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Documenti di Professioni
Documenti di Cultura
15S-29S
cause has not been found, the features of pathophysiology may provide clues leading to the identification of causes, and may also offer guidance in
the development of new methods of treatment.
Methods of reducing acid-pepsin secretion have
been a less successful approach to the prevention of
acute ulcers and erosions or in accelerating their
healing. Yet once healed, these lesions seldom
become chronic or recurrent. It is in this group of
peptic ulcers where improving local defense properties form a most attractive new approach to
treatment.
Treatment with either antisecretory or acid neutralizing agents or substances which appear to affect
only local defense mechanisms has been remarkably effective in accelerating the healing of chronic
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
0163-2116/85/1100-015S$04.50/09 1,985PlenumPublishingCorporation
t5S
BROOKS
TABLE 1. PEPTIC ULCERS. AFTER }]ROOKSFP (1)
A c u t e Ulcers: Often superficial and characterized clinically by
Gastric ulcers
Corpus or fundUs ulcer
Antral or prepyloric ulcers
Pyloric channel ulcers
Combination of gastric and duodenal ulcers
Ulcers resistant to healing under treatment
Duodenal ulcers
Uncomplicated duodenal ulcers
Bleeding duodenal ulcers
Perforated duodenal ulcers
Gastric outlet obstruction due to duodenal ulcer
Ulcers resistant to healing under treatment
Recurrent ulcers after surgery
Anastomotic ulcers
Recurrent duodenal ulcer
Hormonally-induced ulcers
Zollinger-EUison syndrome--gastrinoma
Retained antrum
G-cell hyperplasia
Esophageal ulcers
Ulcer adjacent to Meckel's diverticulum
16S
Erosion
Acute ulcer
Chronic ulcer
u_a
Submucosa
Muscularis
Se rosa
-t/,~llW,',~
Sclerosis
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
Year of
publication
Hospital
Total no.
of patients
1975
60
13 (22%)
1975
1976
400
150
74 (18.5%)
56 (37%)
1978
1973
221
100
15 (7%)
9 (9%)
1975
150
7 (5%)
P e p s i n o g e n ~ Pepsin
/~
H+ ~ . .
~ ~.
'-'t,
[
--
Acute gastric
erosions
Acute duodenal
erosions
13 (9%)
Gastric
ulcers
Duodenal
18 (30%)
5 (8%)
15 (6%)
17 (11%)
5 acute
45 (20%)
15 (15%)
3 acute
29 (19%)
?
25 (17%)
13 acute
71 (32%)
26 (26%)
ulcers
54 (36%)
Modified
uJ~rplfialtsimale
~
Histamine
|
4
.
Plasma
proteins
. x~-t
-//-%r,e,.
.
Drug
instilled
~ -r 3r ~
I .~T~,..--'~I"~[- v
4~
Blood
4c
"l~r .t
-r Sodium
~ Z~acetyisalicylate
J.(Z28mg)
~,...____~
]~( ~--"-~"---~--~Ed;2a-/tl--~nterstit'--~'~al
Potential
difference
(-mY) 30
I ~r-,y~l.
25
~.
"
20
i .....
-]-
15
Cholinergicstimulation
J-
T
T .[Ethanol
i i , , , , T I i u I ~ I ,
6
12
18
24
30
36
42
Time (3 min. intervals)
Digestive Diseases and Sciences, Vol, 30, No. 11 (November 1985 Supplement)
17S
BROOKS
8.0-
Net secretion
Intramural7'57.0
pH
6.5
r= 0720 (p<.001)
N~23
I
J
i
J
-1500 -1000 -500
0
500
Net H+ flux ~Eq/30 min)
J
1000
Shock
Reduced
availability of
HCO~ to
neutralize
incoming H+
Reduced
acid secretion
with lowered
alkaline tide
and available
HC03
Reduced J
mucosal blood I
flow to
I
sweep away
influx ng H+
Reduced
availability
of ATP that
may be
required to
neutralize
luminal H+
I
9
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
30.
% Patients
with
Curling's
ulcer 20
10
20
30
40
50
60
70
% Body surface burned
80
90
1(}O
prophylactic treatment with antacids or H2-antagonists has virtually eliminated this lesion.
Acute Ulcers in Patients with Injury to the Central
Nervous System
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
19S
BROOKS
using polyethylene glycol as an unabsorbable reference compound (53). Recently calculation of intramural pH from the pH of gastric juice and arterial
pCO2 identified a pH < 7.24 in all seven patients
among 103 on intensive care units who developed
massive gastrointestinal bleeding (54).
Gastrocamera studies and endoscopic photographs in patients at risk for stress ulcer, showed
the initial lesion to be one of focal ischemia in the
acid-secreting mucosa progressing to petechiae and
erosions (55).
The results of medical treatment of acute gastrointestinal bleeding have been disappointing (54).
Laser treatment and now possibly heater probe
coagulation seem to be effective in stopping bleeding in a small group of patients identified as being at
high risk for rebleeding, based upon visible vessels
and spurting vessels (1). These results do not contribute much to our understanding of pathophysiology. A single anecdotal report of control of bleeding
from 'hemorrhagic' gastritis with PGE2 after all
other treatments had failed points to the need for
controlled trials (56). Surgical procedures also have
a variable record of success.
Prevention of gastrointestinal bleeding has been
more successful. Both cimetidine and antacids have
reduced the incidence of bleeding in intensive care
units, although in some, antacids titrated to maintain a pH > 3.5-4 have been more effective.
In summary acid-pepsin seems to be an important
permissive factor in stress ulcers, and back diffusion of H into the mucosa an important factor in
denuding the mucosa and exposing blood vessels.
However, once bleeding has occurred, among nonsurgical procedures only methods of coagulating the
vessels appear to significantly alter the course of the
injury.
Authors
Recurrence
rate (%)
Duration o f
follow-up
(years)
Ref.
no.
No. o f
patients
(57)
111
46.8
>5
(58)
101
98.0
(59)
697#
27.0
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
(69)
377
54
83
84
66
59
9
16
25
42
41.9
43.0*
40.0
34.5*
39.0*
39.0*
44.0*
70.0*
48.0*
55.0*
(5/23)
5 (or to
surgery)
2
1
2
1
>3
6-9 months
1
1
I
1
*verified by endoscopy.
t380 resected surgically.
Pathology
CHRONIC AND RECURRENT GASTRIC ULCER
The characteristic clinical feature of chronic gastric ulcer is its tendency to recur as shown in Table
3 (1, 57-69). In three recent controlled trials H2antagonists in maintenance doses significantly reduced the rate of recurrence. This suggests a primary role for gastric acid secretion in leading to
recurrence. In a four-year study in Aberdeen, Scotland, about half the gastric ulcer patients in the
community remained symptom-free whether they
were treated by medical or surgical methods (70).
As with other peptic ulcers, heterogeneity exists
among gastric ulcers. One popular classification
20S
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
Gastric
cancer
Normal
subjects
Duodenal
ulcer
Gastric
ulcer
54
50
Men Women
237
35
43
30
22
7
Men Women Men Women Men Women
10(2
80
Acid output 60
mEq/hr,
40
20
9 ~
~176176
,
.
,m
~176
. . ,
0
...d
Achlorh~ dria - -
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
21S
BROOKS
trimipramine, a combination of the tricyclic antidepressant imipramine and levomepromogine, but the
results are inconclusive (96-98). Cholestyramine,
an effective binder of bile salts, was without benefit
in healing gastric ulcers as evaluated radiologically.
Carbenoxolone was one of the first agents shown to
accelerate the healing of gastric ulcer. Carbenoxolone has been reported to increase the secretion of
mucus, decrease the rate of cell turnover, and to
impair the catabolism of prostaglandins (99). A
general criticism of such studies is that the quantitative importance in improving mucosal resistance
due to any one action is unknown.
These results suggest that both acid-pepsin secretion as an aggressive factor, and improved local
defense mechanisms can accelerate the healing of
gastric ulcers. However, this still leaves unanswered the question of a role for deficient endogenous mucosal defense mechanisms.
The good results of surgical treatment, usually
involving excision of the ulcer and removal of either
gastrin or acid-secreting mucosa, also support the
importance of acid-pepsin aggressive factors.
Factors influencing favorable responses to healing of gastric ulcers include hospitalization and
stopping smoking, while salicylates, smoking and
large ulcer size reduce the percentage which heal
(100-102). These observations suggest that salicylates can contribute to chronic gastric ulceration,
possibly through damage to the mucosal barrier.
Once gastric ulcers have healed, H:-antagonists
have been shown to prevent recurrences, at least
during a year of administration (68). Controlled
trials with agents acting through local mucosal
defense mechanisms, e.g. sucralfate and prostaglandins, are still in progress. These results emphasize the importance of acid-pepsin secretion in
initiating recurrent gastric ulcers.
One of the most glaring gaps in our knowledge is
the lack of understanding of the mechanism of pain
in gastric ulcer. Spraying ulcers with 0.2N HCI for
fifteen minutes through an esophagoscope failed to
elicit pain in four subjects (103). This may explain in
part the relative lack of difference between placebo
and ulcer-healing promoting drugs with regard to
relief of pain.
The development of gastric ulcers following truncal vagotomy for duodenal ulcer, and its prevention
by a pyloroplasty, is compatible with a role for
gastric stasis in the pathophysiology of gastric ulcer, rather than meal-induced hypergastrinemia and
hypersecretion as proposed by Dragstedt (1).
22S
Digestive Diseases and Sciences, Vol, 30, No. ll (November 1985 Supplement)
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
23S
BROOKS
2.2
1.8
H + activity
Meal
1.4
entering
duodenum,
(mEq/10min)1.0
o.~
0.20
-1
U patients
.'~,..
(n= 12)
."l.[ ~'v
.("'[~ I f"lr; Healthy subjects
is
--i.i.ti (n=81
~
l..
****1"**
2
Hours
I****
*I
4
*P<O.05
duodenal ulcer (DU) and healthyvolunteers. *Significantdifferences (P< 0.05) at each 10-minuteinterval. After Malagelada
JR, LongstrethGF, Deering TB, et al. (109); reproduced with
permission from Gastroenterology73:992, i977.
24S
Acetylcholine
N1N~-DMH ~
[O
plexus
N1-MH--"X,
II
Parietalcell
I HistamineI
~
~
O)
",, o!(o!:Mff,
r
":,*'/
~
/ Antr~lm+
"1 s
j~--~'(~----intestine
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
failure of ulcer healing is smoking. Failure to suppress nocturnal acid secretion, the male sex, old
patients, large deep irregular ulcers, peak acid outputs >30 mM/h are associated with failure to heal.
Smoking has been shown to decrease the effectiveness of Hz-antagonists as antisecretory agents.
These results point to the major role of acid
secretion in the healing of duodenal ulcer. However
a number of other agents which have no significant
gastric acid antisecretory effect also accelerate the
healing of duodenal ulcer at rates not significantly
different from Hz-antagonists. These include colloidal bismuth and sucralfate. The failure rate is nearly
the same (119).
The latest addition to the medical armamentarium
is omeprazole. This agent healed 93% of duodenal
ulcers in two weeks at a dose of 40 mg daily (120).
After seven days of treatment of healthy subjects
with omeprazole 30 or 60 mg per day, basal acid
output and peak acid output to pentagastrin were
nearly totally suppressed (121). There was no significant effect of omeprazole on pepsin. This agent
functions as an inhibitor of the parietal cell H +K+-ATPase. It enters the cell and remains there
after 16 hours despite a rapid disappearance from
the plasma. Figure 10 shows a diagramatic representation of the parietal cell and the role of the
H+-K+-ATPase (122).
HCl
Apical /
"
+1\CaM
\,,..~./
Ca++ I
~ oAyP
",:v: Na+
',:',~,:~7 1
'"" ~
c,- ,. /%..
F!O
....... .~
......
NaKelz
Ionpathways
Basal
Fig 10. Schematic model of the parietal cell s h o w i n g the receptor
s y s t e m s and ion p a t h w a y s in the basal-lateral m e m b r a n e , and the
apical m e m b r a n e transition from a resting to a stimulated state.
G = gastrin; A c h = acetylcholine; H = histamine; C a M =
calmodulin; sc = secretory canaliculus; tv = tubulovesicles; m f
= microfilaments. After M a l i n o w s k a D H and Sachs G: (126);
reproduced with permission from Clin Gastroenterol 13:322, 1984.
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
25S
BROOKS
19,74
6. Davenport HW, Kauffman GL Jr: Plasma shedd!ng by the
canine. Oxyntic and pyloric glandular mucosa induced by
top!cal action of acetylcholine. Effect of atropine and
physostymine. Gastroenterology 69:190-197, 1:975
7. Wood J G, Davenpo~ HW: Measurement of canine vascular permeability to plasma proteins in the normal and
protein-losing states. Gastroenterology 82:72.5-733, 1982
8. Geall MG; Phillips SF, Summerskill WHJ: Profile of gastric
potential difference in man: Effects of aspirin, alcohol, bile
and endogenous acid. Gastroenterology 58:437--443, 1970
9. Murray HS, Strottmari MP, Cooke AR: Effect Of several
drugs on gastric potential difference in man. Br Med J
1:1%21, 1974
!0. Morris GP, Wallace JL, Harding PL, Krausse EJ, Lolle SJ:
Correlations between chmiges in indicators of gastric
mucosal barrier. !ntegrity at time of exposure to "Barrier
Breakers" and extent of hemorrhagic erosions one hour
later. Dig Dis Sci 29i6-11, 1984
11. Silen W, Schiessel R, Kiviiaakso E : The gastric mucosal
barrier and ulceration. Brain Res Bull 5(Supp! 1):3--6, 1980
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Digestive Diseases and Sciences, Vol. 30, No, 11 (November 1985 Supplement)
P A T H O P H Y S I O L O G Y OF PEPTIC U L C E R D I S E A S E
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Press, 1984, pp 329-333
Digestive Diseases and Sciences, Vol. 30, No. 11 (November 1985 Supplement)
29S