Despite the generally declining trend in the incidence of peptic ulcers, peptic ulcer bleeding remains a prevalent and clinically significant condition. Additionally, despite the development of therapeutic endoscopy and acid-suppressive therapy, the overall mortality associated with peptic ulcer bleeding has remained at about 6% to 14%. Management of acute peptic ulcer bleeding requires prompt resuscitation, risk assessment, early endoscopic evaluation, and early initiation of pharmacotherapy. Advances in therapeutic endoscopic techniques and antisecretory therapies in the past few decades have reduced the incidence of recurrent bleeding and the mortality rate associated with this disease. Strategies to prevent recurrence have been defined for various causes of peptic ulcer bleeding. This article reviews the current diagnosis and management of acute peptic ulcer bleeding.
Diagnosis* ; Disease Management ; Drug Therapy ; Endoscopy ; Hemorrhage* ; Incidence ; Mortality ; Peptic Ulcer Hemorrhage ; Peptic Ulcer* ; Recurrence ; Resuscitation ; Risk Assessment

Peptic ulcer (PU) bleeding is the main cause of non-variceal gastrointestinal bleeding. Negative outcomes include re-bleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by acute bleeding event. Accurate analysis of risk for clinical features can help physician to decide treatment modality. Endoscopy can detect bleeding stigmata and perform therapeutic hemostasis. Proton pump inhibitor (PPI) compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in upper gastrointestinal (UGI) bleeding significantly reduces the proportion of patients with stigmata of recent hemorrhage (SRH) at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with endoscopic hemostasis for those with major SRH, is likely to be the most cost-effective. The treatment of H. pyori infection was found to be more effective than anti-secretory therapy in preventing recurrent bleeding from PU. H. pyori eradication alone and eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies to prevent ulcer bleeding among H. pyori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective treatment. This review focuses specifically on the current treatment of patients with acute bleeding from a peptic ulcer.
Anti-Ulcer Agents/therapeutic use ; Endoscopy, Gastrointestinal ; Gastrointestinal Hemorrhage/diagnosis ; Helicobacter Infections/diagnosis/drug therapy ; Helicobacter pylori ; Hemostasis, Endoscopic ; Humans ; Misoprostol/therapeutic use ; Peptic Ulcer/surgery/*therapy ; Peptic Ulcer Hemorrhage/surgery/*therapy ; Proton Pump Inhibitors/therapeutic use

BACKGROUND: Since the international guideline of Helicobacter pylori eradication therapy was introduced into Korea, many reports about eradication outcomes have been documented. These data were published mostly from referred university hospital. However, in Korea, majority of patients has been treated with H.pylori eradication regimen in primary care setting. This study was performed to investigate the eradication rate of H. pylori in primary care office of Seoul, Korea. METHODS: Total 173 patients with H.pylori-positive gastroscopy results received eradication regimen-mainly one week PPI based triple therapy-from January 1998 to March 2003. Four weeks after completion of medication, urea breath test, biopsy and CLO test were performed to detect H.pylori. RESULTS: Total eradication rate was 87.9%. The eradication rate of male and female were 90.3% and 84.3%, respectively (p>0.05). The eradication rate of patients older than younger than 60 was 81.5% vs 89.0%, respectively (p>0.05). There was no statistical significance in annual eradication rate. In eradication rate, there was no significant difference among PPI regimen (omeprazole, rabeprazole, pantoprazole). Whether endoscopic diagnosis is gastric ulcer or duodenal ulcer, there was no statistical difference in eradication rate between them. In the same way, there was also no statistical difference between peptic ulcer and H.pylori associated gastritis. CONCLUSION: The current eradication rate of H. pylori in primary care setting of Korea was 87.9%. H.pylori eradication rate in primary care setting was not much different from that in referred hospital in Korea, but it was lower than that reported by controlled trials of 1995 (initial times of introduction of international guide line into Korea). So far, the results have been acceptable, but there still remains to be investigated in PPI-based triple therapy as H.pylori eradication in primary care setting in the future of Korea.
Biopsy ; Breath Tests ; Diagnosis ; Drug Therapy ; Duodenal Ulcer ; Female ; Gastritis ; Gastroscopy ; Helicobacter pylori* ; Helicobacter* ; Humans ; Korea* ; Male ; Peptic Ulcer ; Primary Health Care* ; Rabeprazole ; Seoul ; Stomach Ulcer ; Urea

Gastric ulcer bleeding in neonatal period, mainly in preterm newborn babies or in neonates treated in intensive care units, is relatively frequent, However the occurrence of significant gastric ulcer bleeding in healthy full term infants is unusual. We experienced a case of massive upper gastrointestinal (GI) bleeding in a 3-day-old healthy full term infant. Endoscopic examination confirmed the presence of gastric ulcerations. Treatment was initiated with transfusion and histamine 2 receptor antagonist, and the clinical signs resolved. Mother's serum antibody to Helicobacter pylori (H. pylori) was positive. We collected stool of the patient including other 17 infants in the intensive care unit. A highly sensitive semi-nested PCR for H. pylori DNA was performed, but all infants including the patient revealed negative. H. pylori infection is not related with upper GI bleeding in healthy full term infants. In conclusion, the diagnosis of upper GI bleeding in infant can be easily made by means of pediatric endoscopy, which is a simple and a well tolerated examination.
Blood Transfusion ; Endoscopy, Gastrointestinal ; Female ; Histamine Antagonists/therapeutic use ; Humans ; Infant, Newborn ; Peptic Ulcer Hemorrhage/*diagnosis/drug therapy/therapy ; Stomach Ulcer/*complications

The pathogenesis, incidence, complication rates, response to acid suppression and Helicobacter pylori (H. pylori) eradication therapy in peptic ulcer associated with chronic disease such as liver cirrhosis, chronic renal failure, diabetes mellitus, and critically ill conditions are different from those with general population, so that the management strategies also should be differentiated. The eradication of H. pylori are not so effective for preventing recurrence of peptic ulcer in liver cirrhosis patients as shown in general population, and conservative managements such as preventing deterioration of hepatic function and decrease in portal pressure are mandatory to reduce the risk of ulcer recurrence. The standard triple therapy for H. pylori eradication are as effective in chronic renal failure patients as in normal population, but the frequency of side effects of amoxicillin is higher in the patients not receiving dialysis therapy. Delay in eradication therapy until beginning of dialysis therapy or modification of eradication regimen should be considered in such cases. High prevalence of asymptomatic peptic ulcers and increased mortality in complicated peptic ulcer disease warrant regular endoscopic surveillance in diabetic patients, especially with angiopathy. The prolongation of duration of eradication therapy also should be considered in diabetic patients with angiopathic complication because of lower eradication rate with standard triple regimens as compared to normal population. Prophylactic acid suppressive therapy is highly recommended in critically ill patients with multiple risk factors. Herein, we propose evidence-based treatment guidelines for the management of peptic ulcer disease in special conditions based on literature review and experts opinion.
Amoxicillin/therapeutic use ; Anti-Bacterial Agents/therapeutic use ; Critical Illness ; Diabetes Mellitus/diagnosis/drug therapy ; Helicobacter Infections/diagnosis/drug therapy ; Helicobacter pylori ; Humans ; Kidney Failure, Chronic/diagnosis/therapy ; Liver Cirrhosis/diagnosis/therapy ; Peptic Ulcer/*therapy ; Risk Factors

BACKGROUND/AIMS: Eradication rates of Helicobacter pylori (H. pylori) tend to decrease over the last few years. Apart from the antibiotic resistance and patients compliance, various factors have an influence on the efficacy of eradication therapy. We analyzed the inter-departmental differences in the eradication therapy for H. pylori infection. METHODS: Between January 2003 and June 2007, total 3,072 eradication regimens were prescribed to patients. Eradication rates according to departments - gastroenterology (GE), general internal medicine (IM) and family medicine (FM) - were analyzed retrospectively. RESULTS: The overall eradication rate of first-line triple therapy was 82.5% and second-line quadruple therapy was 71.2%. In the department of IM and FM, the eradication therapy was applied more frequently to the patients with erosion only, not ulcer. Overall eradication rates according to the departments were 87.0% in GE, 81.1% in IM and 77.2% in FM (p=0.02 GE vs. IM and p<0.01 GE vs. FM, respectively). Eradication rate in patients with peptic ulcer was also significantly higher in GE compared with IM or FM. CONCLUSIONS: In primary clinic (IM and FM), the eradication therapy was frequently applied to erosion. The eradication rates of H. pylori in GE department were significantly higher than those of IM or FM. Inter-departmental differences of the eradication rate might be caused by patients' compliance to prescribed medication.
Anti-Bacterial Agents/*therapeutic use ; Anti-Ulcer Agents/*therapeutic use ; Drug Therapy, Combination ; Gastroenterology ; Helicobacter Infections/diagnosis/*drug therapy ; *Helicobacter pylori ; Humans ; Internal Medicine ; Patient Compliance ; Peptic Ulcer/drug therapy ; Retrospective Studies ; Treatment Outcome

OBJECTIVECarica papaya is an important fruit with its seeds used in the treatment of ulcer in Nigeria. This study investigated the anti-ulcerogenic and antioxidant activities of aqueous extract of Carica papaya seed against indomethacin-induced peptic ulcer in male rats.

METHODSThirty male rats were separated into 6 groups (A-F) of five rats each. For 14 d before ulcer induction with indomethacin, groups received once daily oral doses of vehicle (distilled water), cimetidine 200 mg/kg body weight (BW), or aqueous extract of C. papaya seed at doses of 100, 150 or 200 mg/kg BW (groups A, B, C, D, E and F, respectively). Twenty-four hours after the last treatment, groups B, C, D, E and F were treated with 100 mg/kg BW of indomethacin to induce ulcer formation.

RESULTSCarica papaya seed extract significantly (P< 0.05) increased gastric pH and percentage of ulcer inhibition relative to indomethacin-induced ulcer rats. The extract significantly (P< 0.05) decreased gastric acidity, gastric acid output, gastric pepsin secretion, ulcer index and gastric secretion volume relative to group B. These results were similar to that achieved by pretreatment with cimetidine. Specific activities of superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase and glucose-6-phosphate dehydrogenase in the extract-treated groups (D, E and F) were increased significantly over the group B (P< 0.05). Pretreatment with the seed extract protected rats from the indomethacin-mediated decrease in enzyme function experienced by the group B. Similarly, indomethacin-mediated decrease in reduced glutathione level and indomethacin-mediated increase in malondialdehyde were reversed by Carica papaya extract.

CONCLUSIONIn this study, pretreatment with aqueous extract of Carica papaya seed exhibited anti-ulcerogenic and antioxidant effects, which may be due to the enhanced antioxidant enzymes.

Animals ; Anti-Ulcer Agents ; administration & dosage ; Carica ; Disease Models, Animal ; Dose-Response Relationship, Drug ; Duodenal Ulcer ; chemically induced ; diagnosis ; drug therapy ; Gastric Acidity Determination ; Indomethacin ; pharmacology ; Male ; Peptic Ulcer ; chemically induced ; diagnosis ; drug therapy ; Plant Extracts ; administration & dosage ; Rats ; Seeds ; Stomach Ulcer ; chemically induced ; diagnosis ; drug therapy ; Treatment Outcome

An idiopathic peptic ulcer is defined as an ulcer with unknown cause or an ulcer that appears to arise spontaneously. The first step in treatment is to exclude common possible causes, including Helicobacter pylori infection, infection with other pathogens, ulcerogenic drugs, and uncommon diseases with upper gastrointestinal manifestations. When all known causes are excluded, a diagnosis of idiopathic peptic ulcer can be made. A patient whose peptic ulcer is idiopathic may have a higher risk for complicated ulcer disease, a poorer response to gastric acid suppressants, and a higher recurrence rate after treatment. Risk factors associated with this disease may include genetic predisposition, older age, chronic mesenteric ischemia, smoking, concomitant diseases, a higher American Society of Anesthesiologists score, and higher stress. Therefore, the diagnosis and management of emerging disease should systematically explore all known causes and treat underlying disease, while including regular endoscopic surveillance to confirm ulcer healing and the use of proton-pump inhibitors on a case-by-case basis.
Endoscopy, Gastrointestinal ; Humans ; Patient Selection ; Peptic Ulcer/*diagnosis/etiology/*therapy ; Predictive Value of Tests ; Proton Pump Inhibitors/therapeutic use ; Risk Assessment ; Risk Factors ; Treatment Outcome ; Wound Healing/drug effects

Over the past century, since the introduction of non steroidal anti-inflammatory drugs (NSAID), antacid, histamine H2-receptor antagonists (H2RA), proton pump inhibitors (PPI), and discovery of Helicobacter pylori infection, the paradigm of peptic ulcer disease has changed with marked decrease in morbidity and mortality. However, peptic ulcer disease still occupies a position as a major health problem with increase of aged population and NSAIDs usage. In daily general practice, the management of peptic ulcer disease is directed according to the presence of bleeding or not. For non-bleeding peptic ulcer disease, proper acid suppression and the correction of underlying causes such as Helicobacter pylori infection and NSAID use is the main stay of treatment. Though a complete understanding of pathophysiology and a perfect treatment strategy are still a challenge, this guideline aims to provide practical recommendations based on evidences or consensus of experts through in-depth literature review and expert meeting.
Antacids/toxicity ; Anti-Inflammatory Agents, Non-Steroidal/toxicity ; Anti-Ulcer Agents/therapeutic use ; Bismuth/therapeutic use ; Helicobacter Infections/diagnosis/drug therapy ; Helicobacter pylori ; Histamine Antagonists/therapeutic use ; Humans ; Peptic Ulcer/*drug therapy ; Proton Pump Inhibitors/therapeutic use

BACKGROUND/AIMS: In pediatrics, endoscopic examination has become a common procedure for evaluation of gastrointestinal presentations. However, there are limited data on pediatric endoscopy in Korea. The aim of this study was to analyze the current status and clinical impacts of endoscopic examination in children and adolescents. METHODS: We retrospectively reviewed the medical records of outpatients who visited the tertiary hospital. Patients under 18 years of age who underwent endoscopy were included. Endoscopic findings were classified as specific and normal based on gross findings. Specific endoscopic findings were reflux esophagitis, peptic ulcers, and Mallory-Weiss tear. Other findings included acute gastritis classified according to the updated Sydney system. RESULTS: In 722 of 330,350 patients (0.2%), endoscopic examination (554 esophagogastroduodenoscopies [EGDs], 121 colonoscopies, 47 sigmoidoscopies) was performed between January 2008 and January 2013. In EGD, abdominal pain was the most frequent presentation (64.1%). The most common diagnosis was gastritis (53.2%), followed by reflux esophagitis. The frequency of peptic ulcer disease was 12.8%. Frequent symptoms leading to colonoscopic examination were abdominal pain, diarrhea, and hematochezia. In colonoscopy, a negative result was more likely in children younger than 7 years old. After the procedure, the diagnostic yield of EGD and colonoscopy was 88.1% and 45.8%, respectively, and the rate of change in management was 67.1%. CONCLUSIONS: In pediatrics, endoscopic examination was useful for the choice of therapeutic strategy and it would be a standard method for evaluation of gastrointestinal presentation.
Abdominal Pain ; Adolescent ; Child ; Child, Preschool ; *Endoscopy, Digestive System ; Esophagitis, Peptic/diagnosis/drug therapy ; Female ; Gastritis/diagnosis/drug therapy ; Gastrointestinal Hemorrhage/diagnosis ; Histamine H2 Antagonists/therapeutic use ; Humans ; Infant ; Infant, Newborn ; Inflammatory Bowel Diseases/diagnosis ; Male ; Peptic Ulcer/diagnosis/drug therapy ; Proton Pump Inhibitors/therapeutic use ; Republic of Korea ; Retrospective Studies ; Tertiary Care Centers