Peptic Ulcer Disease Treatment and Management

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.

Beat Ulcers Summary


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Peptic Ulcer Disease

It is estimated that one in six people with chronic H. pylori infection will have a peptic ulcer sometime in his or her lifetime. Initial studies indicated that > 90 of peptic ulcers were caused by H. pylori infection. More recent examination of clinical trials in the United States showed that 60 to 70 of duodenal ulcers are causally related to this infection (Laine et al, 1998). Numerous studies from around the world have confirmed that eradication of the infection significantly decreases recurrent PUD. It is now generally accepted that all patients presenting with a peptic ulcer should be tested for H. pylori infection. If positive, the patient should receive appropriate H. pylori eradication treatment. Most authorities feel that once the infection is eradicated, acid suppression for ulcer prophylaxis is unnecessary as long as the patient is not on other ulcerogenic agents, such as non-steroidal anti-inflammatory drugs (NSAIDs) (Liu et al, 2003). The increasing use of NSAIDs and...

Acid Suppression in Bleeding Peptic Ulcers

A proton pump inhibitor (PPI) should be administered once the endoscopic diagnosis of a bleeding peptic ulcer is made as this will reduce the risk of recurrent bleeding and the need for surgery (Bustamante and Stollman, 2000). The optimal dosing regimen, route of administration, and subset of patients that are most likely to benefit have yet to be determined. We initiate an 80 mg bolus of pantoprazole (Protonix) (the only parenteral PPI available at our institutions) and follow it with an 8 mg hr infusion for 72 hours.

Bleeding Peptic Ulcers

Early studies lacking control groups demonstrated the safety and efficacy of hemoclips for the treatment of high risk bleeding peptic ulcers (Binmoeller et al, 1993). Randomized studies are available comparing HC to the other hemosta-tic modalities for bleeding peptic ulcers (Cipolletta et al, 2001) randomized 113 patients to either HP (10 F) or HC (Olympus MH-858 long clips) in the treatment of severe ulcer bleeding. HC was safe and effective and was reported superior to HP for the prevention of early recurrent bleeding. Endoscopic therapy was not technically feasible in eight HP patients and six HC patients. Contrary results were published by Lin and colleagues (2002) who randomized 80 patients to either HC or HP and found that the initial hemostasis rates were better with HP as was the total number achieving ultimate hemostasis. In difficult to access areas, the rate of hemostasis was better with HP. demonstrated that HC was inferior overall to injection therapy. Although their...

Complications and management of peptic ulcer surgery Early Complications

Cigarette smoking is detrimental to mucosal protective mechanisms and increases the likelihood that gastric ulcers will develop. Although these ulcers are generally amenable to ulcer treatment, they can occasionally be refractory to healing. This can be a difficult clinical problem in a patient with symptoms. If multiple biopsies have been negative for cancer, it is highly unlikely to be a malignant ulcer. As the ulcers will heal with cessation of smoking, this is the treatment of choice. The surgeon should be careful about offering a definitive ulcer operation in this patient group. Symptoms are often times not eliminated, and postgastrectomy complications are high. Giant Peptic Ulcer Giant peptic ulcers have traditionally been associated with a high complication rate and have been treated surgically. This is yet another area where surgical principles have changed. With treatment of H. pylori, and modern acid suppression, most giant ulcers can be healed medically (12). Surgery is...

Third Threshold Analysis

Threshold analysis of ulcer management with antibiotics (ABX) versus proton pump inhibitors (PPI). NUD nonulcer dyspepsia p probability of PUD PUD peptic ulcer disease. FIGURE 2-4. Threshold analysis of ulcer management with antibiotics (ABX) versus proton pump inhibitors (PPI). NUD nonulcer dyspepsia p probability of PUD PUD peptic ulcer disease. If the probability of peptic ulcer exceeds .33, it would be worthwhile to subject the patient to an empirical trial of antibiotics before committing him to any long-term therapy with PPI. This last example serves to illustrate that threshold analysis is not necessarily dependent on cost data and that, in principle, any outcome parameter can be used to calculate a threshold probability. To be phrased as a sim- FIGURE 2-5. Threshold analysis of ulcer management with antibiotics (ABX) versus proton pump inhibitors (PPIs). NUD nonulcer dyspepsia p probability of PUD PUD peptic ulcer disease. The letters A through D are used to label...

Supplemental Reading

JAMA 1963 133 725-9. Glick M. Medical considerations for dental care of patients with alcohol-related liver disease. J Am Dent Assoc 1997 128 61-70. Gorlin RJ, Jirasek JE. Oral cysts containing gastric or intestinal mucosa unusual embryologic accident or heterotopia. J Oral Surg 1970 28 9-11. Halme L, Meurman JH, Laine P, et al. Oral findings in patients with active or inactive Crohn's disease. Oral Surg Oral Med Oral Pathol 1993 76 175-81. Hansen LS, Silverman S, Daniels TE. The differential diagnosis of pyostomatitis vegetans and its relation to bowel disease. Oral Surg 1983 55 363-73. Healy CM, Farthing PM, Williams DM, et al. Pyostomatitis vegetans and associated systemic disease a review and two case reports. Oral Surg Oral Med Oral Pathol 1994 78 323-8. Hegarty A, Hodgson T, Porter S. Thalidomide for the treatment of recalcitrant oral Crohn's disease and orofacial granulomatosis. Oral Surg Oral Med Oral Pathol 2003 95 576-85.

Management of Upper GI Bleeding

There is a balance between offensive agents and gastric defensive protective factors that help to protect the gastric mucosa from injury. The gastric mucosa is protected by epidermal growth factor, an intact microcirculation, an alkaline mucosal barrier, and prostaglandins. Factors predisposing to an increased risk for bleeding in PUD include (1) ischemia, (2) bile reflux, and (3) a reduced pH. The majority of cases of upper GI bleeding can be controlled without the requirement of exploratory abdominal surgery by using endoscopy combined with hemostasis and the use of potent antisecretory medications, such as the PPIs. Upper endoscopy permits both the location and cause of upper GI bleeding as well as the determination of risk of re-bleeding based upon the morphology and size of the ulcer. A clean-based peptic ulcer would have < 5 risk of re-bleeding, whereas an actively bleeding ulcer would have an approximately 90 risk of bleeding. Ulcers with either an overlying clot or stigmata...

Helicobacter pylori and Gastroduodenal Disease

Helicobacter pylori infection is associated with multiple gastroduodenal disorders, including gastritis, peptic ulcer disease (PUD), gastric adenocarcinoma (AC), and gastric mucosa-associated lymphoid tissue (MALT) lymphoma. H. pylori infection can be detected in half the world's population. Virtually everyone infected develops chronic active gastritis. Chronic infection is linked to a higher risk of peptic ulcer and a small but increased risk for gastric malignancy, particularly in those individuals who are genetically susceptible. Prevalence of the infection in the general US population is about 20 to 30 , with higher prevalence in some population subgroups, such as those living in crowded and poor socioeconomic conditions. Prevalence of the infection is more common in the older population and in those who have immigrated to the United States from a country with a high endemic prevalence of the infection. It is postulated that prevalence of the infection will continue to decline...

Somatostatin Octreotide

Available evidence does not support the routine use of somatostatin or octreotide in acute NVUGIB. A subgroup analysis of investigator-blinded trials (eight studies) within a meta-analysis demonstrated that the efficacy of somato-statin for the prevention of recurrent bleeding was modest and was limited to peptic ulcer bleeding (Imperiale and Birgisson, 1997). The need for surgery did not differ significantly between the somatostatin group and the control group, nor did the difference in the blood transfusion requirements. Other studies (Lin et al, 1995 Coraggio et al, 1998) have shown similar efficacy compared to H2-receptor antagonists and less efficacy compared to endo-scopic therapy (Barkun et al, 2003).

Truncal vagotomy and highly selective vagotomy

These procedures for chronic peptic ulcer are rarely undertaken, given the efficacy of modern medical therapy. Those who are adept at laparoscopic Nissen's fundoplication (see page 125) will have no difficulty in mobilizing the gastro-oesophageal junction and hiatal area to identify the anterior and posterior vagal trunks. The anterior vagus can readily be isolated from the anterior wall of the oesophagus with a diathermy hook and then divided using this same instrument. However, the posterior vagus nerve frequently contains a substantial blood vessel and it is more prudent to divide the nerve between clips. After truncal vagotomy a drainage procedure is mandatory and the simplest one to perform is the anterior gastro-jejunostomy described above (see page 130). It should be borne in mind that an anterior gastrojejunostomy defies conventional wisdom insofar as at open surgery it is conventional for this to be a posterior gastrojejunostomy.

Specific Investigations in Nonulcer Dyspepsia

Although most dyspepsia in clinical practice is functional, the diagnosis of functional dyspepsia is a diagnosis of exclusion. A search for organic etiologies should be undertaken, because therapy for many organic causes is more satisfying than therapies for functional disorders. Age, symptoms and practical concerns of the patient and physician should guide investigation of the patient's symptoms. Endoscopy is essential in making the diagnosis of nonulcer dyspepsia. In a gastroenterology practice, essentially all patients referred for evaluation of dyspepsia will have already been tested and treated for Helicobacter pylori. Empiric determination of H. pylori status in patients with uninvestigated dyspepsia is an arguable strategy that is heavily dependent upon the prevalence of H. pylori infection and peptic ulcer disease in the population being served (Jones, 2003). Although opinions remain divided, eradication of H. pylori in patients with nonulcer dyspepsia offers a net therapeutic...

Which Lesions to Treat

Peptic ulcers are the most common cause of acute NVUGIB accounting for 37 to 44 of all cases. Endoscopic therapy reduces the rates of recurrent bleeding, emergency surgery, and blood transfusion (Gralnek et al, 1998). The modified Forrest classification (Laine and Peterson, 1994) is widely used to describe the appearance of an ulcer base and predict the likelihood of recurrent bleeding (Table 28-1). The generalizability to clinical practice of this scheme for risk stratification is hampered by interobserver variability in interpreting stigmata of hemorrhage, because estimates have suggested major disparities (Laine et al, 1994 Lau et al, 1997 Mondardini et al, 1998). (For example, what is the risk of recurrent bleeding for the duodenal ulcer illustrated in Figure 28-1) Clean-based ulcers have a very low risk of recurrent bleeding (5 ) and should not receive endoscopic TABLE 28-1. Prevalence and Recurrent Bleeding Risks of Bleeding Peptic Ulcer A potential refinement to the Forrest...

Epidemiology And Pathology

Although the precise incidence is unknown, it is estimated that one to three persons per million develop gastrinomas each year.2 Likewise, gastrinomas are the underlying cause in approximately 0.1 to 1 of patients with peptic ulcer disease.3 They occur in both sporadic and familial or inherited forms, with the former occurring in 80 of cases and the latter in 20 . The familial form is usually associated with multiple endocrine neoplasia (MEN) type I (Table 14-1). In this setting, most associated hor-monally functional neuroendocrine tumors of the pancreas or duodenum are gastrinomas. Gastrinomas are the most common malignant hormonally functional neuroendocrine tumor, and approximately 60 are found to have lymph node, regional,

Clinical Presentation

Certain clinical scenarios should arouse the suspicion of gastrinoma. They include multiple peptic ulcers, persistence or recurrence of ulcer disease despite adequate medical or surgical treatment, ulcers in unusual locations (such as beyond the first portion of the duodenum), and younger age at presentation. Patients with persistent diarrhea and ulcer disease, spontaneous jejunal perforation, or severe esophagitis, also need to be investigated to rule out gastrinoma. Patients with multiple endocrine neoplasia can pre

Refractory Nsaid Ulcers

The most common cause of refractory NSAID ulcer is continued NSAID use. A detailed history, repeated questioning, or interviewing family members often provides a clue to surreptitious use of NSAIDs. Serum salicylates levels are helpful to identify surreptitious aspirin users. Patients with unhealed NSAID ulcers should be treated with a prolonged course of high dose PPI (eg, omeprazole 40 mg twice daily) until the ulcer is healed. Based on the authors' experience, combined treatment with high dose PPI and misoprostol is probably best but this has not been studied prospectively. These chronic, difficult to heal, ulcers recur rapidly when NSAIDs or aspirin are restarted. It is unclear whether switching to a COX-2 inhibitor after ulcer healing would reduce the rate of ulcer recurrence. Substitution of a COX-2 for a traditional NSAID is not thought to have an advantage over conventional NSAIDs with regard to ulcer healing. There is experimental evidence in animals that COX-2 inhibitors...

Clinical Presentations of PUD

Trolled gastric acid hypersecretion is diarrhea, abdominal pain, and, occasionally, upper GI bleeding from postbulbar ulcerations. Classically, patients presenting with PUD will experience a burning or gnawing pain in the epigastrium, or occasionally the hypogastrium, that occurs several hours after meals and typically improves with food ingestion. Presumably acid secretion that is stimulated by meals leads to the pain symptom and the ingestion of food results in buffering of gastric acidity. The pain will be similarly alleviated by the ingestion of antacids or histamine-2 receptor antagonists (H2RAs). Pain related to PUD can be frequently confused with the characteristic pain related to gastroesophageal reflux disease (GERD). In the latter, however, the patients are more likely to report that there is movement of the pain from the epigastrium into the esophagus. The pain related with both PUD and GERD may be improved with meal ingestion, antacids, or H2RAs. A careful history should...

Ulcers and Their Complications

While symptomatic gastroduodenal ulcers may develop during NSAID therapy, one can never be confident that the ulcer is actually benign. If endoscopy is done, a biopsy should be performed on any gastric ulcer to exclude malignancy. It is recommended that a definite ulcer should be followed until complete healing. This is especially important with large ulcers (a 2 cm). Biopsies of the normal appearing mucosa should also be taken to confirm that H. pylori is not present. NSAIDs should be withheld. If H. pylori infection is present, it should be eradicated as it is impossible to determine whether the ulcer was caused by NSAIDs, H. pylori infection, or both. Curing the infection removes one of the most important causes of recurrent ulcer disease. The choice of diagnostic test for H. pylori during the early phase is complicated because many factors may be present that may lead to false negative diagnostic tests, such as the presence of blood in the stomach or recent use of antibiotics,...

Central Nervous System

Some studies have revealed the central actions of AM on gastric function. Intracisternal injection of AM or CGRP dose-dependently inhibits gastric emptying in conscious rats, and the inhibitory effects of AM and CGRP are completely blocked by CGRP(8-37), but not by corticotropin-releasing factor receptor antagonist (Martinez et al., 1997). In addition, the central AM action is abolished by bilateral adrenalectomy or the beta-adrenergic blocker, propranolol, but not altered by indomethacin or subdiaphragmatic vagotomy. These observations indicate that centrally administered AM inhibits gastric emptying through adrenal-dependent, beta-adrenergic pathways independently from activation of central corticotropin-releasing factor receptors. Intracerebroventricular administration of AM is also shown to prevent reserpine-induced gastric ulcers in rats, being mediated via CGRP receptors (Clementi et al, 1998).

Gastroprotective Agents

H. pylori infected patients (which would include a variable number with H. pylori ulcers) from H. pylori negative patients. It has become evident that the prevention of endoscopic ulcers differs between those with and without H. pylori infection. For example, the PPI omeprazole (Prilosec) was superior to low dose ranitidine (Zantac) (150 mg twice daily) or low dose misoprostol (Cytotec) (200 g twice daily) among those with H. pylori infection. In contrast, omeprazole was less effective and not significantly different from ranitidine among those without H. pylori infection and was actually inferior to low dose misopros-tol. Low dose misoprostol was even superior to omeprazole for healing of endoscopic gastric ulcers among those without H. pylori infection (Graham, 2002 Silverstein, 1995). Head-to-head outcome studies using clinically important end points are clearly needed. At the present time it is impossible to determine which combination (H2RAs, PPIs, or misoprostol) is best. It has...

Pharmacologic Management of PUD

In patients who fail to show a response after 8 to 12 weeks of ulcer therapy, one should consider these patients to have refractory PUD. In many cases the issue surrounding this is related to compliance. As noted earlier, for PPIs to have a maximal efficacy for inhibiting gastric acid secretion they should be taken 30 to 60 minutes before protein meal ingestion. If a patient has a problem in gastric emptying (ie, diabetic gas-troparesis), the PPI will not be able to achieve maximal absorption and consideration should be given in these patients to treatment with an H2RA. If H. pylori infection has not been considered up to this point in time a serum or breath test investigation should be undertaken. Similarly, concomitant use of NSAIDs may lead to a refractory ulcer (Lanas et al, 2000). In a patient with duodenal postbulbar ulcerations, consideration should be given to a diagnosis of ZE syndrome by measuring a serum gastrin and performing a gastric analysis. Last, if the ulcer is a...

When things go wrong in life

Eventually, though, after a series of questions about her diet and about whether she had had any history of stomach ulcers, she again became aggressive, even shouting at the doctor about there never having been anything like that in her family. And so it went on after they had admitted her. Each day, she would spend some time being almost obsequiously pleasant to some people, getting them clearly on her side, but then would round on them, throwing back any act of kindness shown to her in an almost vicious way.

Exposure of the duodenum

The ulceration is excised (see Local Excision in the Stomach, STEP 2). As a rule, primary closure of the lesion may not be advisable, as mobilization of the posterior duodenal wall is limited. Hence, a duodenojejunostomy is put in place. The gastro-duodenal artery is exposed and ligated at its origin. In case of bleeding ulcers, this step might be taken first, when the bleeding source has previously been identified in gastroduodenoscopy.

Endovascular Intervention

The left gastric artery supplies the fundus and gastroesophageal junction, whereas the gastroduodenal artery supplies the duodenum, pylorus, and greater curvature. In patients with gastric bleeding, the left gastric artery usually supplies the bleeding vessel and may be embolized safely. Gastric ischemia is rare due to its collateral blood supply and rich submucosal vascular network. In addition to bleeding ulcers, gastric Dieulafoy's lesions have been embolized successfully.

Current surgical treatment of ulcer complications


The primary treatment of bleeding ulcers is endoscopic control followed by treatment for H. pylori if present. Even rebleeding is best treated by repeat attempts at endoscopic control (4). Surgery is indicated for significant bleeding (requiring over five units of blood) that cannot be controlled by endoscopy. Most uncontrolled bleeding ulcers are from the gastroduodenal artery in the posterior aspect of the duodenal bulb. Treatment is by duodenotomy, and ligation of the bleeding site (Fig. 6). The integrity of the pylorus should be preserved. Gastric ulcers should be treated with ulcer excision if amenable. Ulcers located in regions difficult to excise (cardia, prepyloric) should be biopsied and oversewn. Occasional large or penetrating ulcers may be best treated with distal gastrec-tomy for technical considerations or to rule out cancer. Patients with ulcer perforation should be assumed to be H. pylori positive unless there is evidence to the contrary. Duodenal ulcers and prepyloric...

Postgastrectomy syndromes

Efferent Loop Gastrectomy

The most important common postgastrectomy syndromes are dumping, alkaline reflux gastritis, and gastric stasis. Less common postgastrectomy syndromes include small stomach syndrome, postvagotomy diarrhea, afferent loop syndrome, efferent loop syndrome, and recurrent ulcer. Most patients also develop iron deficiency anemia likely caused by exclusion of the duodenum from the enteral stream. The duodenum is the primary site of iron absorption. Poor mixing of the bile and food can result in malabsorption. B12 and folate deficiencies are common nutritional complications. Owing to the hypochlorhydria following vagotomy, postgastrectomy patients may be at greater risk for developing cancer in the gastric remnant. The incidence of postgastrectomy syndromes has decreased overall as a result of the marked decrease in the number of gastric surgeries performed, especially for peptic ulcer disease. This is mainly because of the recognition of H. pylori and its causal relationship with peptic ulcer...

Adenomas and Dysplasia Associated with Other Lesions or Endoscopically Invisible Flat in the Setting of Chronic

If dysplasia is found accidentally at the edges of a gastric ulcer or area of gastric irregularity, the whole lesion should be managed to rule out cancer and synchronous lesions, and it should be removed. The grade of dysplasia for this setting and in adenomas is immaterial. Gastric dysplasia of any grade in a visible lesion should be considered to potentially represent malignancy. This is equivalent conceptually to the DALM lesion in ulcerative colitis.

Clinical Box 11 Why Doesnt Your Stomach Digest Itself

The weakening of these mucosal defense mechanisms results in ulcerations and eventually gastric ulcer disease. A variety of factors including excessive alcohol and tobacco consumption, stress, and nonsteroidal anti-inflammatory drugs such as aspirin can lead to erosion in the lining of the stomach. Additionally, there is also a positive correlation between Helicobacter pylori (H. pylori) bacterial infection and the incidence of gastric and ulcers of the small intestine. H. pylori produces large quantities of the enzyme urease, which hydrolyzes urea to produce ammonia. The ammonia neutralizes the gastric acid in the bacteria's immediate environment thus protecting the bacteria from the toxic effects of its normally toxic acid environment. It is remarkable how some cells find a way to survive even in the deadliest environment.

Focal Biliary Fibrosis Cirrhosis

The presentation of cirrhosis may be that of hepatosplenomegaly and portal hypertension with GI bleeding. Usually this bleeding is from esophageal varices, although of course not all bleeding in patients with cirrhosis is from varices therefore, endoscopy will be needed not just for therapy, but to diagnose the bleeding site and lesion. Endoscopy confirms the site of bleeding and rules out gastric varices, hypertensive gastropathy, or peptic ulcer disease. Usual treatment for varices is then applied, including banding or sclerotherapy. For those where bleeding is

The Borage botanical family Boraginaceae

Moreover, six pyrrolizidine alkaloids were detected in Anchusa strigosa Banks and Sol111 and Heliotrium esfandiarii europine N-oxide112. Alkaloids of both species have bioimpact. Anchusa strigosa is a plant widely distributed in the Mediterranean region. It is used in local folk medicine as a diuretic, analgesic sedative, sudorific remedies and for treatment of stomach ulcers and externally for skin diseases113114. Siciliano et al.115 have analysed the qualitative and quantitative composition of alkaloids in flowers, leaves and roots of A. strigosa. This phytochemical study led to the isolation of nine pyrrolizidine alkaloids, from which three have been unidentified. Many pyrrolizidine alkaloids have been shown to be isolated from leaves, roots and rhizomes of the lungwort species (Pulmonaria spp.). In both Pulmonaria officinalis and Pulmonaria obscura such alkaloids as intermedine, lycopsamine and symphitine have been detected. This means that P. officinalis is not an exception among...

Ruptured Abdominal Aortic Aneurysm

Several other conditions occasionally masquerade as ruptured AAA. Acute myo-cardial infarction is one such condition. In addition, perforated peptic ulcer or other such intraabdominal condition, ureteral colic, or herniated disk may mimic ruptured AAA but these are rarely associated with sustained cardiovascular collapse.

Upper Gastrointestinal Strictures

The most common benign causes of proximal gut obstruction are iatrogenic and best treated by prevention (Table 85-3). These include absolute NSAID interdiction in the patient with recurrent peptic ulcer disease and pyloric channel or postbulbar stenoses (Kozarek et al, 1990 Solt et al, 2003). They also include ulcer (and subsequent stricture) prophylaxis in patients who undergo a pylorus-preserving Whipple procedure or total pancreatectomy. Both of the latter procedures predispose to ulceration because decreased bicarbonate secretion by the pancreas and ulcer risk with or without concomitant stricture, approximate 20 and 50 , respectively, in my medical center.

Targeted Methods Analytical Platform

Induced gastric ulcer in rats(2), and gastric mucosal protection(3). However,the effect of the fucoidan on tumor invasion have never been reported. In the study, we demonstrated that fucoidan derived from Cladosiphon okamuranus Tokida possesses antioxidative potential, suppressing in vitro invasion of HT1080 cells.

Peg Vs Radiological Or Surgical Gastrostomy

Inadvertent and premature removal of the PEG prior to tract maturation results in peritonitis in 0-1 of cases. It may likewise result from perforation of a viscus, preexisting gastric ulcer and leakage around the gastrostomy site. Emergent operative management is indicated in the presence of fever, leukocytosis, abdominal pain, and tenderness. In the absence of peritoneal signs, immediate PEG replacement may be accomplished endoscopically . If the location of the tube remains in question, a fluoroscopic study with a water-soluble contrast agent infused through the PEG should be performed to confirm tube position and to demonstrate the presence or absence of a leak (15). Hemorrhage is a rare complication of PEG placement and occurs in 0-2.5 of cases. It may result from trauma to the esophageal or gastric mucosa, peptic ulcer disease, or trauma to a gastric vessel. Therapy is aimed at applying traction with the internal bumper to tamponade the bleeding vessel, and correcting any...

Clinical Manifestations

Groans refer to the gastrointestinal manifestations of hypercalcemia, seen in 15 of primary hyper-parathyroidism. Patients can present with anorexia, constipation, weight loss, nausea and vomiting, and, peptic ulcer disease. Up to 10 of patients with parathyroid carcinoma can present with acute pancreatitis or recurrent severe pancreatitis. Unfortunately, the degree of anorexia, decreased fluid intake, and vomiting seen with untreated parathyroid carcinoma only aggravates the underlying intravascular depletion caused by hyperparathyroid-induced hypercalcemia.

Investigated and Uninvestigated Dyspepsia

An important distinction should be drawn between patients with dyspeptic symptoms that have not been examined (uninvestigated dyspepsia) and those who have been. Investigated dyspeptics can be divided into two groups those with an identified cause for their symptoms and those whose symptoms have either no obvious cause or a related finding of uncertain clinical significance. Examples of the former category include peptic ulcer disease, gastro-esophageal reflux disease (GERD), or pancreaticobiliary disease. Examples of the latter include such things as delayed gastric emptying and visceral hypersensitivity.

Laser Thermocoagulation

Although laser thermocoagulation was one of the earliest modalities used to treat bleeding peptic ulcers, today it is seldom used due to its expense and technical complexity. A randomized study compared the efficacy of Nd YAG laser, HP, and MPEC in the treatment of active bleeding from peptic ulcers (Hui et al, 1991). Ninety-one patients were randomized to receive laser, HP, or MPEC. There was no significant difference between the groups in the rate of recurrent bleeding, the duration of hospital stay, and the proportion requiring emergency surgery. However, the cost per patient was higher with laser compared to HP and MPEC.

Combination Therapy Injection Therapy Thermocoagulation

Many centers combine injection therapy and thermocoagulation for the endoscopic control of bleeding peptic ulcers. Injection therapy is carried out first followed by thermocoagulation. Supportive evidence includes the study by Lin and colleagues (1999) in which 96 patients with active peptic ulcer bleeding or nonbleeding visible vessels were randomized to receive either epinephrine, BPEC, or combination therapy. Recurrent bleeding episodes were fewer and the volume of blood transfused was less in the combination therapy group compared to the other two groups. No differences were observed in the rates of emergency surgery and mortality among the three groups. High risk patients with arterial spurting may receive a greater benefit from combination therapy. A study by Chung and colleagues (1997) randomized 276 patients with actively bleeding ulcers to either epinephrine injection or epinephrine plus HP. Overall, there were no differences in the rates of initial hemostasis, recurrent...

Two Way Sensitivity Analysis

Besides varying the costs or probabilities of the decision tree, as alluded to in the previous paragraph, one could also redraw parts of the tree or change its overall appearance. How far and how detailed should the medical history and the disease progression be followed into the future The final outcomes of the present tree may seem somewhat arbitrary in that one could have easily proceeded further and spelled out many more details about the subsequent development of the patient's peptic ulcer. One could, for instance, subdivide pain into different types and severities or associate the hospital admission with far more detailed descriptions of the disease progression, such as ulcer bleeding, perforation, surgery, and their respective clinical outcomes. Because parameters on the far right of the decision tree become multiplied with an ever increasing number of probability values, they also tend to exert an ever decreas

Decision Models

For instance, they concern different management options in reflux disease, peptic ulcer, dyspepsia, hepatitis C infection, colorectal cancer, and Crohn's disease, to name just a few. The underlying intentions of such decision analyses are to advocate particular health policies that would be then taken up by the majority of gastroenterologists, be endorsed by professional societies, or even become mandated by governmental agencies. Because of their intended general audience and far-reaching purpose, the analyses try to paint a rather detailed and all-inclusive picture of the disease in question, which considers all potential disease scenarios, even if they are only associated with a low probability of occurrence. For these reasons, many such decision models have become rather complex and somewhat difficult to understand. Besides its general application as an instrument to promote a particular health policy, medical decision analysis also plays an important role as a clinical bedside...

Markov Chains

Any acute ulcer can go in two directions It can heal or it can stay acute. Similarly, any healed ulcer can become acute again or stay healed. The natural history of PUD can, therefore, be conceptualized as ongoing transitions between two health states (ie, acute and healed peptic ulcer). All that one needs to know to be able to set up the Markov model are the healing rate (HR) of acute ulcers and the relapse rate (RR) of healed ulcers. For the model of Figure 2-6, it was assumed that during a 1-month time period 40 of all acute ulcers would heal spontaneously and 8 would relapse. Because the entirety of possibilities to exit any given health state needs to add up to 100 , the monthly rate of patients remaining unhealed equals 100 - HR 60 , and the monthly rate of healed ulcers without recurrence equals How does ulcer prevention with COX-2 affect its natural history COX-2 maintenance therapy may half the RR 4 , but it will probably leave the HR 40 unaffected. Under these conditions the...


Church and colleagues (2003) randomized 247 patients presenting with severe peptic ulcer bleeding to heater probe (HP) plus thrombin injection or to HP plus placebo injection. Successful primary hemostasis was achieved in 97 of the patients. Recurrent bleeding developed in 15 of both groups. There was no difference in emergency surgery and mortality rates and there were no adverse events. Kubba and colleagues (1996) randomized 140 patients to injection with epinephrine alone versus epinephrine combined with large doses of human thrombin (600 to 1000 IU). Only 4.5 of patients in the thrombin group experienced recurrent bleeding compared with 20 in the epinephrine group. Thus, thrombin had a significant benefit in arresting peptic ulcer bleeding.

Figure 1222

Peptic ulcer disease (PUD) and pancreatitis. Patients with PUD or pancreatitis must undergo evaluation and treatment before transplantation. Both conditions may be exacerbated by corticos-teroids used after transplantation. (From Kasiske and coworkers 1 with permission.) Peptic ulcer disease (PUD) and pancreatitis. Patients with PUD or pancreatitis must undergo evaluation and treatment before transplantation. Both conditions may be exacerbated by corticos-teroids used after transplantation. (From Kasiske and coworkers 1 with permission.)

Other Agents

It should be given as 50 to 100 g sc at night before bed. However, metronidazole or other antibiotics should be given during the day to further address bacterial overgrowth. Somatostatin actually inhibits gastric emptying and hence daytime use would require concomitant prokinetics and administration should not directly precede meals. It can be very effective for treating dumping syndrome when given preprandially in this specific clinical setting usually observed postvagotomy or gastric surgery. There is no chapter on peptic ulcer surgery in this edition.

H pylori and NSAIDs

The meta-analysis from Huang and colleagues (2002) showed that H. pylori infection and NSAID use were independent risk factors for PUD together they contribute at least an additive increased risk for ulcer development. Both factors also increased the risk of ulcer bleeding but NSAIDs appeared to be a more frequent cause of bleeding than H. pylori infection. These conclusions were confirmed by the above-mentioned study from Arkkila and colleagues (2003). Eradication of H. pylori resulted in a significantly decreased ulcer recurrence at the 1-year follow-up in patients initially presenting with a bleeding peptic ulcer. In those patients using ASA or NSAIDs, only 4 of patients with successful H. pylori eradication developed ulcer relapse compared with 58 of those who were H. pylori-positive. The use of both ASA and NSAIDs increased ulcer rates to 75 in those with H. pylori infection compared with only 6 of those without H. pylori infection. This study suggested that H. pylori infection...

Acid Peptic Disorders

Smoking impacts on the development and prognosis of acid-peptic disorders. It causes hyposalivation and aerophagia and may make GERD worse by interfering with acid clearance from the esophagus and increasing the number of reflux episodes. Tobacco use is clearly associated with peptic ulcer disease, specifically duodenal ulcer (DU) (Calam and Baron, 2001). Current smokers are twice as likely to develop a DU and have impaired ulcer healing. They are also 10 times as likely to develop a perforation compared to nonsmokers and are also more prone to


Epinephrine for the treatment of bleeding peptic ulcer was pioneered by Chung and colleagues (1988). We prefer epi-nephrine as the initial agent to stop active bleeding and give a clear view of the vessel. A four-quadrant injection of epinephrine 0.1 mg mL (1 10,000 dilution) using a 23 gauge needle (Marcon-Haber, Wilson Cook) requires approximately 10 mL. We follow this with direct injection into the responsible vessel. Nonbleeding visible-vessels are managed the same way. Resistance to injection occurs commonly in chronic peptic ulcers with fibrotic bases and may require a metallic needle (NM-1K, Olympus). Epinephrine does not cause tissue damage, and cardiovascular effects are rare due to its extensive first pass metabolism in the liver. Despite adequately delivered epinephrine, the rate of recurrent bleeding from ulcers remains 15 to 20 . Thus,


It is essential to exclude atherosclerotic heart disease, primary gastrointestinal Differential diagnosis disease such as peptic ulcer disease or colitis, bladder or urinary tract anatomical abnormalities leading to retention (in males, consider prostatism) and drug induced changes in pupils and sweating.

Joseph R PisegnaMD

The stomach plays a central role in the digestive tract owing in large part to the fact that it is the initial site for gastrointestinal (GI) digestion and that, through the release of peptide mediators, it regulates both secretion and motility. In the twentieth century, key discoveries were made in understanding the hormonal regulation of acid secretion with the discovery of gastrin, secretin, and cholecystokinin (CCK), as well as their receptors. The description of a syndrome linked to the gastric hormone gastrin, Zollinger Ellison (ZE) syndrome, showed a direct cause and effect relationship between this hormone and the development of uncontrolled gastric acid. The discovery of the organism, Helicobacter pylori, and its role in the genesis of peptic ulcerations, came to light late in the twentieth century and has provided new insights into the role of this organism and gastric mucosal host defense mechanisms. Similarly, with the increasing use of nonsteroidal anti-inflammatory drugs...


Colonoscopy can be both diagnostic and therapeutic. Studies have shown that it is a safe and accurate test early in the course of acute lower GI bleeding. Urgent colonoscopy is usually done within 6 to 24 hours of admission after a rapid colonic lavage using 4 to 8 L of a polyethylene glycol solution given orally or via NG tube over 3 to 5 hours until the rectal effluent is clear. There is ample evidence that a colonic purge is safe and will not reactivate or increase the rate of bleeding. The likelihood of finding a bleeding source is increased by performing urgent colonoscopy. The yield increases if the colonoscopy is performed while the patient is actively bleeding. The patient should be adequately resuscitated prior to performing urgent colonoscopy so that he or she can tolerate bowel purge and conscious sedation. As with peptic ulcer disease, criteria have been used to identify a colonic bleeding site. These include the finding of active bleeding, a nonbleed-ing visible vessel or...

Tumor Removal

The treatment of ZE syndrome due to sporadic gastrinoma in the era of 1950 to 1980 often consisted of palliative gastrectomy to prevent life threatening bleeding and other complications of intractable peptic ulcer disease. Currently, PPIs can control acid related problems in almost all patients and therefore there is virtually no role for palliative surgery. Surgical intervention now consists of locating and excising the primary tumor with lymph node dissection and resection of metastases, if present. Ten-year disease-free survival and eugastrinemia can be obtained in about one-third of patients with sporadic gastrinoma.


In 1955, Zollinger and Ellison described two patients with peptic ulcer disease in the jejunum and an islet cell tumor of the pancreas.14 It is now understood that the predominant feature of the syndrome (Zollinger- tive bioassay. The usual presenting clinical features are abdominal pain, upper gastrointestinal bleeding, diarrhea, and weight loss. Particularly suggestive of a gastrinoma are peptic ulcers that fail to heal or recur after medical or surgical therapy and ulcers beyond the duodenum. About 15 to 26 of gastrinomas occur as part of MEN type I16 and about 60 are malignant.17 Some authors, however, suggest that all

Symptoms And Signs

The mean age at diagnosis of ZES is 50 years, and the male-to-female ratio is approximately 2 1. In patients with MEN type I, ZES is usually diagnosed in the third decade of life.4 Clinical manifestations are related to the excessive secretion of gastric acid. The most common symptoms are epigastric pain, diarrhea, heartburn, and dysphagia. Almost all patients with ZES will be found to have peptic ulcers, with the proximal duodenum as the most commonly involved site. A minority of patients will have multiple ulcers or ulcers in unusual locations such as the distal duodenum or jejunum.15 In 7 to 10 of patients, a perforated peptic ulcer may be the initial sign of the disease. Gastric acid hypersecretion also leads to secretory diarrhea, which occurs in up to 40 of patients with ZES and may be the sole presenting complaint in 20 of individuals.16 In those with diarrhea, malabsorption


The majority of patients with gastrinoma will present with symptoms and signs of peptic ulcer disease at some stage. The diagnosis is established based upon a battery of tests. A basal gastric output of > 15 mEq h (> 5 mEq h if the patient had any prior acid reducing surgery) is helpful in diagnosis, but gastric acid analysis is a test that is rarely performed. Serum gastrin levels are used to diagnose gastrinoma (Maton, 1994). Fasting serum gastrin levels of > 200 pg mL (> 100 pg mL prior to 1994) and an incremental increase by > 200 pg mL after secretin stimulation is performed to confirm the diagnosis of gastrinoma. After withdrawing all acid inhibiting medications, secretin is injected as a bolus (2 U kg). Serum gastrin levels are measured at 2, 5,10, and 20 minutes after injection, and an incremental rise in the gastrin of > 200 pg mL (95.4 pmol L) is considered positive. It should also be

Natural History

Although most individuals with stress-related mucosal injury remain asymptomatic, 10 to 20 of those who do not receive prophylactic therapy experience GI bleeding of an occult or overt nature. The lesions of SRES differ from those of classic peptic ulcers in that they tend to be shallower and more diffuse in location. The initial lesions are almost invariably found in the acid secreting areas of the stomach, the fundus and the body, and occur within hours of systemic insult. The lesions consist of multiple, shallow, punctate, subepithelial defects, usually associated with little or no surrounding inflammatory reaction, which tend to ooze rather than bleed massively. If risk factors persist or worsen, the erosions and subepithelial petechial hemorrhages may worsen both in depth and extent, so that extensive ulceration can occur in extended areas of the upper GI tract (distal esophagus, gastric antrum, and duodenum) approximately 4 to 5 days after the initial injury. In a small...

Figure 1064

Most of the spores, once in the tissue, are contained by the phago-cytic response. If this fails, as it often does in patients with diabetes mellitus and those otherwise immunosuppressed, germination begins and hyphae develop. The hyphae, as shown in the micrograph, are large, nonseptate, rectangular, and branch at right angles. Infection begins with the invasion of blood vessels, which causes necrosis and dissemination of the infection. The most common site of involvement is the rhino-orbital-cerebral area, accounting for approximately 70 of cases however, pulmonary, cutaneous, gastrointestinal, and disseminated infection may be seen. The chest radiograph during pulmonary infections may show an infiltrate, nodule, cavitary lesion, or pleural effusion. Gastric involvement may range from colonization of peptic ulcers to infiltrative disease with vascular invasion causing perforation. Although classic for mucormycosis, a black eschar of the skin, nasal mucosa, or palate is present in...

Emotions and health

Emotion can be involved in any medical condition. For example, a broken leg can lead to anger and frustration, anxiety, fear, sadness, and so on. Or it may be that one's emotional condition was a precipitating factor in whatever led to the leg being broken in the first place. But the most problematic circumstance comes with the idea of psychosomatic disorders, in which the disorder is clearly physical (migraine, skin rashes, indigestion, peptic ulcers, asthma, genito-urinary conditions, and so on) but the causative factors seem to be emotional. The emotion most commonly implicated is anxiety. The extent of the emotional is hard to determine, one view being that all illness has an emotional component, causa-tively. For example, long-term stresses may well have a deleterious impact on the efficacy of the immune system and thus leave a person more vulnerable to infection.

Other Diseases

In coronary balloon angioplasty, increased extracellular matrix deposition frequently occurs, leading to restenosis. Studies have shown increased type I collagen production following experimental angioplasty, as well as decreased MMP activity (119). The broad-spectrum MMP inhibitor Galardin 2 reduced both collagen synthesis and degradation in an iliac artery model of restenosis following balloon angioplasty. Increased matrix turnover has also been linked to the destabilization of atherosclerotic plaques (120), and elevated gelatinase-B activity has been implicated as a causative factor in the enlargement of abdominal aortic aneurysms (40). Other diseases that have been considered as targets for MMP inhibitor therapy include emphysema (121), gastric ulcers (122), and inflammatory bowel disease (123). In each case, there is evidence to suggest that MMPs secreted by inflammatory or stromal cells are responsible for the tissue remodeling and degradation that occurs in these conditions.

Injection Therapy

A meta-analysis of trials of patients with high risk bleeding ulcers confirmed the effectiveness of injection therapy by showing significant reductions in recurrent bleeding and emergency surgery rates (Cook et al, 1992) Reduced mortality was not shown with injection therapy alone but did exist with combination therapy (discussed below).

Recurrent Bleeding

Although initial hemostasis rates following endoscopic treatment in patients with severe bleeding ulcers exceed 94 , the rate of recurrent bleeding is substantial (15 to 20 ). The patients at highest risk of recurrent bleeding are those whose bleeding developed during hospitalization for another reason, and those with large or deep ulcers, hypotension at presentation, comorbid illness, and severe coagulopathy.

Late Complications

The most frustrating problem that faces the surgeon is the patient who has undergone cholecystectomy and returns with symptoms identical to those prior to surgery. The return of episodic upper abdominal pain after cholecystectomy may indicate other underlying pathology such as peptic ulcer disease or pancreatitis, or even angina. A search for other conditions should be undertaken. There is also the possibility that the patient has common bile duct stones. These can certainly mimic the symptoms that precipitated the cholecystectomy in the first place. Common bile duct stones that develop in the bile duct after cholecystectomy are known as primary common bile duct stones. These are typically soft brown crumbly stones that occur in an abnormal, poorly emptying duct. More commonly, post cholecystectomy common bile duct stones are retained stones stones that came from the gallbladder before it was removed.

Operative techniques

Subtotal Gastrectomy Surgery

Producing parietal cells, but the grinding function of the antrum and the emptying ability of the pylorus are preserved. Proximal gastric vagotomy (also called highly selective vagotomy or parietal cell vagotomy) was technically more demanding, and high recurrent ulcer rates were seen until the procedure was standardized. Once all the nuances of the procedure were appreciated, recurrent ulcer rates were 10 or less and postgastrectomy side effects were much less than those seen with vagotomy and pyloroplasty (3). Proximal gastric vagotomy was not as effective for gastric ulcers and was not used by most surgeons for this indication.

Heater Probe

The heater probe tip consists of a Teflon-coated hollow aluminum cylinder with a heating coil inside (Fig. 20.14). The Teflon coating is designed to prevent the probe from adhering to tissue. Temperature at the tip is constant. The most recent model from Olympus (HeatProbe) delivers thermal energy in two strengths (diameters of 3.7 mm and 2.8 mm), at six different heat levels (5-30J), and includes an opening in the tip for washing off the mucosa. Heater probe therapy has been used successfully for various causes of bleeding in the colon including diverticular bleeding, angiectasia, radiation proctitis, and Dieulafoy lesions. Coagulation depth achieved using a heater probe is similar to bipolar coagulation (30). The mechanism is different, however, as the heat is produced in the probe tip and transmitted directly to the tissue. It should be noted when comparing the two methods that electrocoagulation induces heating of the tissue by electrical current. The heater probe has proved...

Management of PCS

Management of PCS has to address the specific cause. Irritable bowel syndrome (see Chapter 39, Irritable Bowel Syndrome), peptic ulcer disease (see Chapter 25, Peptic Ulcer Disease), cholelithiasis (see Chapter 132, Cholelithiasis), and chronic pancreatitis (see Chapter 139, Chronic Pancreatitis) are important diagnostic considerations in the management of this syndrome. However, in this chapter we will focus on SOD.One study that systematically examined patients after cholecystectomy found that IBS was the most common cause of PCS.

Second Look Endoscopy

Although some studies have shown lower recurrent bleeding rates with repeated treatments, most studies have shown no benefit. The caveats of repeated endoscopy are at least twofold. Firstly, the delay of a definitive surgical intervention may be deleterious, particularly if the patient's clinical status deteriorates during that time (Olejnik et al, 2003). Secondly, endoscopic retreatment may increase the risk to the gastric or duodenal tissues, including necrosis which could lead to perforation. Most studies suggest that the number needed to treat (NNT) to prevent one episode of recurrent bleeding is too high to recommend routine second-look endoscopy. Selection of high risk patients based on clinical and endoscopic parameters may make the NNT smaller.

Adjuvant Analgesics

Significantly improve quality of life and to have beneficial effects on appetite, nausea, mood and malaise. The mechanism of analgesia produced by these drugs may involve anti-oedema effects, anti-inflammatory effects and a direct influence on the electrical activity in damaged nerves. The relative risks and benefits of the various corticosteroids are unknown and dosing is largely empirical. In the United States, the most commonly used drug is dexamethasone, a choice that gains theoretical support from the relatively low mineralocorticoid effect of this agent. Dexamethasone has also been conventionally used for raised intracranial pressure and spinal cord compression. Prednisone, methylprednisolone and prednisolone have also been widely used for other indications. Patients who experience pain and other symptoms may respond favourably to a relatively small dose of cortico-steroid (e.g. dexamethasone 1-2 mg twice daily). In some settings, however, a high-dose regimen may be appropriate....

Goals of Treatment

The test results should be presented and explained to the family and child to tell them which conditions have been excluded. Typically, I review with the family the radiographic studies and all prior tests to show that they were normal. If the family is worried about a particular condition or illness, it must be tested for or the family made aware that the symptoms do not fit the condition. Discuss with the family why the child does not have a variety of common GI disorders, including peptic ulcer disease, IBD, and cancer.

What is abnormal

Balance can vary from time to time and person to person within one disorder. For example, a stomach ulcer might have its main cause in the food eaten or it might have its main cause in living a stressful life. Whatever the balance of causes, it remains a stomach ulcer. So, to say to someone 'It's just psychological' or 'It's all in your mind' is nonsense.

Nematodes Roundworms

With an estimated 1 billion people infected worldwide, it is among the most common intestinal helminthes. Adult worms can reach up to 20 to 40 cm. Clinically, if the worm burden is small then no symptoms are apparent. With heavy worm burden, peptic ulcer-like symptoms and vague abdominal discomfort can occur. Rarely, the worms migrate to other areas of the abdomen and the respiratory

Figure 913

Side effects of immunosuppressive agents. A, The major side effects of several immunosuppressive agents. The major complication of pulse steroids is increased susceptibility to infection. Other potential problems include acute hyperglycemia, hypertension, peptic ulcer disease, and psychiatric disturbances including euphoria and depression. B, Vasoconstriction of the afferent arteriole (AA) caused by cyclosporine. (From English et al. 22 with permission.)