Antimicrobial resistance in Helicobacter pylori in Barbados

OBJECTIVE: Helicobacter pylori eradication is essential in patients with peptic ulcer who are infected with the organism. The rate of eradication is related to the level of antimicrobial resistance to metronidazole, clarithromycin, amoxycillin and tetracycline in H pylori in this community. DESIGN AND METHODS: Gastric biopsies from all patients undergoing upper gastrointestinal endoscopy were cultured. Isolation was done on Thayer-Martin medium under microaerophilic conditions and isolates were sub-cultured on chocolate agar. MICs were determined using the E-test. RESULTS: 64 isolates were available for testing. Metronidazole resistance (MIC > 8mg/l) was observed in 39 percent (25/64), clarithromycin resistance (MIC > 2mg/l) in 4.7 percent (3/64), amoxycillin resistance (MIC > 8mg/l) in 4.7 percent (3/64) and tetracycline resistance (MIC > 4mg/l) in 3.1 percent (2/64). CONCLUSIONS: The high level of metronidazole resistance precludes the use of this antibiotic as first line therapy for H pylori in Barbados. It is recommended that a proton pump inhibitor, amoxycillin and clarithromycin be the combination of choice for eradication of H pylori in patients in Barbados.(Au)

Helicobacter pylori and peptic ulcer diseases

The recent recognition of the association between Helicobacter pylori and peptic ulcer disease (PUD) has revolutionised the approach to the management of ulcers. Up to 95 percent of patients with duodenal ulcers and 70-80 percent with gastric ulcers have H. pylori infection. Peptic ulcer disease is a chronic recurrent disorder. The eradication of H. pylori in patients with PUD results in a significant decrease in the relapse rate of ulceration and alters the natural history of PUD. Several regimes are available for H. pylori eradication and most include two antibiotics given for a least seven days. Patients with either a first or recurrent attacks of peptic ulcer should be considered for eradication therapy. These patients should also receive an adequate course of an antisecretory medication for promotion of ulcer healing.(AU)

Peptic ulcer disease and Jamaican patients' awareness of their disorders

In the management and prevention of recurrence of peptic ulcer disease, patients' awareness of their disorder is essential. Fifty-one patients with peptic ulcer disease were studied regarding their awareness of their disorder and compliance with medications. There were 30 women and 21 men with a mean age of 45 years. Thirty-five per cent had secondary school education; 22 per cent had tertiary training and 10 per cent had no formal education. Sixty-three per cent of patients knew their ulcer location but 37 per cent were unaware of their diagnosis. Twenty-nine per cent received most of their information from their pharmacists. Twenty per cent of patients smoked cigarettes; 31 per cent drank alcohol, and 14 per cent took non-steroidal analgesics. Seventy-six per cent thought that poor eating habits were a contributory cause of their ulcer, 39 per cent thought that stress was a cause and 16 per cent implicated heredity. Seventy-six per cent of patients took their medications daily, and 24 per cent only when symptomatic. Jamaican patients' awareness of their ulcer disease is inadequate. There is a need for more physician education of their patients as well as public health promotion about peptic ulcer disease. (AU)

Childhood peptic ulcer disease in Jamaica

Thirty-one children with peptic ulcer disease (PUD) were diagnosed in two major hospitals in Jamaica between 1979 and 1988. There were 21 girls and 10 boys with a mean age of 9 years. There were 26 duodenal ulcers and 5 gastric ulcers. Five patients (19 percent) with a duodenal ulcer had a family history of peptic ulcer. Recurrent abdominal pain was the predominant presenting feature in 68 per cent and pain was present for a mean of 20 months. Bleeding occured in seven patients (23 percent). Twenty-nine patients were successfully treated medically. Two with duodenal ulcers required surgery. The majority of patients have remained well after a mean follow-up of 14 months. Although uncommon in children peptic ulcers should be considered in patients with recurrent abdominal pain. The majority will respond to medical treatment. (AU)

Endoscopic and gastric acid studies in homozygous sickle cell disease and upper abdominal pain

Upper endoscopic and gastric acid output studies were done in 51 patients with homozygous sickle cell (SS) disease and recurrent epigastric pain. Twenty (39 percent) had abnormalities in the upper gastrointestinal tract including 18 (35 percent) with peptic ulcers. Mean bassal and maximum acid output were similar in patients with and without duodenal ulcer (DU). Because DU in SS disease does not appear to be associated with high acid outputs observed in other populations, it may reflect reduced mucosal resistance, possibly resulting from ischaemia. This hypothesis was supported by the significantly lower fetal haemoglobin level among SS-DU patients. (Summary)

Endoscopic and gastric acid studies in homozygous sickle-cell disease and upper abdominal pain - abstract

Patients with homozygous sickle-cell disease frequently experience recurrent upper abdominal pain, the cause of which usually remains unknown. In order to determine the frequency of peptic ulcer disease, upper endoscopic and gastric acid studies were performed in 51 patients with homozygous sickle-cell (SS) disease and recurrent epigastric pain. Twenty (39 percent) had abnormalities in the upper gastrointestinal tract of which 18 (35 percent) had peptic ulcers. The clinical features were similar between patients with ulcers and those with a normal upper gastrointestinal tract. Mean basal and maximum acid output were similar in patients with and those without a duodenal ulcer (DU). Acid output in 15 haematologically normal patients with DU was significantly greater than in those with sickle-cell disease. Since duodenal ulceration in SS disease does not appear to be associated with the high acid output observed in other populations, it may reflect reduced mucosal resistance; this could result from ischaemia. This hypothesis was supported by finding significantly lower foetal haemoglobin levels in SS-DU patients (3.6 percent) than in SS controls (5.7 percent) (AU)

Licorice, more than just a flavour

Licorice (liquorice) is widely known as a flavouring agent. It is also commonly recgonized as a folk medicine for sore throats. It is not as widely known, however, that licorice has cortisone-like activity and side effects. Nor is it commonly known that preparations from licorice are clinically useful in treating peptic ulcers. Currently, focus is on the role of licorice in treating various herpes infections. Data is presented vindicating many traditional uses and evaluating the role of licorice and its derivatives in current clinical medicine (AU)

Peptic ulcer disease in Barbadian children and adolescents

Fourteen patients (10 boys and 4 girls) under eighteen years of age with peptic ulcer disease were admitted to the Queen Elizabeth Hospital, Barbados, between September 1978 and August 1983. The ages ranged from four to eighteen years. Thirteen patients had duodenal and one a gastric ulcer. Patients presented with gastro-intestinal bleeding, typical asnd atypical abdominal pain and vomiting. All responded to medical therapy with cimetidine or antacids, but there were three recurrences which again responded to medical treatment. The incidence appears to be as common as in developed countries and may often go undiagnosed because the diagnosis is not entertained in children (AU)

Peptic ulcer disease in Barbadian children - abstract

Fourteen patients under eighteen years of age with peptic ulcer disease were admitted to the Queen Elizabeth Hospital, Barbados between September 1979 and August 1983. The ages ranged from four to eighteen years with five cases under twelve years. Twelve cases were confirmed by X-ray examination and by two endoscopy. There were thirteen patients with duodenal ulcers and one with a gastric ulcer. There were ten boys and four girls. A predisposing cause was found in three cases, while three patients had a positive family history of peptic ulcer disease. The modes of presentation were gastro-intestinal bleeding and/or melena, typical ulcer pain, atypical abdominal pain and vomiting. Five patients required transfusion. Three patients had a recurrent ulcer. Medical treatment was successful in all cases. No patients required surgery. There were no deaths. Nine of fourteen patients (64.3 percent) received cimitidine only. The other five patients were treated with antacids. Two of these were subsequently treated with cimetidine because of continued symptoms. No side-effects were observed. Peptic ulcer disease is considered rare in Barbadian children. However, this study shows that three children per year require admission to hospital. The number of undiagnosed cases may be higher in the community. The diagnosis must be entertained not only in those patients with typicaly symptoms but also in those with unexplained abdominal pain or persistent nausea and/or vomiting (AU)

Anastomotic ulcer: an unusual cause

A case of recurrent stomal ulcer is reported due to retained excluded antral mucosa during a Bancroft procedure. The diagnosis was suspected from the severity of the ulcer diathesis, and the elevated basal acid secretion despite previous trans-thoracic vagotomy and repeated gastric resection. It was confirmed by finding retained antral mucosa in the "duodenal" stump, and a normal pancreas at operation; and by a marked fall in acid levels following antral excision.The diagnosis and treatment of this condition are discussed. Continual awareness of retained excluded antrum as a cause of stomal ulcer will decrease the frequency of this complication and ensure prompt diagnosis and treatment when it occurs (AU)

Effects of oestrogens on carbonic anhydrase activity in human and canine gastric mucosa. The role of carbonic anhydrase inhibitors in the treatment of peptic ulcer - abstract

Carbonic anhydrase which is present in abundance in the mammalian gastric mucosa is concerned with the production of hydrochloric acid. The aim of the present study was to determine whether oestrogens had any effects on the activity of this enzyme in the gastric mucosa of man and dogs. Biopsies were taken from the body of the stomach of 20 male duodenal ulcer patients, 10 of whom had a pre-operative course of diethylstilboestrol. Ten male dogs were used in the animal experiments. Immediately after a biopsy was taken from the anerior wall of the stomach, midway between the cardiac end and the pylorus, 40 mg of equine conjugated oestrogens were injected intravenously in the dogs. Thirty minutes later a second specimen was collected from a site adjacent to the first one. The homogenate obtained from the mucosal layer of each specimen was used for the estimation of its carbonic anhydrase activity by the colorimetric method of Philpot and Philpot. Reaction times were also noted for various dilutions of pure hyophilized carbonic anhydrase. On the basis of a two-tailed test using a 't' distribution it was found that there is a significant difference in the results before and after injection of equine conjugated oestrogens and between the stilboestrol treated patients and the controls. A mean inhibition of 43.5 percent was achieved in man and 21.2 percent in dogs. One patient who was 14 weeks pregnant had an inhibition of 63.4 percent compared with the controls. Truelove and other workers were convinced that ulcer patients experienced symtomatic relief when put on a course of stilboestrol. Similar results were reported in dogs. On the basis of the present work the oestrogens seem to be carbonic anhydrase inhibitors and hence can account for the regular occurrence of hypochlohydria during pregnancy and the lower incidence of peptic ulcer in women of the child-bearing age. Although acetazalamide has been found to reduce the severity of ulcer symptoms, this beneficial action was overshadowed by a concomitant production of persistent acidosis and tingling and numbness in the fingers. The use of carbonic anhydrase inhibitors for the treatment of peptic ulcer merits further investigations. An ideal drug would be a non-feminizing steroid with good peptic ulcer healing powers (AU)

Comparative radiology of the proximal gastro-intestinal tract in Jamaica

A study of the radiological appearances and pathological features of a series of 17 cases of hypertrophic pyloric stenosis of the adult revealed several interesting features. It was shown that the generally accepted radiological description of smooth, severe and regular narrowing and elongation of the pyloric canal is only present in a proportion of cases. The radiological picture is very variable and many cases presented with an irregular pyloric canal and antrum with only moderate degree of narrowing or of pyloric stenosis. The classical pathological changes are said to be those of hypertrophy and hyperplasia of the circular muscle of the pyloric canal and adjacent part of the antrum. The use of special staining techniques revealed varying amounts of fibrous tissue in the hypertrophied smooth muscle in every case, a feature only briefly referred to in one or two previous communications. The presence of fibrous tissue is compatible with the theory that hypertrophic pyloric stenosis of the adult is secondary to pyloric channel ulcer and further evidence is presented in support of this. In a significant proportion of cases, the pyloric muscle hypertrophy is complicated by the presence of a benign ulcer on the lesser curvature of the stomach. The significance of this is also discussed

Concomitant gastric and duodenal ulcers

Three thousand eight hundred consecutive barium meal examinations performed in the X-ray Department of the University Hospital of the West Indies are analysed. A high percentage of the cases with gastric ulcers were found to have concomitant duodenal ulcers. The relationship between the gastric ulcer and duodenal ulcer in cases with concomitant ulcers is discussed and evidence from the present series and the literature suggests that the gastric ulcer is secondary to the duodenal ulcer in these cases. Two theories of the cause of gastric ulcer, (a) the retention theory and (b) the reflux theory, especially in relation to concomitant gastric and duodenal ulcers, are reviewed. The reflux theory appears to be the most acceptable, and on the basis of this theory, gastric ulcers are classified into (a) primary and (b) secondary (concomitant) to duodenal ulcer or pyloric channel disease (pyloric ulcer or hypertrophic pyloric stenosis). The high incidence of concomitant gastric and duodenal ulcers in Jamaica is compared with the incidence in other countries. It is shown that the incidence of these concomitant ulcers depends upon two factors, which are, the duodenal ulcer, gastric ulcer ratio and the incidence of gastric ulcers which are secondary to duodenal ulcers. In Jamaica, both these factors are high which accounts for the high incidence of concomitant ulcers. (AU)

The incidence of hookworms in peptic ulcer in Jamaica

An analysis of over 200 patients who had gastrectomy and gastro-jejunostomy at Kingston Public Hospital, Jamaica, is made so far as incidence of hookworms, age, sex and ratio of duodenal to gastric ulcer. The incidence of hookworms in these patients is compared with other series. The role of hookworms as one of the possible aetiological factors in peptide ulcer is studied. Although no direct relation is made between hookworms and peptic ulcer, it is suggested that vigorous detection and treatment of hookworms improves morbidity and mortality rates (AU)

Surgical treatment of chronic peptic ulcer in Jamaica

In Jamaica, patients attending the Surgical Department of the University College Hospital of the West Indies for peptic ulcer have been mainly in the lower income group. The symptomatology of the uncomplicated ulcer is the same as in other countries but often the patient does not seek medical attention until there is severe stenosis. The indications for operation are the same as in other countries. Apart from simple suture of the perforated ulcer, sub-total gastric resection and gastro-jejunostomy have been the standard operations. The technical difficulties are discussed. Follow-up has been short but so far the results have been good. Persistent post-resection symptoms so commonly found in Great Britain (Henley 1953) have been conspicuous by their absence. Nearly every patient has gained weight. The probable causes of anaemia which is usually transient have been discussed. The dangers of gastric replacement operation in the treatment of peptic ulcer in the Jamaican patient have been stressed. (Summary)