Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified?

BACKGROUND AND STUDY AIMS: This study aimed to reassess whether the Forrest classification is still useful for the prediction of rebleeding and mortality in peptic ulcer bleedings and, based on this, whether the classification could be simplified. PATIENTS AND METHODS: Prospective registry data on peptic ulcer bleedings were collected and categorized according to the Forrest classification. The primary outcomes were 30-day rebleeding and all-cause mortality rates. Receiver operating characteristic curves were used to test whether simplification of the Forrest classification into high risk (Forrest Ia), increased risk (Forrest Ib-IIc), and low risk (Forrest III) classes could be an alternative to the original classification. RESULTS: In total, 397 patients were included, with 18 bleedings (4.5%) being classified as Forrest Ia, 73 (18.4%) as Forrest Ib, 86 (21.7%) as Forrest IIa, 32 (8.1%) as Forrest IIb, 59 (14.9%) as Forrest IIc, and 129 (32.5%) as Forrest III. Rebleeding occurred in 74 patients (18.6%). Rebleeding rates were highest in Forrest Ia peptic ulcers (59%). The odds ratios for rebleeding among Forrest Ib-IIc ulcers were similar. In subgroup analysis, predicting rebleeding using the Forrest classification was more reliable for gastric ulcers than for duodenal ulcers. The simplified Forrest classification had similar test characteristics to the original Forrest classification. CONCLUSION: The Forrest classification still has predictive value for rebleeding of peptic ulcers, especially for gastric ulcers; however, it does not predict mortality. Based on these results, a simplified Forrest classification is proposed. However, further studies are needed to validate these findings.

Medical and endoscopic treatment in peptic ulcer bleeding: a national German survey.

OBJECTIVE: Peptic ulcers are the leading cause of upper gastrointestinal (GI) bleeding. The aim of this study was the evaluation of the recent clinical practice in drug therapy and endoscopic treatment of ulcer bleedings in Germany and to compare the results with the medical standard. METHODS: A structured questionnaire (cross-sectional study) was sent to 1371 German hospitals that provide an emergency service for upper GI bleeding. The project was designed similar to a nationwide inquiry in France in 2001. Forty-four questions concerning the following topics were asked: hospital organisation, organisation of emergency endoscopy service, endoscopic and drug therapy of ulcer bleeding, endoscopic treatment of variceal bleeding. Return of the questionnaires was closed in August 2004. RESULTS: Response rate was 675 / 1371 (49 %). Mean hospitals size was < 200 beds, 49 % (n = 325) had basic care level. 92 % provided a 24-hour endoscopy service, specialized nurses were available in 75 %. Fiberscopes were used only in 15 %. A mean of 10 +/- 12 (range: 0 - 160) bleeding cases/month were treated, 6 +/- 6 cases per month (60 %) were ulcer bleedings. Endoscopy was performed in 72 % immediately after stabilization but in all cases within 24 hours. The Forrest classification was used in 99 % whereas prognostic scores were applied only in 3 %. Forrest Ia,/Ib/IIa/IIb/IIc/III ulcers were indications for endoscopic therapy in 99 %/ 99 %/ 90 %/ 58 %/ 4 %/ 2 % respectively. Favoured initial treatment was injection (diluted epinephrine, mean volume 17 +/- 13 mL/lesion) followed by clipping. In re-bleedings, 93 % tried endoscopic treatment again. Scheduled re-endoscopy was performed in 63 %. PPI were used in 99.6 %, 85 % administered standard dose twice daily. PPI administration was changed from intravenous to oral with the end of fasting in nearly all hospitals. PPI administration schemes can be improved. Indications for Helicobacter pylori eradication followed rational principles. CONCLUSION: Medical and endoscopic treatment of bleeding ulcers reached a high standard, although some therapeutic strategies leave room for improvement. Bigger hospitals tend to be closer to the medical standard.

[Dysbacteriosis of mucosal microflora of the gastroduodenal zone in inflammatory and ulcer lesions: diagnosis and classification].

AIM: To study mucous (parietal) gastroduodenal microflora in healthy persons, patients with ulcer and chronic gastritis, to develop diagnostic criteria and classification of gastroduodenal dysbacteriosis. MATERIAL AND METHODS: Biopsy specimens were obtained from gastroduodenal mucosa of 134 patients with ulcer, 36--with chronic gastritis and 28 healthy subjects. The mucous microflora agents were isolated microbiologically from biopsy specimens obtained from different compartments of the stomach and duodenum. The spectrum of their enzymatic activity and cytotoxic properties were determined. RESULTS: Gastroduodenal mucous microflora of healthy subjects was represented with 1-2, less often with 3-4 cultures of 12 species, enzymatic activity spectrum of microorganisms was small, cytotoxicity was absent. In ulcer recurrence and exacerbation of chronic gastritis gastroduodenal zone showed dysbacteriosis characterized by overgrowth of mucous microflora (up to 22 species of microorganisms) with a wide spectrum of enzymatic activity and cytotoxic properties. The criteria of dysbacteriosis diagnosis and classification are proposed. CONCLUSION: The role of gastroduodenal mucous microflora in ulcer and gastritis course is specified. New approaches to effective treatment of gastroduodenal diseases may be developed with consideration of dysbacteriosis.

Oesophagogastric ulceration in pigs: a visual morphological scoring guide.

OBJECTIVE: To provide a visual guide for oesophagogastric ulcer scoring and recognition of different morphological changes in the pars oesophagea. DESIGN: Pig stomachs were collected at slaughter and visually evaluated and scored for parakeratosis, erosion and ulceration in the pars oesophagea. RESULTS: A visual and descriptive guide is presented that will aid in the objective assessment and scoring of oesophagogastric ulceration in pigs within the pig health monitoring system (PHMS), namely to the four categories of 0 = normal stomach, 1 = parakeratosis and thickened epithelium, 2 = erosions and 3 = developed ulcers with and without stenosis. CONCLUSION: A visual guide has been developed that illustrates the full range of morphological changes that can occur in the pars oesophagea of the stomach within the few currently recognised stages of the disease.

Dysplasia of nonmetaplastic gastric mucosa. A proposal for its classification and its possible relationship to diffuse-type gastric carcinoma.

In a review of 192 gastric resections, histological changes believed to represent dysplasia of nonmetaplastic gastric epithelium were observed. This paper presents a proposal for their classification. The main feature of this dysplasia is replacement of the differentiated cells lining the glands by undifferentiated cells with varying degrees of cytological abnormalities and cellular pleomorphism, but with absence of architectural glandular derangement. The classification is justified by cytokinetic and histologic observations in experimental gastric carcinogenesis and early human gastric carcinoma. The severity of the changes is graded, first, by the extent of involvement of the gland (crypt) as measured from the proliferative zone (PZ), and, second, by the degree of cytological abnormality. It utilizes a modification of the terminology of Riddell et al. (45) for dysplasia in inflammatory bowel disease wherein the term "dysplasia" denotes intraepithelial neoplasia. The changes are classified into (a) negative for dysplasia, (b) atypical, i.e., indefinite for dysplasia, and (c) positive for dysplasia. Changes negative for dysplasia are considered regenerative and consist of enlargement and vesicular transformation of the nucleus in the cells of the PZ and adjacent part of the crypt. Atypical changes consist of equivocal lesions difficult to classify as definitely regenerative or definitely dysplastic, and are hence called indefinite for dysplasia. They consist of loss of cytoplasmic differentiation of the cells lining the glands (i.e., mucus production and parietal and chief cell differentiation) with increased nuclear-cytoplasmic ratio and moderate cytological atypicality. Based on the extent of gland involvement, the group with atypical mucosa is subdivided into two categories--atypical, probably negative for dysplasia (AtN) and atypical, probably positive for dysplasia (AtP). Mucosa exhibiting unequivocal cytological features of neoplasia with cellular and nuclear pleomorphism is classified as positive for dysplasia (D). This is subdivided into low-grade and high-grade dysplasia, the latter representing carcinoma in situ. Glandular architecture remains undisturbed in all stages and the cells remain cuboidal, without transformation into intestinal-type cells. This type of dysplasia was found in a significantly higher number of diffuse-type carcinomas than in intestinal-type carcinomas. The previously well-recognized adenomatous or metaplastic dysplasia was significantly more prevalent in intestinal-type carcinoma than in diffuse-type.(ABSTRACT TRUNCATED AT 400 WORDS)

Type IV gastric ulcer: a new hypothesis.

In 1965 Johnson proposed his classification for gastric ulcer, which was subsequently adopted by the majority of surgeons. However, for many years we have observed the high frequency of subcardial or juxtacardial ulcers near the esophagogastric junction, which has not been reported elsewhere. In this article we describe the characteristics of this type of gastric ulcer and propose to designate it as a type IV gastric ulcer. This nomenclature is based on its clinical and pathophysiologic features. The anatomically "high" gastric ulcer has an incidence of 27.4%; its main features include a frequent association with the type O blood group; a low basal and stimulated acid output, a high incidence of upper gastrointestinal bleeding, a slower emptying of fluids, and a high percentage of deep penetrating ulcer.

Type I gastric ulcer treated by parietal cell vagotomy and mucosal ulcerectomy.

BACKGROUND: Type I gastric ulcers occur at the gastric incisura and do not coexist with duodenal or pyloric ulcers. Antrectomy and Billroth I anastomosis are the most frequent operations used for treatment of patients with this lesion. STUDY DESIGN: Postoperative results, including recurrence, were evaluated in 48 patients with a Type I gastric ulcer who were treated by parietal cell vagotomy and mucosal excision of the ulcer and had a mean follow-up of eight years. RESULTS: There was no operative mortality and no major operative complications occurred. The patients have had follow-up examination for a mean of eight years. All but four patients were in Visick I and II categories when last examined. Four patients were in category IV because they required a second gastric operation. The cumulative probability of recurrent ulcer rate calculated by life table analysis was 6.5 plus or minus 9.5 (standard error of the mean) percent at nine years. CONCLUSIONS: Parietal cell vagotomy and ulcerectomy is an excellent operation for patients with Type I gastric ulcers and provides an alternative to antrectomy for patients with this lesion.

Ranitidine vs cimetidine: short-term treatment of gastric ulcer.

We compared the clinical effectiveness and endoscopic results of ranitidine and cimetidine treatment; 71 outpatients, all affected with benign gastric ulcer, were selected for the study (43 type I, 7 type II and 21 type III, according to Johnson's classification). The patients were treated randomly for 4 weeks with ranitidine (300 mg daily) or cimetidine (1 g daily). An endoscopic examination was repeated within 3 days after the end of the treatment. Clinical checks were performed weekly in order to monitor the clinical course of pain and antacid consumption, according to the patient's needs. The patients who did not demonstrate complete healing on endoscopic examination were treated for an additional 4 week period. At the end of this 4 week period, another endoscopic examination was done. Thirty-six patients treated with ranitidine and 33 with cimetidine completed the first period of therapy. The two groups were homogeneous with regard to sex, age, duration of disease, smoking habits, alcohol consumption, and type and size of ulcer. Ranitidine and cimetidine treatments did not demonstrate any significant difference with regard to ulcer healing after the 4th or the 8th week of therapy. Both ranitidine and cimetidine were less effective in healing type I than type II and III G.U., at the 4th week of treatment. No significant differences between the two groups were noted with regard to pain or weekly antacid consumption. No significant side effects were reported.

[Cushing's ulcer. Various physiopathological studies and considerations]. / L'ulcera di Cushing Alcune osservazioni e considerazioni fisiopatologiche

28 cases of acute Cushing's ulcer observed out of 2670 necropsies at the S. Spirito Hospital of Rome are reported. Special attention is paid to the most recent physiopathological aspects of the condition.

Gastric ulcers in finishing pigs: their prevalence and failure to influence growth rate.

In an abattoir survey the stomachs of 1242 pigs from 15 farms were examined. Ulceration of the pars oesophagea was present in 22.95 per cent with a range from 4.7 to 57.4 per cent. The ulcers were graded mild in 9.5 per cent and severe in 13.4 per cent of the stomachs. Bile staining and hyperkeratinisation of the pars were significantly more common in stomachs with ulcers than in those without (P < 0.001), although the difference between the hyperkeratinisation in cases with severe ulcers and cases without ulcers was not significant. The daily liveweight gains of 208 males and 150 females from two units with a high prevalence of ulcers were calculated from their weaning weights at about five weeks of age and their slaughter weights at around 90 kg. At the abattoir their stomachs were examined for the presence of ulcers of the pars. The daily liveweight gain of the males was significantly greater than that of the females (P < 0.001), but the presence of mild or severe ulcers had no influence on the rate of gain of the pigs from either unit. The prevalence of ulcers in the males and females was 57.2 and 49.3 per cent, respectively, but the difference was not significant.

Factors affecting depth of gastric ulcers.

PURPOSE: We investigated the differences in background factors, clinical features, and gastric function tests among gastric ulcers of various depths. PATIENTS AND METHODS: The subjects were 68 patients (male 64, female 4) who were diagnosed as having a gastric ulcer at the angulus. The ulcers were classified according to depth based on the following: UL2 (shallow) ulceration to the submucosa; UL3 (intermediate), to the muscularis propria; and UL4 (deep excavation), beyond the muscularis propria. The depth of each ulcer was determined by endoscopic ultrasonography and/or ordinary endoscopic findings. We assessed clinical features, age, gender, smoking habit, alcohol consumption, ulcer history, presence of H. pylori, gastric acid secretion, gastric emptying, serum gastrin level, healing rate, and recurrence rate. RESULTS: Patients with UL4-type ulcers had a higher rate of recurrence and a significantly higher incidence of H. pylori infection. Patients with hyperacidity and currently smoking or consuming alcohol were significantly more likely to have UL4-type ulcers than of UL2 or 3 ulcers. Furthermore, a close relationship was recognized between recurrence, intractability and deeply excavated ulcers. Ulcer depth was not correlated significantly with any of the following factors: 1) patient's profile; including gender and hemorrhagic symptoms; 2) gastric function; including gastric emptying and serum gastrin levels. CONCLUSIONS: Smoking, alcohol consumption, recurrence of ulcers, hyperacidity and H. pylori infections are important factors associated with deep ulcers.

The ulcer disease: an updated classification system.

The study included 736 probands with ulcer disease and 110 healthy subjects as well as all their relatives up to a third-degree of relation (n = 21889). All subjects underwent a thorough genealogical analysis, blood group, PTC and dermatoglyphic studies were performed on the whole contingent. Using extensive genealogical, genetico-mathematical and multifactorial analysis we studied the manifestations of anticipation, the influence of hereditary predisposition on gastric secretion and acidity under conditions of maximum pentagastrin stimulation as well as the disease inheritance pattern. The results of our comprehensive studies suggest that type I gastric ulcer according to H. Johnson, unlike type II and type III, is not genetically determined. On the other hand, type II and type III gastric ulcer do not differ substantially from duodenal ulcer and should therefore be categorised as belonging to this form of the disease. On this basis we propose a new classification system which accepts the existence of two ulcer diseases: gastric ulcer disease, and ulcer disease of the pyloroduodenal region.

Influence of the type of family predisposition on the age of ulcer disease onset.

736 probands with endoscopically and/or roentgenologically proven ulcer disease of the stomach and duodenum were studied. Of these 429 were with hereditary predisposition to the disease (including in the study all their third-degree relatives). Our findings suggest that the age of disease onset is markedly dependent on the type of familial predisposition. It occurs the earliest and relatively the most frequently in probands with two affected parents (familial predisposition type III). The peak frequency of the disease for non-predisposed subjects is between 30 and 39 years of age while in subjects with familial predisposition of the first type (two healthy but genetically predisposed parents) the II-A type (a sick father) and the II-B type (a sick mother) it occurs a decade earlier. Type III familial predisposition causes the disease to affect the probands even earlier by another decade so half of all the probands of this type of familial predisposition are affected by the disease by the age of 19. The different types of familial predisposition to gastric ulcer (types II and III) and duodenal ulcer reflect the hereditary ulcerogenic load received by the offspring. All other conditions being equal, the greater it is the earlier the disease occurs.

[The clinical and morphofunctional characteristics of different types of stomach ulcer]. / Klinicheskie i morfofunktsional'nye osobennosti razlichnykh tipov iazvy zheludka.

AIM: The study of a complex of anamnestic, clinicoendoscopic and functional-morphological characteristics in type I and II (according to Johnson) gastric ulcer. MATERIALS AND METHODS: Esophagogastroduodenoscopy, gastric secretion tests, determination of blood group and Rh factor were performed in 91 patients (52 patients with ulcer type I and 39 with ulcer type II). RESULTS: Ulcers type I have arisen in the presence of long-term chronic gastritis. They were associated with marked changes in the mucosa of gastric body, its atrophy and intestinal metaplasia, persistent recurrences in the same gastric zone. Ulcers type II are characterized by hereditary loading, 0(I) blood group, combination with gastroduodenal erosions, season occurrence, trend to migration and recurrence in different gastric or duodenal zones, HCl hypersecretion, high occurrence of Helicobacter pylori infection. CONCLUSION: It is thought valid to include types of gastric ulcer in current classification of ulcer.

[The characteristics of rarely encountered forms of stomach ulcers]. / Nekotorye osobennosti redko vstrechaiushchikhsia form iazv zheludka.

Studies carried out by the authors provided basis for distribution of rarely occurring chronic gastric ulcers into groups: according to the site (proximal ulcers), to the size (giant ones), to the number (multiple ones), and to the typologic features (combined with duodenal ones and ulcers of the pyloric ring and prepyloric part of the stomach). The given ulcers differ from genuine ones in the appearance and the rate of complications determined by morphologic criteria.

[Endoscopic stage classification of peptic ulcer and characterization of the healing process by proton pump inhibitors].

Proton pump inhibitors are highly effective for gastric acid secretion and have been shown to be superior to histamine H2-receptor antagonists. The superiority of proton pump inhibitors over H2-receptor antagonists was more pronounced in duodenal ulcers. Omeprazole reduced the time required by H2-receptor antagonists the healing of duodenal ulcers by 2/3 to 1/2. On the other hand, unusual endoscopic findings, such as shallow white coat or protrusion of the ulcer floor, were noted in the healing stage of gastric ulcers with H2-receptor antagonists. Whereas these findings were rarely seen with conventional drugs. Histologically, the protrusion was made up granulation tissue consisting of cell infiltration and renewed capillaries with or without regenerated epithelia. These unusual endoscopic findings may be observed in the peptic ulcers treated with proton pump inhibitors.

[Characteristics of the treatment of persistent gastric ulcers]. / Osobennosti lecheniia dlitel'no nezazhivaiushchikh iazv zheludka.

Three variants of persistent gastric ulcers have been distinguished for the first time: primary torpid, torpid progressive, torpid favourable. This should be taken into consideration in treatment, which is based on therapeutic tactics used for primary torpid ulcer. Treatment of torpid favourable as well as torpid progressive ulcers should be based on the effectiveness of the previously used means. Treatment in the period of relative remission requires special attention. In the absence of the effect, two latter variants of ulcers should be treated in the same way as primary torpid ulcers.

[Classification of stomach ulcers and choice of the surgery method]. / Klassifikatsiia iazv zheludka i vybor sposoba operatsii.

The article generalizes the findings of examination and experience in the surgical treatment of 404 patients with gastric ulcers. A classification of gastric ulcers is suggested: Type I, true gastric ulcers; Type II, combined gastric and duodenal ulcers; Type III, suprapyloric and pyloric ulcers; Type IV, multiple ulcers of the stomach; Type V, secondary gastric ulcers. On the basis of this classification the authors substantiate the wide use of modified resections of the stomach after Billroth I. Chronic disorders of duodenal patency was revealed in 10 (2.47%) of patients who underwent operation, compensated duodenal stasis was encountered in only one of them. Billroth I operation was performed on 357 (88.4%) patients and Billroth II on 47 (11.6%) patients. The postoperative mortality was 1.73%. The Billroth I operation produced excellent and good late-term results in 90.1% of patients with gastric ulcers.

[The morphostructural disorders of the gastric mucosa in peptic ulcer]. / Morfostrukturnye narusheniia slizistoi obolochki zheludka pri iazvennoi bolezni.

200 patients with ulcerative disease of the stomach have been examined. It is indicated that 87% of patients showed chronic gastritis, more often with mucosal atrophy. 7.9% of patients revealed isolated dysplasia of various expression degree, in 38.2%--isolated regenerative disturbances, and in 24.3%--associations of dysplasia with regeneration defects. 9.5% of patients showed malignant ulcer (with atrophic and atrophic hyperplastic gastritis--in 13.8% of cases, and with isolated dysplasia--in 41.7%, with isolated regenerative disturbances--in 5.2%, with association of dysplasia and regenerative defects--in 29.7%). To determine resection value one should account extensions morpho-structural alterations in gastric mucosal membrane.

[The individualized choice of the method of operation in the planned surgery of gastric and duodenal peptic ulcers]. / Individualizirovannyi vybor sposoba operatsii v planovoi khirurgii iazvennoi bolezni zheludka i dvenadtsatiperstnoi kishki.

A working classification of gastroduodenal ulcers was developed by the authors on the basis of surgical treatment of 1838 patients with ulcer disease of the stomach and duodenum. When used in combination with the complex examination of the patients it allows to individually choose the operative method. The indications and contraindications for different kinds of surgery are given. Specific features of the postoperative management are described.