Bleeding is a serious complication of peptic ulcer and mortality rate has remained at approximately 10% or more. Traditionally surgeons selected patients who were at significant risk of continued or re-bleeding and advocated early surgery. However, patients with bleeding peptic ulcers are generally elderly with coexisting medical illness and surgery results in significant morbidity and mortality. In the last decade, endoscopic haemostatic therapy has been effective in arresting the bleeding with surgical option considered only after endoscopic treatment has failed. We report the outcome of 196 patients who were endoscopically diagnosed to have bleeding from peptic ulcers. One hundred and thirty patients were to have active bleeding or recent bleed from the ulcer. Endoscopic adrenaline injection therapy was used in 53 patients who had active bleeding ulcers and another 77 patients with endoscopic evidence of recent bleed. The injection therapy was successfully in 127 (97.7%) patients. The treatment failed in three patients and they underwent urgent surgery. Re-bleeding occurred in 26 (20.5%) patients and endoscopic adrenaline therapy was repeated in these cases. Haemostatic was achieved in 19 patients, however 7 patients continued to bleed and required surgery. There were 3 deaths, principally from advanced age and coexisting medical illness. Endoscopic therapy for bleeding peptic ulcers is simply to apply, safe and effective. In cases of re-bleeding after initial endoscopic hemostasis, re-treatment is a preferable alternative to surgery. The role of surgery is limited to bleeding that is refractory or inaccessible to endoscopic control.
Six groups of adult male Sprague Dawley rats, each consisting of six animals were used throughout the experiment. The gastroprotective effects of aqueous plant extract alone, honey alone or honey in combination with ethanolic or aqueous extracts of A. conyzoides and cimetidine were investigated in rats against ethanol-HCl induced gastric ulcer. Efficacy was assessed by determination of ulcer index and inhibition percentage. Oral administration of ethanol-HCl (5 ml kg-1 body weight) to fasted rats produced extensive lesions of gastric mucosa (Group 1). Pre-treatment with honey (2.5 g kg-1 body weight) alone (Group 2), aqueous plant extract alone (10% w/v 5 ml kg-1) (Group 3), or honey in combination with each of alcoholic extract (10% w/w 5 ml kg-1) (Group 4), aqueous extract (10% w/w 5 ml kg-1) (Group 5) or cimetidine (10 mg/ml honey 5 ml kg-1) (Group 6) orally 30 minutes before administration of absolute ethanol-HCl significantly (p < 0.05) protected gastric lesions by 46.74%, 61.50%, 76.68%, 78.39% and 56.55% respectively. Although the mechanism of gastric protection is unknown, honey in combination with each plant extract appears to increase the resistance of gastric mucosal cells to the necrotizing effect of strong irritants in the absolute ethanol-HCl mixture. The results suggest that honey in combination with each plant extract might be beneficial in the treatment of a variety of diseases in which gastric mucosal injury is present.
Abdominal pain is one of the common presentations in severe dengue infection. We report a rare case of perforated gastric ulcer in a young man diagnosed with severe dengue infection and the challenges we faced in managing this patient. Perforated gastric ulcer need to be considered if there are signs of peritonitis and persistent abdominal pain that does not conform to the natural history of dengue. Proper imaging and early surgical intervention in perforated gastric ulcer is vital in preventing further complication and reducing the risk of mortality.
Several lines of evidence suggest that, of the three main races of Singapore, peptic ulcers are more common among the Chinese and Indians when compared to the Malays. These include studies on hospital series of patients with or without appropriate control groups, studies on the incidence of surgery for perforated ulcer as well as mortality statistics. A reduction in the Chinese:Malay difference in the incidence of perforated ulcer over three decades suggests that environmental factors are involved in producing these racial differences. However, we have to date been unable to determine the factor(s) responsible. The incidence of perforated ulcer in Singapore is increasing while ulcer mortality is declining. This is similar to the situation in Hong Kong but different from that in the western countries.
Observations of racial differences in the prevalence of Helicobacter pylori in Malaysia have been intriguing. The Indians and Chinese consistently have a higher prevalence compared to the Malays. The racial cohort theory has been proposed to explain these differences where transmission and perpetuation of infection takes place within a racial group rather than between races, races being separate owing to the low rate of interracial marriages. Studies have demonstrated distinctive bacterial strains between races. Phylogenetic studies have shown that H. pylori isolates amongst Chinese and Indians are distinctive while Malays have Indian and other strains suggesting a more recent acquisition of the bacterium from Indians. H. pylori is recognized as the major causative factor in peptic ulcer disease and gastric cancer. Despite the high prevalence of H. pylori, Indians have a relatively low prevalence of peptic ulcer disease and a low incidence of gastric cancer. This paradox with regards to gastric cancer has been termed the "Indian enigma". Bacterial strain differences between races may be putative but this observation may also indicate gastroprotective environmental factors or a lower genetic susceptibility to develop cancer in the Indians.
The characteristics of patients and the endoscopic features of 196 patients with bleeding peptic ulcer in a multi-ethnic population were investigated. There was a male preponderance (M: F= 6.3: 1) and their mean age was 63.5 years. The prevalence of peptic ulcer bleeding in the Malays and Indians was similar to the ethnic distribution of population. However, the Chinese were over represented. Nearly 40% of patients studied had at least one co-existing medical illness. Hypertension and ischaemic heart disease were the most common diseases. History of non-steroidal anti-inflammatory drug usage was identified in 48% of the patients and it was the commonest risk factor associated with bleeding ulcers. More than 80% of bleeding ulcers were located in the duodenum and the pylorus. Endoscopic features of active bleeding or recent bleed were identified in more than 60% of the patients. The study notes that bleeding peptic ulcer is a serious and a potentially life threatening condition. It is a disease of the elderly and, with the steadily increasing elderly population in the country, the admissions rates of peptic ulcer bleeding is expected to rise. There is a need to plan for appropriate technical support, critical care facilities and expertise to avoid unacceptable outcomes.
A review of the records at a teaching hospital in Kelantan revealed that 175 new cases of peptic ulcer disease were diagnosed endoscopically over a period of 5 years. The ratio of duodenal to gastric ulcers was 2:1. Male patients outnumbered females by 2.7:1. There was a disproportionately high number of Chinese patients. A striking observation was that an unusually large proportion (45%) of patients had presented with acute gastrointestinal bleeding. The implication is that peptic ulcer disease in this region may be underdetected; the diagnosis often coming to light only after a serious complication has supervened.
The link between Helicobacter. pylori and peptic ulcer disease in 1997 is an irrefutable one. The association between infection and ulcerogenesis has been shown to be biologically plausible with induction of epithelial inflammation and cell damage and its effect on gastrin/acid homeostasis. The association of H. pylori infection and peptic ulcer disease is a close and consistent one. There is ample evidence indicating that H. pylori eradication results in virtual abolition of ulcer relapse. Several studies have demonstrated that eradication of H. pylori results in ulcer healing and there is evidence showing a temporal relationship between infection and development of peptic ulcer disease.