STICHTING BG. STICHTING MB AMSTERDAM 31-1-2056 PEPTIC ULCER

STICHTING BG

STICHTING MB

AMSTERDAM

31-1-2056

PEPTICULCER

1900 – 1950:

• increasing incidence 1930: 10-12 % of the population• diagnosis by X-ray• etiology: excess acidification by:

infection (teeth,tonsils) stress/emotion:fear,horror deep disgust

PEPTIC ULCER

Bertram Welton Sippy (1866–1924) was born in the village of Neptune in Richland County, Wisconsin. After 2 years at the University of Wisconsin he transferred to Rush Medical College in Chicago where he was awarded his MD degree in 1890. He took a job as a railroad surgeon in Montana in order to obtain funds for an 18-month tour of hospitals and clinics in Europe, including a stint with the famed Professor Carl Ewald in Berlin. On his return to Chicago he set up a practice of internal medicine, with an emphasis on neurology but without neglect of the broader field. He quickly acquired a reputation as an astute diagnostician and superb teacher. It is said his showmanship held his students spellbound and doubtlessly contributed to his success with patients. An ardent believer in Schwartz’ dictum (“No acid, no ulcer”), he promoted for the treatment of acute peptic ulcer disease a strict regimen of hourly milk and cream feedings supplemented by frequent, large doses of antacids and often by periodic gastric aspiration. A generation of physicians found this a highly effective means of hastening the healing of peptic ulcers. Unfortunately, the Sippy regimen did little to prevent ulcer recurrence, and Sippy’s program was later superceded by more efficacious

therapy

Peptic ulcer epidemiology 1984

US:

1970-1978:decrease in hospitalization rates for DU,not for GU

● low rates in summer ?

● smoking,aspirin,steroids

● genetic factorsKurata JH1984

Ulcer - 1984

EPIDEMIOLOGY peak around 1950: ca 8 % of the working

population disease of middle-aged DU: male-female ratio 2-4/1 genetic influences: blood group 0 poorer part of the population war and social unrest: increased incidence tobacco,alcohol,ulcerogenic drugs

Copyright ©2001 BMJ Publishing Group Ltd.

Logan, R. P H et al. BMJ 2001;323:920-922

No Caption Found

Prevalence of H pylori infection by age in developing and developed countries

Risk factors for Helicobacter pylori infection

Birth in a developing countryLow socioeconomic statusCrowded living conditionsLarge familiesUnsanitary living conditionsUnclean food or waterPresence of infants in the homeExposure to gastric contents of infected individuals

Peptic ulcer epidemiology 1994

5 known causative factors:

● Hp● NSAID● Cigarette smoking● Environmental stress● Dietary habit

Lam SK1994

Time-trends in the epidemiology of peptic ulcer bleeding

0

10

20

30

40

50

60

bleedingulcer

DU GU %> 70yrs

%NSAIDs

1989/1990

1999/2000

per 100.000 person-years Ohmann et alScand J Gastroenterol 2005

Duodenal ulcer: the helicobacterization of a psychosomatic disease?

Melmed RN, Gelpin Y

Isr J Med Sci. 1996 Mar-Apr;32(3-4):211-6

Is Hp the primary cause of DU ?

Arguments against:

1. Regional and ethnic differences in DU prevalence in countries with high prevalence of

Hp

2. Prevalence of Hp-negative DU

3. DU-recurrence after Hp -eradication

Recurrent peptic ulcers after successful

Hp-eradicationMulticenter study: 4940 patients

● Ulcer recurrence (NSAIDs excluded):

1,9 % / year

84 % recurred at the same site as the previous ulcers

Hiroto Miwa2004

Hp-negative/NSAIDs-negative peptic ulcer

prevalence● different data: high in US , Asia and

Australia low in Europe:

Freston (USA) : 11 – 44 % (1)

Kent-Man Chu (Hong Kong): 29,6 % of 1343 pat. (2)

Arroyo (Spain) : 2,1 % of 754 pat. (3)

Arents (Drente) : 4,9 % of 405 pat. (4)

Xia (Australia) : 43 % (5)

1. Aliment Pharmacol Ther,2001

2. World J Gastroenterol 2005

3. Helicobacter 20044. Eur J Gastroenterol 20045. Drugs 1999

Hp-negative/NSAIDs-negative DU

characteristicsCompared with Hp-positive DU:

- older age

- more concomitant problems

- pre-existing malignancy

- recent surgery

- underlying sepsis

- relative acid hypersecretion

- reduced efficacy of antisecretory drugsKent-Man Chu,2005Freston,2001Hung,2005

Hung et alGastroenterology 2005

Long-term outcome of Helicobacter-negative idiopathic bleedingulcers:a prospective cohort study

Hung et al,2005

Cumulative probability of recurrent ulcer bleeding in the group with Hp-negative idiopathic ulcers and the group with Hp-ulcers,who received eradication therapy

Peptic ulcer disease in patients with chronic liver disease

Compared with the general population patients with

cirrhosis have:● higher bleeding complications● delayed healing● greater ulcer recurrence rates● less benefit from Hp-

eradication

The effects of eradication of Helicobacter pylori on the recurrence of duodenal ulcer in

patients with cirrhosis

Liver cirrhosis + DU: 102 patients● Hp + : 54 (52%)● Hp - : 50 (48%)

Recurrence after 1 year:

● After Hp eradication: 21/36 58 %● Hp+ after eradication: 8/18 44 %● Hp - : 24/50 48 %

Lo et al.Gastrointest Endosc2005

Conclusions

● Peptic ulcer is still a multifactorial disease

Hp and NSAIDs are not the only factors

Idiopathic ulcers (Hp-neg,NSAID-neg) are difficult to treat

Peptic ulcers in patients with liver cirrhosis are often

not related to Hp

RTC: 20 horses: gastroscopy: no ulcer

10 horses: day 0:trailer transport to another site day 1-3: exercise day 4: transport backGastroscopy day 5:

gastric ulcer: 7 /10

10 horses: no transport

Gastroscopy day 5:

gastric ulcer: 2/10

Mc Clure,J Am Vet Med Assoc,2005