, and leutinizing hormone.
The NCP system cannot be inserted in patients who have undergone a prior left cervical vagotomy. Furthermore, the safety of VNS has not been tested in several conditions in which impairment of vagus nerve function might produce deleterious effects. Thus, relative contraindications include progressive neurological or systemic diseases, pregnancy, cardiac arrhythmia, asthma, chronic obstructive pulmonary disease, active peptic ulcer disease, and insulin-dependent diabetes mellitus 1 .
PRV is frequently discovered incidentally when a complete blood count is performed for another reason. When symptoms are present, they are usually nonspecific. Fatigue, headache, and diaphoresis are common. Pruritis, often following a hot shower, is a frequent complaint. Up to 15 of patients may present with a thrombotic episode. Thrombotic cerebrovascular accidents, coronary artery thrombosis, Budd-Chiari syndrome, and pulmonary embolus all occur. Cavernous sinus thrombosis may also occur in untreated or poorly controlled disease. Erythromelalgia is specific to PRV and ET, and it is associated with an elevated platelet count and paradoxical vasodilation. It is characterized by redness, warmth, and a burning pain affecting the digits and responds promptly to aspirin. Gout may be a presenting manifestation of an MPD. There is an increased incidence of peptic ulcer disease in patients with PRV. Iron deficiency may occur and may initially mask the diagnosis. An elevated hematocrit with...
Several In vivo studies have Identified anti-Inflammatory and antinociceptive activity for feverfew extracts and parthenollde. When feverfew extracts were orally administered, or pure parthenollde was Injected IP, significant dose-dependent anti-Inflammatory and antinociceptive effects were observed In animal models (Jain & Kulkarnl 1999). Similarly, when feverfew extracts and parthenollde from Tanacetum vulgarewas administered orally In a rat model, gastric ulcer Index was significantly reduced (Tournler et al 1999).
Figure 11.3 Certain transgenic knock-out mouse strains suffer from gastric ulcers, colitis, and rectal prolapses, as shown by this gastric ulcer in a plasminogen knock-out mouse. (Photo courtesy Kirsten Dahl.) Figure 11.3 Certain transgenic knock-out mouse strains suffer from gastric ulcers, colitis, and rectal prolapses, as shown by this gastric ulcer in a plasminogen knock-out mouse. (Photo courtesy Kirsten Dahl.)
Right Upper Quadrant Cholecystitis, cholangitis, hepatitis, gastritis, pancreatitis, hepatic metastases, gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome), retrocecal appendicitis, pneumonia, peptic ulcer. Epigastrium Gastritis, peptic ulcer, gastroesophageal reflux disease, esophagitis, gastroenteritis, pancreatitis, perforated viscus, intestinal obstruction, ileus, myocar-dial infarction, aortic aneurysm. Left Upper Quadrant Peptic ulcer, gastritis, esophagitis, gastroesophageal reflux, pancreatitis, myocardial ischemia, pneumonia, splenic infarction, pulmonary embolus.
The duration of anti-coagulant therapy is influenced by balancing the risks of recurrence of thrombosis and of anti-coagulant related haemorrhage (ARH), and by the patient preference. The risk of bleeding during the initial period of anti-coagulation with UFH or LMWHs is 2 to 5 , while the estimated risk of major bleeding with oral anti-coagulant therapy is about 3 annually.156 As 20 of major bleeds are fatal, the annual case fatality rate from ARH is about 0.6 . The risk of bleeding is increased by patient-specific factors, such as, age (65 years or older) and co-morbidity (renal failure, liver disease, diabetes, peptic ulcer disease, cerebrovascular disease, malignancy) and by the concomitant use of anti-platelet agents.157,158 Evidence also indicates that the risk of bleeding on anti-coagulant therapy is reduced over time, so the long-term fatality rate is likely to be lower in patients who have tolerated months or years of anti-coagulant treatment without bleeding. On the other...
Differential Diagnosis Calculus cholecystitis, cholangitis, peptic ulcer, pancreatitis, appendicitis, gastroesophageal reflux disease, hepatitis, nephrolithiasis, pyelonephritis, hepatic metastases, gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome), pleurisy, pneumonia, angina, herpes zoster.
Other physical consequences include peptic ulcer, pancreatitis, gastritis, cardiomyopathy, myopathy, gout, vitamin deficiencies, drug interactions (the effect of psychotropic drugs may be either enhanced or reduced), and raised susceptibility to infections, including tuberculosis and malignancies.
Cholinergic agonists, such as pilocarpine and carbachol, should be avoided in conditions where pupillary constriction and intraocular vascular congestion are undesirable, such as in acute iritis or visually significant lens changes. These agents should also be avoided where there is a history of, or predisposition to, retinal detachment, or a proven sensitivity to these agents, or, for the membrane delivery dosage form, the presence of acute infectious conjunctivitis or keratitis. Patients with severe asthma, bronchial obstruction, acute cardiac failure, active peptic ulcer, hyper-thyroidism, gastrointestinal spasm, urinary tract obstruction, Parkinsonism, recent myocardial infarction, and, perhaps, poorly controlled blood pressure disorders are at risk for having these conditions exacerbated by cholinergic agonists.3
An important marker of the virulence of Helicobacter pylori strains is cagA encoding the cytotoxin-associated gene protein (cagA) 4 . Almost all Helicobacter pylori isolates from patients with peptic ulcers, atrophic gastritis and gastric cancer are cagA+ 56 . As there is an inverse relation between carcinoma in the cardia and lower oesophagus and colonization with cagA+ strains 57 it has been proposed that Helicobacter pylori colonization with especially cagA+ strains may protect against the development of GORD and its complications.
Actions irreversibly inhibits platelet cyclo-oxygenase, inhibits the formation of platelet-aggregating substance thromboxane A2 platelet aggregation, acts on hypothalamus heat-regulating center to reduce fever. Indications treatment of mild to moderate pain, inflammation, and fever adjunctive treatment of Kawasaki disease used for prophylaxis of myocardial infarction and transient ischemic episodes. Dose (adult) analgesic and antipyretic 325-650 mg every 4-6 hours PO or rectal anti-inflammatory 2.4-5.4 g day PO in divided doses myocardial infarction prophylaxis 75-325 mg day PO. Dose (ped) analgesic and antipyretic 10-15 mg kg PO PR every 4-6 hours (up to 60-80 mg kg 24 hr) antiinflammatory 60-100 mg kg day PO divided every 6-8 hours Kawasaki disease 80-100 mg kg 24 hrs PO in 4 divided doses during febrile phase until defervesces, then decrease to 3-5 mg kg 24 hrs PO every am (continue for at least 8 weeks). Clearance primarily by hepatic microsomal enzymes. Adverse effects may cause...
Anti-ulcer activity A number of in vivo studies have identified antiulcer activity for ginger extract and several of its isolated constituents. The orally administered acetone extract of ginger at a dose of 1000 mg kg and zingiberene, the main terpenoid in this extract, at 100 mg kg significantly inhibited gastric lesions by 97.5 and 53.6 , respectively. Additionally, the pungent principle, 6-gingerol at 100 mg kg, significantly inhibited gastric lesions by 54.5 . These results suggest that both zingiberene and 6-gingerol are important constituents responsible for ginger's anti-ulcer activity (Yamahara et al 1988). Other constituents demonstrating antiulcer properties in gastric ulcer models in rats include beta-sesquiphellandrene, beta-bisabolene, ar-curcumene and shogaol (Sertie et al 1992, Yoshikawa et al 1994).
It has long been known that gastric ulcers are frequently a reaction to stress. As early as 1827 the American Indian doctor John Williams in the book The American Indian Doctor Dr. John Williams' Last Legacy, A Useful Family Herbal praised ginseng roots as an excellent medicine to alleviate inward hurts and ulcers when used in combination with other herbal drugs such as comfrey, spikenard, elecampane, camomile, angelica and fir boughs in a dilute alcoholic vehicle (Harriman, 1973). Tang and Craze in their book Chinese Herbal Medicine (1995) also refer to the use of ginseng to treat peptic ulcer due to stagnating stomach qi (or ch'i), weakness of spleen or excess heat and advise avoidance of alcohol, coffee and tea. Cheng et al. (1985) noted that ginseng pectin polysaccharide and dextrin could reduce the amount of gastric acid and the activity of the enzyme pepsin. Ginseng pectin inhibited histamine-induced secretion of gastric acid and was effective versus indomethacin-induced and...
In patients with atypical symptoms or symptoms over and above those of typical reflux, endoscopy may also have utility in ruling out alternative diseases, such as peptic ulcer disease, eosinophilic esophagitis and complications like adenocarcinoma. Eosinophilic esophagitis, also known as primary eosinophilic esophagitis or idiopathic eosinophilic esophagitis, occurs in adults and in children and represents a subset of eosinophilic gastroenteritis with an isolated severe esophageal eosinophilia. Patients with eosinophilic esophagitis present with symptoms similar to those of gastroesophageal reflux but may be less responsive to antireflux medication. The importance of recognizing this entity, especially in children is underscored by the need for different treatment approaches, e.g., dietary restriction or corticosteroids and in preventing unnecessary fundoplication 62 . Dyspepsia and GERD may overlap and sometimes they may be difficult to distinguish by symptoms alone. Many patients...
Past Medical History (PMH) Past diseases, surgeries, hospitalizations medical problems history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.
Although no clinical studies are available, one study using an animal model of aspirin-induced gastric ulceration has identified significant antiulcer activity for the fresh juice from the whole plant of Bacopa monniera (Rao et al 2000). The study found that brahmi had a beneficial influence on the natural mucosal defensive factors, such as enhanced mucin secretion, mucosal glycoprotein production and decreased cell shedding, thereby reducing ulceration (Rao et al 2000). A follow-up in vivo study in various gastric ulcer models further confirmed brahmi's ability to increase the body's Brahmi 140 prophylaxis and treatment of gastric ulcers (Sairam et al 2001). In addition, brahmi was shown to reduce lipid peroxidation. An in vitro study demonstrated that B. monniera significantly inhibited Helicobacter pylori and the effect was comparable to that of bismuth subcitrate, a known H. pylori growth inhibitor (Goel et al 2003).
Polysaccharides derived from dong quai have been found to have a protective effect on colon injury in acetic acid-induced rat colitis, through promotion of growth factors, decreasing oxygen free radicals and some anti-inflammatory effects (Liu et al 2004), as well as relieving the inflammation reaction and colon injury in immunological colitis in rats (Liu et al 2003a,b). A polysaccharide containing extract of dong quai was also shown to promote migration and proliferation of normal gastric epithelial cells and enhance gastric ulcer healing in animal models (Ye et al 2003).
PEPTIC ULCERS PEPTIC ULCERS PEPTIC ULCERS PEPTIC ULCERS PEPTIC ULCERS PEPTIC ULCERS Outliners make use of this power of classification. The screenshots above are taken from my lectures notes on peptic ulcers. The structure of the document helped me learn the details. The first screenshot also shows an extra advantage - you can see all the major headings on one screen. Given the small screen of some handhelds, this is a great feature.
Peptic Ulcer Disease The term peptic ulcer refers to an open sore on the esophagus, stomach, or duodenum. The reason why peptic ulcers develop is not well understood. It has been postulated that there is a shift in the balance of mucosa-protecting (secretion of HC03 and mucus) and mucosa-damaging (secretion of acid and pepsin) mechanisms. Peptic ulcer disease can account for as many as 4,000,000 hospital days per year in the United States. Although individuals with duodenal ulcer disease clearly have increased rates of gastric acid secretion, and although gastrin is a potent secretagogue of HC1 secretion, it has not been possible to directly implicate gastrin in the etiology of duodenal ulcer disease. The drugs cimetidine and ranitidine have a proven value in the treatment of duodenal ulcer disease through their capacity to inhibit the secretion of gastric acid in hypersecretory states, particularly those involving peptic ulceration. Zollinger-Ellison syndrome is characterized by...
H. pylori is a Gram-negative bacterium found in the human stomach and plays an important role in the pathogenesis of chronic gastritis and peptic ulcers (6). Additionally, both epidemiological and clinical evidence has indicated that H. pylori is associated with an increased risk of gastric carcinoma (7,8) and as such it is the first bacterium to be termed a definitive cause of cancer by the International Agency for Research into Cancer (IARC). The cag pathogenicity island appears to play an important role in the aetiology of the disease since, in developed countries, strains of H. pylori that carry it are associated with an increased risk of peptic ulcer and adenocarcinoma than strains that are negative for the cag island (9). Overexpression of cyclooxygenase 2 (COX-2) has also been observed in tissues of human gastric cancer. There are two isoforms of COX COX-1 and COX-2. These are key enzymes that convert arachidonic acid to prostaglandins. COX-1 is expressed in most human tissues,...
The term acute abdomen implies a presentation with the sudden onset of abdominal pain with features on examination of tenderness, guarding and rebound tenderness. It most commonly arises from intra-abdominal pathologies, such as perforated peptic ulcer, pancreatitis, perforated diverticulum, perforated appendix, ruptured aneurysm, is-chaemic bowel or trauma. However, rarely, extra-abdominal disease, such as pneumonia, myocardial infarction or acid-osis, can mimic the acute abdomen.
Common cold prevention A 12-week, double-blind randomised study involving 146 people demonstrated that allicin-containing garlic preparations significantly reduce the incidence of colds and accelerate recovery compared with placebo (Josling 2001). More specifically, the number of symptom days in the placebo group was 5.01 compared with 1.52 days in the garlic treated group. Additionally, garlic reduced the incidence of developing a second cold whereas placebo did not. Helicobacter pylori infection It has been suggested that gastrointestinal lesions, such as gastric ulcers, duodenal ulcers and gastric cancers, are strongly associated with H. pylori infection (Scheiman & Cutler 1999). Medical treatment consisting of 'triple therapy' has a high eradication rate, yet is associated with side-effects and has started to give rise to antibiotic resistance. Since garlic intake has been associated with a lowered incidence of stomach cancer, researchers have started investigating whether garlic...
Based on the promising results of this study, the antiulcer activity of the individual anthocyanidins was studied. One anthocyanidin, chloride (IdB 1027, Inverni della Beffa S.p.A., Milan) showed particular promise, and so it was produced synthetically so that its effects on several animal models of acute and chronic stomach ulcers could be studied further (4). IdB 1027 administrered orally or intraperitoneally was able to inhibit acute gastric ulceration induced by pyloric ligation, stress (cold plus restraint), phenylbutazone, indometha-cin, reserpine, ethanol, and histamine, as well as duodenal ulceration induced by cysteamine and chronic gastric ulcers induced by acetic acid. Results of additional experiments suggest the mechanism of action involves stimulation of protective gastric mucosal secretions. A drawback of this study is that the severity of ulceration caused by phenylbutazone, indomethacin, ethanol, and histamine was assessed using nonvalidated ordinal scales.
As alluded to above, surgery for chronic peptic ulceration is now unusual. It aims to remove the gastric ulcer and the gastrin-producing G cells that drive acid secretion. This is accomplished by a Bilroth I distal gastrectomy with a gastroduodenal anastomosis (Figure 2.3). Alternatively, blockage of gastric innervation is achieved by transecting the vagus nerve trunks as they emerge through the diaphragmatic hiatus (truncal vagotomy) resulting in reduced gastric secretions and motility. Because of the latter, a drainage procedure, either pyloroplasty or gastrojejunostomy must also be done. This approach is used in elderly frail patients or for refractory DU. Highly selective vagotomy preserves pyloric innervation, negating the need for a drainage procedure. The now-rare Bilroth II gastrectomy for DU comprises a distal gastrectomy with oversewing of the duodenal stump and fashioning of a gastrojejunal anastomosis of either Polya or Roux-en-Y type. The latter prevents bile reflux as...
Flexible endoscopy is the cornerstone for investigation and diagnosis of gastric-related symptoms. Biopsies for gastritis should be taken according to the Sydney protocol from antrum, body and incisura and any abnormal areas. Specific lesions such as ulcers need multiple biopsies from the base and margin quadrants. A peptic ulcer has a classic endoscopic appearance in that it is round oval and sharply punched out with straight walls. Heaping up of mucosal margins is rare in benign ulcers and should raise the suspicion of malignancy. Size does not reliably differentiate between benign and malignant ulcers as 10 of benign ulcers are greater than 4 cm in diameter. Tumours covered by intact mucosa such as diffuse gastric carcinoma or GISTs are often difficult to demonstrate by mucosal biopsy and endoscopic FNA may be employed.
Helicobacter spp. have been isolated from nearly all species of rodents,32 but clinical significance has only been documented in relation to a few of these. H. hepaticus and maybe also H. bilis cause chronic hepatitis in mice.32 H. hepaticus is probably also responsible for liver tumors in mice.32 Susceptibility to disease seems to be genetically dependent, e.g., A JCr33 and B6C3F34 mice seem to be highly susceptible, while C57BL33 mice seem to be resistant. H. cholecystus causes hepatitis and pancreatitis in hamsters. Infection with Helicobacter spp. is probably rather common in rodent colonies.32,35 A range of transgenic mice as well as some rats suffer from a syndrome consisting of gastric ulcers, colitis, proctitis, and rectal prolapses (Figure 11.3), which in its features resembles several aspects of human inflammatory bowel disease. The syndrome is primarily observed in strains in which transgenesis has disrupted the normal mucosal homeostasis by features such as cytokine...
Among the symptoms of prolonged stress are persisting anxiety, depression, irritability, fatigue, loss of appetite, headache, and backache. Continuing stress can affect the course and severity of physical disorders such as peptic ulcers, migraine headaches, skin conditions, chronic backache, and bronchial asthma.
Actions competitive inhibition of histamine at H2 receptors of the gastric parietal cells inhibits gastric acid secretion, gastric volume, hydrogen ion. Indications duodenal and gastric ulcers esophageal reflux reduction of gastric volume increasing gastric pH prevention of acid aspiration pneumonitis during surgery prevention of stress ulcers.
Indications gastric acid hypersecretion conditions gastritis gastroesophageal reflux (GERD) erosive gastritis peptic ulcer disease prevention of acid aspiration pneumonitis during surgery. Dose (adult) Duodenal ulcer 20 mg day PO for 4-8 weeks. GERD or severe erosive esophagitis 20 mg day for 4-8 weeks maintenance therapy for erosive esophagitis 20 mg day. Gastric ulcer 40 mg day PO for 4-8 weeks. Pathological hypersecretory conditions 60 mg PO once daily to start doses up to 120 mg 3 times day have been administered administer daily doses 80 mg in divided doses. Dose (ped) 0.6-0.7 mg kg dose PO once daily increase to 0.6-0.7 mg kg dose PO every 12 hrs if needed (effective range 0.3-3.3 mg kg day). Clearance extensive hepatic metabolism 80 renal elimination.
Precipitating Factors Alcohol, gallstones, trauma, postoperative pancreatitis, retrograde cholangiopancreatography, hypertriglyceridemia, hypercalcemia, renal failure, Coxsackie virus or mumps infection, mycoplasma infection. Lupus, vasculitis, penetration of peptic ulcer, scorpion stings, tumor. Differential Diagnosis of Midepigastric Pain Pancreatitis, peptic ulcer, cholecystitis, hepatitis, bowel obstruction, mesenteric ischemia, renal colic, aortic dissection, pneumonia, myocardial ischemia. Disorders Associated with Pancreatitis Alcoholic pancreatitis, gallstone pancreatitis, penetrating peptic ulcer, trauma, medications, hyperlipidemia, hypercalcemia, viral infections, pancreatic divisum, familial pancreatitis, pancreatic malignancy, methyl alcohol, scorpion stings, endoscopic retrograde cholangiopancreatography, vasculitis.
Small-bowel tumors are rare, but GISTs account for more than 10 of neoplasms in this location. Patients with GISTs of the small intestine often present with nonspecific abdominal complaints, such as pain or hemorrhage. These tumors may be misdiagnosed as peptic ulcer disease, gas-troesophageal reflux, or cholelithiasis. In many cases, they are initially detected by the small-bowel follow-through portion of a barium swallow larger lesions may be detected by computed tomography (CT) radiography, and bleeding lesions may be detected by angiography.
Acute spinal cord injury 30 mg kg IV over 15 minutes, followed in 45 minutes by a continuous infusion of 5.4 mg kg hr for 23 hrs. Clearance hepatic metabolism renal elimination. Contraindications serious infections except septic shock or tuberculous meningitis. Adverse effects may cause hypertension, pseudotumor cerebri, acne, Cushing's syndrome, adrenal axis suppression, GI bleeding, hyperglycemia, and osteoporosis. Comments use caution in hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, hypertension, osteoporosis, thromboembolic tendencies, CHF, convulsive disorders, myasthenia gravis, thrombophlebitis, peptic ulcer, diabetes.
The percentage of patients with reflux symptoms found to have esophagitis at endoscopy varies notably in the published series, from 38 to 75 35 , with an average of 50 or less 36 . Indeed, several recent community-based European studies found even a lower prevalence, of about 30 37 , 38 . In large endo-scopic series, reflecting the percentage of patients in general gastroenterological practice, the prevalence of esophagitis is nowadays higher than that of duodenal and gastric ulcer, and ranks first in the upper GI endo-scopic diagnosis in Europe and USA, with a figure around 20 35 . A recent work from Japan 39 investigating the correlation between symptoms and endoscopic finding in RE was conducted in 8031 subjects undergoing upper GI endoscopy for various reasons (and not randomly selected from the community) and who had not taken medication for GI disease the study found an overall prevalence of 14.9 for RE, with a slight tendency for symptoms to increase in frequency with the...
The patient was a 74-year-old Caucasian man who was admitted to the hospital because of 4-month history of epigastric pain, weight loss of 11 kg and episodes of hematemesis and hemoptysis. The epigastric pain had an insidious onset, was dull, non-radiating, non-exertional, and was not associated with food intake. In addition, he experienced intermittent difficulty in swallowing for which he took antacids with some relief. He also described malaise, hyporexia and nausea. There was a history of hypertension treated with diuretics. The patient also complained about occasional dyspnea on exertion, mild ankle swelling and intermittent claudication. The latter symptoms had developed over a period of a few years, and the patient attributed them to his age. There was no history of rheumatic heart disease, coronary artery disease, gallbladder disease, pancreatitis, hepatitis, change in bowel habits, tuberculosis, bleeding diathesis, or trauma. Surgical history revealed a partial gastrectomy at...
Excessive secretion of gastrin usually has its origin in a tumor of the gastrin-producing GEP endocrine cells located in the duodenum or in the pancreatic islet. This condition, known as the Zollinger-Ellison syndrome or gastrinomas, is characterized by excessive secretion of hydrochloric acid by continuously stimulated parietal cells. The excess acid cannot be adequately neutralized in the duodenum, thereby leading to gastric and duodenal ulcers. Gastric ulcers are present in 95 of patients with this syndrome and are 6 times more prevalent than the duodenal ulcers. Treatment of Zollinger-Ellison syndrome in the past involved blockage of the parietal cell membrane receptors that stimulate HCI production. Recently, proton pump inhibitors have become the treatment of choice in managing HCI hypersecretion. In addition, surgical excision of the tumor, when possible, removes the source of gastrin production and alleviates symptoms.
Patients with undetected drinking problems commonly present in primary care or hospital settings because of the physical or psychiatric complications of alcohol. Patients with, for example, depressive illness or peptic ulcer will not improve if treatment is directed to these diagnoses without attention to the underlying alcohol misuse. Ways of improving recognition include the following