摘要:

SUMMARYAn intractable duodenal ulcer is an ulcer that has not healed after 8 weeks of full‐dose treatment with a modern antiulcer drug. Such ulcers are relatively rare ‐ perhaps five in 100 patients will have intractable duodenal ulceration. The differential diagnosis includes non‐compliance as a cause of continuing ulceration, hypersecretion of gastric acid or other rare causes of ulcers in the duodenum. Investigations should include biopsy of the continuing ulceration at endoscopy, measurement of fasting plasma gastrin and routine haematology and biochemistry profiles. An intractable duodenal ulcer can be treated either by using a powerful antisecretory regimen (high doses of ranitidine or famotidine or a conventional dose of omeprazole), by changing to tripotassium dicitrato bismuthate or, in exceptional circumstances, by extremely careful surgical interve

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00654.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThe epidemiology and character of peptic ulcer has changed over the last 20 years, with only some of the change being due to the introduction of H2‐receptor antagonists in the mid‐1970s. There is evidence that duodenal ulcer was declining before this change in therapeutics. H2‐receptor antagonists have, however, greatly reduced the morbidity and the time off work due to peptic ulcer disease. There is no strong evidence, however, that mortality due to peptic ulcer disease, which was already relatively small, has been reduced. The incidence of complications such as gastric haemorrhage, perforation and obstruction, may have increased in elderly patients. This may be associated with independent variables, such as increased use of non‐steroidal anti‐inflammat

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00655.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThis article reviews the pathophysiology and management of bleeding peptic ulcer. Ulcers bleed when and because they erode into a blood vessel, and bleed massively when they erode into a medium‐ or large‐sized artery. Focal pathology at the bleeding point (such as arteritis, aneurysmal dilatation or recanalized thrombus) contributes to the timing and clinical pattern of ulcer bleeding. Big bleeds are probably associated with erosion into big arteries. The identification of a visible vessel in the floor of an ulcer that has recently bled is predictive of further bleeding, while the absence of a visible vessel or stigmata of recent haemorrhage is strongly predictive that further bleeding will not occur. Unfortunately, no conventional method of managing gastrointestinal bleeding from ulcers has been convincingly shown to be better than placebo in controlled clinical trials. The value of transfusion and surgery has never been tested in controlled trials, while many small studies of drug therapy, especially of H2‐receptor blocking agents, and a few small studies of early surgery afford generally negative or equivocal results. There is some evidence that new physical methods such as lasers or bipolar probes applied at endoscopy are superior to placebo though negative trials have also been reported. Studies randomizing larger numbers of patients with bleeding ulcers are required if therapeutic benefit of any aspect of management is to be demonstrated or re

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00656.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThere are two major principles of ulcer therapy. Today, the most widely accepted drugs are those which substantially reduce aggressive factors (i.e. acid and pepsin), namely histamine H2‐receptor antagonists, antimuscarinics and antacids. Less frequently applied are mucoprotective agents like colloidal bismuth compounds and sucralfate. Prostaglandins both reduce acid secretion substantially and are believed to enhance mucosal resistance. Their anti‐ulcer efficacy, however, is solely explicable by their antisecretory activity. Although mucosa‐strengthening agents and H2‐receptor blockers have nearly identical healing rates, mucosa‐strengthening agents have inconvenient dosage regimens (four times or twice daily) and are probably less effective in relieving pain. The same holds true for antacids. Prostaglandins, antimuscarinics and antacids have dose related side effects. In contrast, H2‐receptor blockers are characterized by a clear mechanism of action, convenient dosage regimes, good tolerance and a low incidence of side‐effects. H2‐receptor antagonists are the most effective anti‐ulcer drugs pr

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00657.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThe H2‐receptor antagonists which are used for ulcer therapy fall into four main structural classes. Cimetidine is an imidazole derivative; ranitidine belongs to the basically substituted furans, famotidine is a member of the guanidinothiazole group; and roxatidine belongs to the aminoalkylphenoxy series. Famotidine is the most potent, selective H2‐receptor antagonist yet available for ulcer therapy. On a weight basis, famotidine is approximately eight times more potent than ranitidine and 40 times more potent than cimetidine. Cimetidine, ranitidine and famotidine are competitive antagonists, while the long‐acting H2‐receptor antagonists, e.g. loxtidine and lamitidine, are insurmountable H2‐receptor blockers. Famotidine has a longer duration of action than either ranitidine or cimetidine. Because famotidine does not interact with cytochrome P‐450 of the hepatic enzyme system, it does not appear to affect the metabolism of drugs metabolized by this system. The overall number of side‐effects of the H2‐receptor antagonists is in the range of 2–3% and no irreversible adverse effects are known. Famotidine has been found to be generally well tolerated. In a first post‐marketing study, the number of patients with side‐effects was only 0.43%. Side‐effects such as headache, dizziness, constipation and diarrhoea have been observed only occasionally. Thus, famotidine is a safe and potent H2‐receptor

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00658.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYFamotidine now presents physicians in the USA and many European countries with a third option when considering H2‐antagonist therapy. A dose of 40 mg in the evening decreases nocturnal gastric acidity for 10–12 hours, leaving daytime‐stimulated acidity virtually unaffected. This single evening dosage regimen produces effective healing of gastric and duodenal ulceration; maintenance of healing can then be achieved satisfactorily with 20 mg in the evening. In extensive clinical studies, the adverse effect profile of famotidine is similar to placebo. Famotidine has no known drug interactions and there are no identified mechanisms by which it might be expected to produce them. Circulating plasma hormone concentrations in man are not affected by famotidine and no antiandrogenic properties have been observed in animal studies. Future potential uses of famotidine may include the treatment of haemorrhage from peptic ulcers and the healing of oesophageal ulcer

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00659.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThe old dictum‘no acid—no ulcer’is no longer a sufficient explanation of the pathogenesis of ulcer disease. The real question is‘if acid—why ulcer?’Although acid remains predominant, some of the other factors influencing ulcerogenesis are nocturnal acid secretion, pepsin enzyme subspecies, the mucus layer, bicarbonate level, prostaglandins,Campylobacter pyloriinfection, consumption of non‐steroidal anti‐inflammatory drugs, and smoking habits. Although the ulcer burden has been greatly reduced by the introduction of H2‐receptor antagonists, complications such as bleeding and perforation remain a problem, especially in the elderly. Medical treatment, in the form of H2‐receptor antagonists, is effectiv

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00660.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYIntragastric pH monitoring has shown that the distribution of acidity within the stomach is not homogeneous. Not only is it affected by meals but it also has a circadian rhythm in which nocturnal pH falls to very acid levels in normal subjects. Although results of pH monitoring are highly reproducible within individuals, considerable inter‐individual variation has been shown. Duodenal ulcer patients do not appear to possess the normal buffering reaction to meals, but their night‐time acidity is within the normal range. In these patients, antacids and pirenzepine have a small acid‐neutralizing effect in the stomach; cimetidine is less potent than ranitidine and famotidine. Clinicians can choose between a single dose of either ranitidine or famotidine in the evening with dinner and a twice‐daily

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00661.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThere is an explosion of interest in the role ofCampylobacter pylorias a cause of active chronic gastritis. This curved spiraled microorganism can readily be detected within the mucus gel covering the stomach mucosa, especially in patients suffering from peptic ulcer disease or non‐ulcer dyspepsia. To what extent this intriguing microorganism is causally related to peptic ulcer disease remains to be elucidated, but all the evidence which is available so far supports a pathogenetically important role. There appears to be a striking discordance between in‐vitro sensitivity and in‐vivo efficacy of antibiotic therapy. At present, the combination of colloidal bismuth subcitrate and amoxycillin or tinidazole appears most effective in temporary elimination of these microorga

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00662.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY

摘要:

SUMMARYThe pathogenetic role of non‐steroidal anti‐inflammatory drugs (NSAIDs) in peptic ulcer disease is reviewed, on the basis of available experimental and epidemiological knowledge. In addition, original clinical data are provided concerning the prophylactic and therapeutic role of the H2‐receptor antagonists ranitidine and cimetidine, and colloidal bismuth subcitrate, in the treatment of NSAID‐associated peptic lesions in rheumatic p

ISSN:0269-2813    

DOI:10.1111/j.1365-2036.1987.tb00663.x

出版商:Blackwell Publishing Ltd    

年代:1987

数据来源: WILEY