Duodenal and Gastric Ulcer

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The most obvious disease associated with H. pylori is peptic ulceration (Fig. 24-4). More than 90% of duodenal ulcers are associated with toxin-producing H. pylori.56 When a patient with a duodenal ulcer does not have H. pylori infection, etiologic factors such as Zollinger-Ellison syndrome or nonsteroidal anti-inflammatory drug (NSAID) use are likely.57

In gastric ulcer, two causes prevail, and many patients will exhibit both. Most gastric ulcers have H. pylori and these can be identified by presence of the bacterium or chronic gastritis. The stomach is also directly exposed to ingested agents such as an NSAID and is more likely than the duodenum to ulcerate in response to these agents. Therefore, in the United States, about 50% of gastric ulcers are not associated with histologic chronic gastritis or H. pylori but are caused by NSAIDs.48

In tropical countries where NSAIDs are less widely used and H. pylori is very common, most gastric ulcers are caused by H. pylori.58 Perhaps because of this, gastric ulcers are more likely to be malignant and require endoscopy and biopsy for histologic examination.

The proposed causation of duodenal ulcer is as follows. Persons with H. pylori, but with colonization mainly in the antrum, have high acid secretion but a defective mucosal barrier. Inflammation in the antrum impairs the growth of D cells (which make somatostatin) and thus decreases their inhibitory effects on the gastrin-producing G cells. This results in higher gastrin production, which may in turn, over the lifetime of the patient, cause a hyperplasia of the acid-secreting mucosa. Gastric mucus cells normally present in the duodenal bulb become colonized with H. pylori, seeded from the infection present in the antrum. Neutrophil invasion of the duodenal epithelium (duodenitis) increases susceptibility to ulceration. Inflammation is more severe when the H. pylori secretes CagA, thus associating the cytotoxin with duodenal ulcer.59,60

All persons with peptic ulcer should be tested for H. pylori and treated with antimicrobial agents when evidence of the infection exists.4,61 Ulcer recurrence is less than 10% when H. pylori is eradicated, whereas more than 90% of ulcers recur when the bacterium persists.62 Thus, most patients are cured of their ulcer disease with effective antibiotic treatment.63

FIGURE 24-4 Disease associations with Helicobacter pylori (HP). The large circle represents a typical population in a developed country where 60% of persons are not infected with H. pylori. The darker circle represents the 40% of persons who are infected with H. pylori. Even so, nearly all the duodenal ulcers and gastric ulcers occur in the H. pylori-positive group. Each year, 1% of infected patients undergo transition from asymptomatic gastritis to symptomatic peptic ulcer. Note that most gastric adenocarcinomas and gastric mucosa-associated lymphoid tissue (B-cell) lymphomas also occur in the H. pylori-positive persons. Controversy reigns as to the role of H. pylori in persons with dyspepsia but in whom ulcers are not found: Should H. pylori be treated in these persons, or ignored?

FIGURE 24-4 Disease associations with Helicobacter pylori (HP). The large circle represents a typical population in a developed country where 60% of persons are not infected with H. pylori. The darker circle represents the 40% of persons who are infected with H. pylori. Even so, nearly all the duodenal ulcers and gastric ulcers occur in the H. pylori-positive group. Each year, 1% of infected patients undergo transition from asymptomatic gastritis to symptomatic peptic ulcer. Note that most gastric adenocarcinomas and gastric mucosa-associated lymphoid tissue (B-cell) lymphomas also occur in the H. pylori-positive persons. Controversy reigns as to the role of H. pylori in persons with dyspepsia but in whom ulcers are not found: Should H. pylori be treated in these persons, or ignored?

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Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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