Tuesday, 26 November 2013

Gastric Ulcers: Treatments In conventional medicine perspective

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of
1. Gastro-esophageal reflux disease (GERD) in old age.
2. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide.
3.  H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis
4.  Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID(1) and/or aspirin(2).(a)
II. Gastric ulcers
Gastric ulcer, a type of peptic ulcer is defined as a condition of a localized tissue erosion in the lining the stomach.
F. Treatments
F1. In conventional medicine perspective
1. Antibiotics
Antibiotics for gastric ulcer caused by H. pylori. Unfortunately, monoresistant strains were prevalent with rates of 89% for metronidazole, 36% for clarithromycin, 37% for amoxicillin, 18.5% for ofloxacin and 12% for tetracycline. Furthermore, clarithromycin resistance was on the rise from 2005 to 2008 (32% vs 38%, P = 0.004) and it is significantly observed in non ulcerative dyspeptic patients compared to gastritis, gastric ulcer and duodenal ulcer cases (53% vs 20%, 18% and 19%, P = 0.000). On the contrary, metronidazole and ofloxacin resistance were more common in gastritis and gastric ulcer cases. Distribution analysis and frequencies of resistant mutants in vitro correlated with the absence of cagA gene with metronidazole and ofloxacin resistance, according to the study to determine antibiotic resistance of Helicobacter pylori (H. pylori) in Pakistan and its correlation with host and pathogen associated factors(34).
2. Sequential therapy
In the study to compare the effectiveness of sequential therapy for Helicobacter pylori (H. pylori) infection with that of triple therapy of varying durations, showed that he overall eradication rate was 81.0%, and eradication rates were 75.7% for 7-d conventional triple therapy, 81.9% for 10-d conventional triple therapy, 84.4% for 14-d conventional triple therapy, and 82.0% for 10-d sequential therapy. Neither intention-to-treat analysis nor per protocol analysis showed significant differences in eradication rates using sequential therapy or the standard triple therapy (P = 0.416 and P = 0.405, respectively)(35).
3. Endoscopy
Endoscopy in most cases is used to control ulcer bleeding, but according to the study of evaluation in a retrospective manner by reviewing all gastric ulcers that were followed with serial endoscopy and all gastric cancers diagnosed at the University of Alabama at Birmingham, found that if either the endoscopic impression or the biopsy and cytology is suspicious for malignancy, then follow-up endoscopy until healing should be done. On the other hand, if, at the initial examination, the ulcer appears benign and biopsy plus cytology are negative, then serial endoscopy has a low benefit relative to its cost(36).
4. Probiotic therapy
In the study to investigate the influence of fungal colonization and probiotic treatment on the course of gastric ulcer (GU) and ulcerative colitis (UC), showed that
1) Fungal colonization delays process of ulcer and inflammation healing of GI tract mucosa. That effect was attenuated by probiotic therapy.
2) Probiotic therapy seems to be effective in treatment of fungal colonization of GI tract.
3) Lactobacillus acidophilus therapy shortens the duration of fungal colonization of mucosa (enhanced Candida clearance is associated with IL-4, INF-gamma response)(37).
3. Surgery 
Surgery will always be the last resources in treating gastric ulcer, and only be performed if patients do not respond to medicines or endoscopy
The aim of the surgery is to control the secretion of stomach acid by cutting of the vagus nerve.
2. Pyloroplasty
Pyloroplasty is a surgical procedure to widen the opening in the lower part of the stomach (pylorus), allowing stomach contents to empty more quickly into the intestine.
3. Partial gastrectomy
Partial gastrectomy is a surgical procedure in the removal part of the stomach.
But according to the Progress report in Vagotomy for gastric ulcer, Vagotomy and pyloroplasty has not yet been established as a routine treatment for all gastric ulcers. The attraction of a potentially lower mortality rate, especially when high lesser curve ulcers have to betreated by surgeons not widely experienced in gastric resection, cannot be gainsaid. However, an ulcer in this situation gives rise to technical difficulties if it has to be exposed through a separate gastrotomy incision, to permit a full inspection and an adequate biopsy. The lower morbidity of vagotomy and pyloroplasty has to be balanced against the two factors: first, recurrent
ulceration is not less than after Billroth I gastrectomy and may be more: secondly, the risk of leaving a gastric cancer in situ. This small, but definite, risk must be avoided. The surgeon must ensure that this operative diagnosis is correct. Short of excision of the ulcer, this requires a biopsy of all the edge
of the lesion and not just of four quadrants. The results reported to date do not justify the abandonment of partial gastrectomy in the treatment of benign gastric ulcer(38).
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(a) http://www.ncbi.nlm.nih.gov/pubmed/15588798
(1) http://www.ncbi.nlm.nih.gov/pubmed/16001646
(2) http://www.ncbi.nlm.nih.gov/pubmed/22542157
(34) http://www.ncbi.nlm.nih.gov/pubmed/22611319
(35) http://www.ncbi.nlm.nih.gov/pubmed/22654429
(36) http://www.ncbi.nlm.nih.gov/pubmed/8425440 
(37) http://www.ncbi.nlm.nih.gov/pubmed/17242486 
(38) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1553030/pdf/gut00684-0094.pdf

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